We recently discussed in the May 2019 issue of First Report Managed Care the need to address chronic pain treatment strategies for patients at risk of becoming chemically dependent or developing a substance abuse disorder. New developments occur what seems like every day in the battle against fentanyl, and primary care providers are in need of the proper tools to win the fight, especially in rural areas.
New data shows that use of prescription opioids in the United States fell at a historic rate in 2018, down 17%. The decline suggests adherence to and implementation of opioids prescribing guidelines by the Centers for Disease Control and Prevention (CDC) aimed at reducing both the volume of opioids prescribed as well as high doses.
As much as this news is welcome, it does not negate the fact that overdoses and deaths continue to climb among people turning to illicit drugs to feed their dependency. Recent data from the CDC show that between 2013 and 2016 the rates of drug overdose deaths involving fentanyl increased from 1663 to 18,335.
Beyond the lasting damage for individual lives, families, and communities, the turn to illicit drugs has paved the way for the substance fentanyl placing an enormous burden on the health care system. Recent research at West Virginia University documented the high economic cost to both emergency rooms and crime labs because of the rise in synthetic drug use.
A critical need highlighted by the turn to illicit drugs by opioid users that initially were prescribed opioids for chronic pain is the ongoing challenge of treating both the pain and opioid dependency in people who are chemically dependent on opioids or those with opioid use disorder/substance use disorder (OUD/SUD).
“Pain can be very difficult to treat and having opioid use disorder makes it more so,” said Roger Chou, MD, professor, department of medicine, Oregon Health & Science University School of Medicine, Portland, OR. “These patients would ideally be managed in integrated care settings where there is ready access to the evidence-based therapies that we know can be effective in these patients.”
Primary care providers play a key role in managing these patients as they are most often the first-line physicians who diagnose and treat chronic pain as well as follow patients on their medications. In rural areas in particular, they may be the only providers.
Kurt DeVine, MD, a family medicine doctor at CHI St. Gabriel’s Health, Little Falls, MN, stressed just how important primary care doctors are in helping to curb the opioid epidemic. “This is a primary care problem that will be solved by primary care doctors.”
Educating primary care providers on best practices for chronic pain management in patients with opioid dependence or OUD/SUD is therefore essential, as is addressing barriers to care such as lack of reimbursement. Gaps in education and reimbursement, however, remain challenging. This is highlighted in recently published guidelines by The Pain Management Best Practices Inter-Agency Task Force that provide a litany of pharmaceutical and nonpharmaceutical options for pain management based on an individualized patient-centered approach. Underscored in the guidelines are gaps in education and reimbursement for many of these best practices, such as the role of complementary/ integrative health and behavioral health modalities that often are not reimbursed. Similarly, primary care providers need more and better education on and reimbursement for best practices for SUD.
Just how difficult it can be to navigate this terrain for providers is highlighted by the misinterpretation and misapplication of the 2016 guidelines by CDC on opioid therapy for chronic pain. Dr Chou, coauthor of the guidelines, highlighted that the CDC recommends that clinicians be cautious about increasing opioid doses above 50 morphine equivalent dose (MED) and to avoid increasing doses above 90 MED, as well as reassessing patients above 90 MED. In addition, Dr Chou pointed out that the guideline recommends assessing patients for OUD and treating those who have OUD appropriately with medication-assisted therapy (MAT).
Importantly, the guideline does not recommend routinely tapering patients on >90 MED if the benefits outweigh the harms. “And certainly [the guideline] does not recommend abruptly discontinuing opioids in anyone,” said Dr Chou.
Misinterpretation of these recommendations, however, led to the abrupt discontinuation of opioids in some patients rather than the recommended tapering. For people dependent on opioids or with SUB, this draconian approach is what, in part, may have led to the increased turn to illicit drugs.
To clarify the recommendations, CDC published a follow-up “perspective” in the New Journal of England of Medicine that underscores the need for appropriate implementation of the guideline. Of particular emphasis, is that there are no shortcuts to safer opioid prescribing or to safe reduction or discontinuation of opioid use.
“Starting fewer patients on opioid treatment and not escalating to high dosages in the first place will reduce the numbers of patients prescribed high dosages in the long term,” stated the authors. “In the meantime, clinicians can maximize use of nonopioid treatments, review with patients the benefits and risks of continuing opioid treatment, provide interested and motivated patients with support to slowly taper opioid doses, closely monitor and mitigate overdose risk for patients who continue to take high-dose opioids, and offer or arrange medication-assisted treatment when opioid use disorder is identified.”
Despite the challenges for primary care providers, Dr Chou emphasized that caring for these patients is doable and rewarding. “I think there is a misconception about managing these patients and fear about how difficult it can be,” he said. “But patients often do quite well if they are managed appropriately and it can be quite rewarding to do this.”
Both Drs Chou and DeVine are involved in educational programs for primary care providers that offer accessible, online resources on a range of issues on managing patients with chronic pain and OUD/SUD. Following is a brief description of each with links to online sources. The final section briefly looks at innovative alternative payments strategies for reimbursing primary care providers for managing these patients.
EDUCATIONAL RESOURCES FOR PRIMARY CARE PROVIDERS: EMPLOY “EVIDENCE-BASED” PRACTICES
Among the resources available for primary care providers to become better educated on managing chronic pain in patients with OUD/ SUD are two websites that offer easy-to-access, free information sources.
One resource is the Clinical Support System (PCSS), a program created to train primary care providers in evidence-based prevention and treatment of chronic pain and OUD. Supported by a coalition of 20 organizations, PCSS offers a number of free online resources through its website (https://pcssnow.org/about/). Resources include a core curriculum, webinars, videos, mentoring, and access to important documents like waivers.
Dr Chou, also a lead developer of the PCSS pain curriculum, emphasized the need to educate primary care providers on the effectiveness of evidence-based strategies, including appropriate medications as well as behavior support and nonpharmacological therapies such as exercise therapy, cognitive behavioral therapy, and coping strategies.
He stressed the importance of MAT for people with OUD. “There is still likely to be some stigma using medications like buprenorphine or methadone to treat patients with OUD, but PCSS and others have engaged in efforts to educate about the effectiveness of these therapies.”
In addition to educating primary care providers on the effectiveness of MAT, he stressed the need for providers to have access to these therapies. One important step in gaining access is to obtain a waiver to prescribe buprenorphine, another resource provided by PCSS through its waiver training for physicians and nurse practitioners. The waiver can be found through PCSS’ website.
Another resource for primary care physicians, particularly in rural areas, is through a portal called Project ECHO (Extension for Community Healthcare Outcomes), an educational tool developed to provide best-practice specialty care through virtual clinics with community providers. Dr Devine and colleague Dr Heather Bell at CHI St. Gabriel’s Health, a primary care facility in a small town in central Minnesota, created and conduct a program on best practices for primary care providers around a range of opioid issues including prescribing practices, community collaboration, pharmacological and physiological effects of prescribed and illicit opioids, and buprenorphine clinics in the primary care setting. Resources including clinical materials and data on outcomes can be found through Project ECHO’s website (www.chistgabriels. com/echo.)
Offered via weekly video conferences through Project ECHO, the program provides participants with some of the knowledge and experience Drs Devine and Bell have obtained through an innovative program they developed at CHI St. Gabriel’s Health to manage the rampant opioid problem in their community. Nationally recognized, the program uses a coordinated care approach to identify and monitor patients on pain medications and individualize care of these patients, including using MAT to help taper patients off opioids when appropriate.
According to Dr Bell, unique to this program is that it is conducted by primary care providers for primary care providers. “It provides best practices on what you would actually do in a primary care setting,” she said, adding that, because the ECHO program brings together providers from around the country, most often in rural areas, it also serves as a referral for patients to be transferred within a network or within a state.
Dr DeVine highlighted that one of the biggest problems encountered among providers is eliminating opioids from patients they suspect are misusing them. “In our weekly ECHO, we constantly tell providers that the old way of cutting people off opioids if you find out they are taking too many pills or if you suspect them of doctor shopping is not the way to manage these patients,” adding that these people will get very sick and may turn to synthetic drugs. “That is the key to recognize that they have an opioid use disorder problem and need to taper off the opioids.”
Dr Bell emphasized the need to educate primary care providers on the benefits of MAT to help people taper off opioids. However, she stressed that tapering is hard work that requires the patient’s willingness and commitment to succeed. Given that, she said some primary care providers are reluctant to offer it. To help primary care providers, Dr Devine suggested including help from a pharmacist. “We have a pharmacist here who helps set up a taper,” he said. “These things can be slow, but they don’t have to be torture.”
INCENTIVIZING PRIMARY CARE PROVIDERS
A gap in both chronic pain management and treatment for OUD/SUD is access to care, a main barrier of which is reimbursement. A number of health plans are adopting innovative value-based payment strategies to encourage SUD treatment in primary care. These include incentivizing primary care doctors to obtain a waiver to prescribe buprenorphine, providing enhanced payments for increasing care coordination and management of SUD patients, and rewarding providers for meeting quality measures related to SUD such as urine toxicology screening.
Payers may find further ways to incentivize providers through alternative payment strategies described in a recently published report by the American Medical Association and the American Society of Addiction Medicine. The Patient-Centered Opioid Addiction Treatment (P-COAT) report provides a range of goals for using alternative payment models to reimburse OUD care including encouraging more primary care practices to provide MAT and providing appropriate financial support to successfully implement it. The report also includes a section, “P-COAT in Practice” that describes a number of case studies in which various alternative payment models are used.