Balancing the needs of patients with chronic pain with policy makers’ efforts to rein in the nation’s growing prescription drug crisis is a delicate task that requires nimble planning and a touch of entrepreneurship. So claim the authors of an opinion piece published online today in the New England Journal of Medicine, as they offer their vision for an “ideal” software for curbing Rx drug overuse.
“Paradoxically, there are simultaneous pressures to increase opioid prescribing for the benefit of individual patients and to reduce it for the sake of public health,” write Jeanmarie Perrone and Lewis Nelson, who are teaching physicians of emergency medicine and toxicology at the University of Pennsylvania and New York University’s schools of medicine, respectively.
They cite a number of factors that have contributed to the liberalization of opioid drug prescribing, including the classification of pain by the Joint Commission in 2001 as a “vital sign” that requires immediate attention, the use of pain “scores” to measure patient comfort, and the practice of treating long-term, non-cancer-related pain with powerful opioids.
As a result, prescribing physicians, dentists, pharmacists and nurses, rather than street drug dealers, are contributing disproportionately to the escalating use of prescription drugs, which in 2009 caused more deaths than those caused by car accidents, according to the Centers for Disease Control and Prevention. This is not to say that health care workers are willing facilitators – many of them are complying with accepted standards of care so as to shield themselves from malpractice lawsuits. But ultimately that backfires on patients who do not use the drugs for medical reasons, or who go on to develop addictions.
Prescription drug monitoring programs have existed for nearly two decades, but have had a limited impact because of technical hurdles and resistance from professional societies, as I wrote in a recent post about New York State’s effort to widen use of Rx monitoring software. For physicians who don’t want to shoulder the blame for undertreating a patient with chronic pain, withholding requested painkillers can be an ethical concern. For pharmacists juggling multiple tasks under time pressure, the time-consuming data entry such programs require can be impractical.
To solve such concerns, the authors propose an “ideal” prescription-drug monitoring program that should be a worthwhile project for IT innovators looking to have real impact. PDMPs are no panacea for the complex issues surrounding pain management and prescription drug abuse, Perrone and Nelson write, but designing a highy functional tracking system is a step in the right direction.
The envisioned software would first and foremost track and save patient prescriptions over time. With a simple log-in, physicians who are unsure whether patient-reported pain is legitimate would be able to check whether past prescription drug use warrants new and more medication. This capability would help doctors avoid confrontational approaches such as urine tests that check for traces of opioids, but that may foster resentment and mistrust in patients. It would benefit patients by allowing immediate intervention when unusual drug use is first noted and while the patient is still in the doctor’s office. And without tapping additional resources, it would alert physicians to simultaneously used drugs whose chemical interactions may result in serious harm.
To lighten the burden on pharmacists, the system would allow them to log in using a unique code issued by the Drug Enforcement Administration, which would do double duty as an identification number against forged or stolen prescriptions.
