That’s because some doctors write opioid prescriptions more often, and for longer, than other doctors. Research shows that the likelihood of chronic opioid use increases with each additional day of medication supplied, so taking opioids for just five days instead of three – days, mind you, not weeks or months – can lead to long-term use. Do doctors appreciate that when they write initial prescriptions for nine days instead of three, they are increasing the risk of opioid addiction? Many do not.
Of course, there are people who need opioids for short-term pain management and for whom opioids are a legitimate treatment option. But easy availability and a lack of appreciation for the true risk of addiction have contributed to the opioid epidemic. To loosen opioid's grip on America, we need to curb overprescribing by helping physicians better understand what constitutes appropriate use of opioids. Helping physicians navigate appropriate prescribing is an important next step in controlling the nation's opioid epidemic.
Helping physicians navigate appropriate prescribing is an important next step in controlling the nation's opioid epidemic.
MORE AND BETTER GUIDELINES
The medical community is beginning to see guidance on responsible prescribing. The Centers for Disease Control and Prevention (CDC) released guidelines for primary care clinicians who prescribe opioids for chronic pain. The American Society of Interventional Pain Physicians has issued guidelines for responsible opioid prescribing for treating chronic non-cancer pain. Many hospitals have also adopted their own guidelines.
But the available guidance is typically high- level and designed to avoid blatant misuse. What is missing is contextual relevance. As a physician, how do I know if I'm overprescribing for my specific patient population? What if some of the surgical procedures I perform are more involved than others, and those patients legitimately need that extra day of pills?
IDENTIFYING THE OUTLIERS
Practicing Wisely has analyzed physician behavior across several medical practices to determine the normal range of opioids being prescribed and then identify those operating outside the generally accepted practice.
Source: Oliver Wyman analysis, Practicing Wisely
To shed light on what constitutes the appropriate use of opioids for a given procedure and specific patient population, I am working with Dr. Marty Makary, a surgeon at Johns Hopkins and a national leader in patient safety, on a new initiative to give physicians visibility into standard prescribing practices.
Through a detailed analysis of claims data from more than 100 insurance companies (collected over the span of five years), we are able to assess opioid prescribing patterns for specific procedures and types of patients. From there, we have been able to develop "appropriateness measures," as we call them, which show the range of prescribing patterns and identify the average number of pills prescribed for this procedure or that type of patient.
These measures are grounded in detailed conversations with specialists from across the country – interviews conducted to develop a sense of what range of prescribing behavior could be considered extremely inconsistent with the practice of peer physicians, and thus potentially harmful to patients. The appropriateness measures also incorporate a thorough review of the clinical literature. They are intended to serve as actionable guideposts for physicians, helping them understand how their own prescribing patterns in a given situation compare to the standard practice of their peers, locally and nationally.
When we compare physicians' practices, even within a single hospital system, we see sometimes shockingly wide variations. For example, our analysis shows that the national average length of an opioid prescription after a routine caesarean section is less than five days. Yet, individual physicians prescribe them for zero to 10 days.
The doctor who prescribes significantly more opioids than his or her peers is not lazy or a bad doctor; more likely, he or she simply does not have a clear understanding of what is suitable. But now, with appropriateness measures, we can empower individual physicians and healthcare organizations with the data they need to identify outliers and curb the high rates of unnecessary opioid prescriptions.
Arming physicians with appropriateness measures can help them determine whether their prescribing behavior for opioids is consistent with peer-developed guidelines. The measures can also help administrators identify physicians whose prescribing patterns routinely fall outside the best-practice range. They could then partner those physicians with pain specialists and other experts to develop individual prescribing standards, based on the latest best practices.
Appropriateness measures do not seek to second guess a physician's clinical judgment on individual cases. But when a provider's clinical judgment, manifested by his or her treatment patterns, consistently deviates from standard practice, it becomes an issue of patient safety as well as one of quality and cost. In the case of opioid prescribing, it puts people's lives and livelihoods at risk.
Our initiative is focused on bringing transparency to opioid prescribing behavior in a way that does not threaten the doctor- patient relationship. Instead, we are giving physicians the data they crave to understand their own and their peers' practice patterns. This approach of holding a mirror to physicians' own practicing patterns has been shown to spark meaningful behavior change without bringing a physician's clinical judgment into question.
This effort to develop appropriateness measures is an entirely doctor-developed, home-grown solution, one that uses the wisdom of clinicians to put actionable and relevant data into the hands of physicians. Doctors may have contributed – however unknowingly – to the current opioid crisis. And doctors can help bring us back from it.
About the Author
Bruce Hamory, MD is a partner and chief medical officer in the health and life sciences practice of Oliver Wyman, an international management consulting firm.
This article originally appeared on STAT on August 25, 2017.