As the epidemic of over prescribing pain meds, drug addiction and associated overdoses rages on, there is evidence that efforts to universally direct and limit the prescribing of controlled substances has had a positive effect on one of the largest underpinnings of this public health crisis.  The Department of Health and Human Services has directed initiatives to help limit the prescribing practices for opioids. There has been: updated training and education guidelines, increased use of naloxone and an increase in medication-assisted treatment combining medication with counseling and behavioral therapies to treat substance abuse disorders. Refer to New weapons combat opioid addiction, ID tools, e-prescribing are key, by Mari Edlin; Managed Healthcare Executive, Vol. 25 No. 5, May 2015, p 45-48.  The collection of more accurate data is facilitating the use of informatics to better define who is at greatest risk, and help change the behaviors of both patients and providers.

The article quoted an Express Scripts study, which found that “three out of every five Americans who use opioid painkillers use them in dangerous combinations with other medications.”  Reportedly, all states have prescription drug monitoring programs (PDMPs), barring Missouri.  Additionally, more states have recognized the added utility of e-prescribing along with PDMPs to offer insight into relationships between patient demographics and providers’ prescribing practices.  More real time use of PDMPs is being used to change prescribing practices and associated skewed patient expectations and behaviors, with better satisfaction outcomes.  There is real value in pushing forward with using data to support sustainable reduction in opioid addiction.

Prime Therapeutics has created a controlled substance scoring method to help identify those at greatest risk.  “There is a linear relationship between higher scores and more utilization, which leads to higher costs.”  Cathy Starner, as cited in New weapons combat opioid addiction, ID tools, e-prescribing are key, by Mari Edlin; Managed Healthcare Executive, Vol. 25 No. 5, May 2015, p 45-48.  The PDMPs are now being linked to e-prescribing so that key information about patients is obtained before another prescription is written.  This along with tighter and more comprehensive control by the FDA to reschedule prescriptions for hydrocodone, for example, to a Schedule II controlled substance, rather than Schedule III, has also helped to redirect the practices of providers and pharmacists. Through more restrictive educational and technological adjuncts, provider behavior can be refined.  This is in keeping with what so often may be taken for granted after years of practice, but should be appreciated, since fortunately it is a minority of providers that write for the most narcotics outside of guidelines that often change the expectations of far too many patients.

Providers can be pressured into conforming to atypical prescribing practices due to the demands of patients, along with feeling forced to satisfy these demands at the risk of creating negative patient satisfaction scores.  These scores are frequently poorly aligned with real clinical outcome measures, but rather are tied to shared reimbursement mandates, for organizations by insurers, that are then pushed upon providers.  If there are poor patient satisfaction scores based on generic survey questions, such as “Was your pain adequately addressed?”, providers may lose bonuses or jeopardize their employment status.  More significant is understanding the importance of communication on many levels, where increasing patient satisfaction can be galvanized, and this is not a novel concept.

It has been recognized that taking time to communicate with patients as to why they do not need more medication results in greater overall patient satisfaction than simply caving in and writing unnecessary and potentially harmful prescriptions.  “The mean overall patient satisfaction scores for patients receiving analgesics or opioid analgesics were actually lower than for those who didn’t receive them, but the study pointed to long waits and patient flow as the more likely culprits for the low scores.” Refer to Breaking News: Patient Satisfaction Scores Boosted by Better Communication, not Analgesics, by Alissa Katz, Emergency Medicine News, May 2015, Vol. 37, NO.5, p33. Patients of all walks turn to providers for sound and careful advice and medical care.  There is no reason for sound clinical practice behaviors to be shrouded and rerouted to generate upticks in poorly correlated patient satisfaction questionnaires, where undesirable behaviors only beget more of the same.

The problem is largely behavioral, for providers and patients.  One of the most cost effective and necessary positions to realize and take ownership of is to not be manipulated by the atypical circumstances that have become overwhelmingly challenging.  It is not a question of who moved our cheese, but rather of taking it back and holding on to it by using available resources in conjunction with consistent caring communication with our patients. Failure to address these real behavioral issues limits the effectiveness of being able to make more timely progress in reducing the prescribing –addiction epidemic. 


Lukas Kolm, MD, MPH

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