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National Summit on Opioid Safety: a "hair-on-fire" situation

Friday, November 16, 2012   (0 Comments)
Posted by: Joy Ingram
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A Summit participant's report by Lynn Gerlach, Member Services Manager 

Executive Summary

Management of chronic non-cancer pain with opioids is a complex problem. Marked increases in use of opioids to manage chronic non-cancer pain has made a difficult clinical area even more complex, more contentious and, at times, more hazardous. A review of the limited data on the subject suggests that what we don’t know about the subject far outweighs what we do know. This has created an urgent and dangerous situation with high stakes for the patients on chronic opioid therapy, the providers who prescribe opioids, and their communities. While models for making opioid prescribing more selective and cautious are being developed, there are as yet no clear pathways to safe and effective chronic pain care for all concerned parties.

The opioid problem has a long history, dating back centuries. Conventional wisdom about the use of opioids for medicinal purposes has shifted many times, each shift based, in part, on false assumptions. Some issues that have never been resolved include: tension between short-term analgesia and long-term benefits; the long-term efficacy and safety of opioids in providing lasting benefits for quality of life; the roles and responsibilities of the prescriber, the pharmacist and the patient; and the effects of opioids on the broader communities in which they are prescribed.

Compounding the issues of insufficient scientific data is the large profits for manufacturers of these drugs. Opioid prescribing reformers have faced opposition from the pharmaceutical industry and their spokespersons, who have made unsubstantiated claims for the long-term effectiveness and safety of opioids for managing chronic non-cancer pain. Dollars spent marketing opioids, the amount of opioids prescribed nationally, and rates of addiction, abuse and overdose deaths have traced parallel increases over the past 15 years.

The expert panel at this national Summit called for nothing short of a cultural transformation to change how patients and clinicians approach the management of chronic non-cancer pain, an immediate effort to reverse epidemic levels of prescription opioid misuse, abuse and overdose, efforts to overturn misguided public policies, and adoption of best practices to make opioid prescribing for chronic non-cancer pain more selective and cautious. At the conclusion of the Summit, participants had agreed on the following principles:

Principles for All Chronic Non-Cancer Pain Patients
  1. Self-care is the foundation for effective chronic non-cancer pain care.
  2. Your relationship with the patient supports effective self-care.
  3. Guide care by progress toward resuming activities.    
  4. Prioritize long-term effectiveness over short-term pain relief. 
Principles When Considering Long-term Use of Opioids
  1. Put patient safety first.
  2. Think twice before prescribing long-term opioids for axial low back pain, headache and fibromyalgia.
  3. Systematically evaluate risks.
  4. Consider intermittent opioid use.    
  5. Do not sustain opioid use long-term without decisive benefits.
  6. Keep opioid doses as low as possible.
Principles for Patients Using Opioids Long-term
  1. Clearly communicate standardized expectations to reduce risks.    
  2. Adhere to recommended precautions.    
  3. Avoid prescribing opioids and sedatives concurrently.
  4. Revisit discontinuing opioids or lowering dose.              
  5. Identify and treat prescription opioid misuse disorders.    


A Hair-on-Fire Situation

“Our hair should be on fire!” Probably the most colorful statement from the impressive lineup of national experts, that comment by Gary Franklin, MD, MPH, Research Professor at the University of Washington and Medical Director for Washington State Department of Labor and Industries, best describes the urgency of the opioid crisis for some patients, many providers, and entire communities. Dr. Franklin invoked Franz Kafka: “To write prescriptions is easy, but to come to an understanding with people is hard.” 

It’s really about what we don’t know

Following an introduction by the Summit’s organizers, Michelle Seelig, MD, and Michael Von Korff, ScD, participants were treated to a series of expert presentations that, together, covered just about every aspect of the opioid crisis. Roger Chou, MD, Associate Professor of Medicine for OHSU and Director of the PNW Evidence-Based Practice Center, gave the keynote addressin the Summit’s first plenary session. Chou reviewed evidence that made clear what Von Korff had indicated in his introductory remarks: When it comes to opioid use for chronic non-cancer pain, what we don’t know far outweighs what we do know.

Dr. Chou raised the stakes immediately with evidence that poisoning deaths involving opioids have spiked dramatically since 2000. Methadone deaths rose 500% in six years. Other opioid deaths more than doubled, and poisoning deaths by other synthetic narcotics increased by more than 300% from 2000 to 2006. However, prescription opioids are the source of serious problems for more than the patients for whom they are prescribed. Dangerous diversion to non-patients, usually given to friends or family for free or taken from the medicine cabinet, is compounded by the lucrative street prices opioids bring. A 40 mg tablet of Oxycontin can net $150, as can 10 Oxycodone tablets. Ten tablets of Propoxyphene can net $200!

Moreover, current guidelines for prescribing opioids are generally based on low-quality evidence or on consensus opinion, Dr. Chou explained. The potential adverse effects of opioids are somewhat better documented: hyperalgesia, ironically causingincreased sensitivity to pain; hypogonadism; falls and fractures; and, sometimes, poor functional outcomes. Data about risks of opioid abuse, addiction and misuse among patients, he said, is inadequate, and risk-prediction tools available are not well validated. Even well intentioned and prudent risk mitigation strategies are not well tested for efficacy. Prescription Drug Monitoring Programs (PDMPs) are available and show promise, according to Dr. Chou, but they have their own inherent problems in terms of who is able to access them. Even Urine Drug Screening (UDS) has not been well studied.

Several speakers at the Summit, including Dr. Chou, pinpointed the pharmaceutical industry as a significant driver of changes in prescribing. Dr. Chou cited the $600-million Purdue settlement of 2007, in which the company was convicted of having made false claims about Oxycontin, including that it is less addictive than its competitors, less subject to abuse and diversion, and less likely to cause withdrawal symptoms, “all in an effort to maximize its profits,” quoting John Brownlee, U.S. Attorney, who commented on the judgment for CNN.

Dr. Chou’s final comments were related to dosing and tapering. He pointed out that high opioid dose appears to increase risks. He cited the work of Washington State as a good example of an attempt to influence dosing. In 2007, the state set ceilings related to worker’s compensation: 120 mg ME (morphine equivalent) per day the level at which consultation was recommended. Subsequently, prescriptions of more than 120 mg/day decreased by 35%, and, over three years, Washington saw a 50% decrease in opioid-related deaths. The speaker pointed out that few studies evaluate optimal methods for discontinuing opioids. The medical community needs follow-up studies of patients who have discontinued opioid therapy. Dr. Chou’s final warning was stark: No opioid is “safe.”


The Case for Selectivity and Caution

The most poignant statement by an expert came from Dr. Jane Ballantyne, MD, FRCADepartment of Anesthesiology and Pain Medicine, University of Washington: “I think we are dealing with a lost generation of patients,” referring to patients on high doses who have become addicted to prescription opioids. Dr. Ballantyne, respected nationally and internationally for her knowledge of complex chronic pain management, began her presentation by quoting Silas Weir Mitchell, the “father of neurology,” who noted as long ago as 1866 that an individual withdrawing from morphine after six months of pain management “will have become irritable, nervous and cowardly. The nerves, muffled, so to speak, by narcotics, will have grown to be not less sensitive but acutely, abnormally capable of feeling pain, and of feeling as pain a multitude of things not usually competent to cause it.”

According to Dr. Ballantyne and numerous other speakers, the “wisdom” related to prescribing opioids for chronic pain management took a new turn in the 1980s. Prior to that, the teaching was that opioids were not a satisfactory solution for chronic pain, and they posed high risks of addiction. Two things happened in the 1980s, however. Palliative care specialists began to urge that chronic non-cancer pain ought to be managed with strong analgesics, believing at the time that pain itself would guard against addiction. Concurrently, sustained release opioid formulations offered new avenues for highly profitable marketing of opioid analgesics.

As early as 2003, Dr. Ballantyne was publishing the opinion that, contrary to the encouraging observations of patients who stayed on low-dose opioids for no more than two years without significant adverse effect, controlled research was indicating just the opposite for high-dose, long-term opioid use: modest analgesic effects; poorer functional outcomes; and increasingly common dose escalation with unsubstantiated benefits. What begins as promising pain relief in the first six months, she reported, sometimes progresses to multiple dose escalations, poor quality of life, and, ironically, less pain relief. The more opioids a patient ingests and the longer the opioids are taken, the greater the risks and adverse effects: higher rates of overdose and death, substance abuse, mental disorders, falls and fractures, endocrinopathy, immune dysfunction, and lesslikelihood of improved function or returning to work. In layman’s terms, the patient may get worse rather than better.

Two simple principles emerged from Dr. Ballantyne’s presentation: 90% of chronic pain is not effectively treated with opioids; and opioids have not been proven safe for long periods at high doses. In the face of those facts, she suggested, what we need is a cultural transformation of pain management by clinicians and patients.


How Did we Get to This Point?

Andrew Kolodny, MD, Chair, Department of Psychiatry, Maimonides Medical Center, Brooklyn, New York, was teleconferenced into the Summit to present a striking report on how the opioid analgesic epidemic happened. He showed a series of U.S. maps, from 1999 through 2009, depicting in shocking visual terms the growth of the prescription opioid epidemic and its resultant hospitalization rate over that ten-year period.

Displaying a bar graph of the unintentional drug overdose deaths per 100,000 in the U.S. from 1970 to 2006, Dr. Kolodny pointed out that the last slight dip in overdose deaths occurred in 1990. From that time on, the death rate has risen steadily. And what might be the cause of this steady, tragic rise? The number of unintentional overdose deaths from opioid analgesics paralleled the rising per capita sales of opioid analgesics. In another graph, based on National Vital Statistics, Dr. Kolodny demonstrated that the rates of prescription painkiller sales, deaths and substance abuse treatment admissions exactly paralleled each other from 1999 to 2010. The more opioids prescribed, the more people sought treatment for opioid abuse and the more overdose deaths.

Next Dr. Kolodny revealed national growth in Oxycodone and Hydrocodone use from 1996 to 2006. What might have been the cause for such drug use to increase seven-fold in ten years? According to the GAO, dollars spent marketing Oxycontin during those years grew from $10 million to $30 million. According to Dr. Kolodny, who leads Physicians for Responsible Opioid Prescribing (PROP), the message of the drug industry regarding opioids has been: Addiction is rare in pain patients; physicians allow patients to suffer out of fear of prescribing; opioids are safe, effective treatment for chronic pain; and opioid therapy is easy to discontinue. “Pain” became the fifth vital sign, and Responsible Opioid Prescribing: a Physicians Guide was distributed by 21 state medical boards to over 150,000 clinicians. The guide’s sponsors included Abbott Laboratories, Alpharma Pharmaceutical LLC, Cephalon, Endo Pharmaceuticals, King Pharmaceuticals and Purdue Pharma. Influenced by such “education,” the new paradigm embraced increased use of opioids for patients with chronic non-cancer pain. And the epidemic continued to grow.

Dr. Kolodny proposed a three-pronged approach to controlling the opioid epidemic: prevent new cases of opioid addiction; provide effective treatment for those who are addicted; and control the supply by reducing over-prescribing and black market availability. Working against such control, however, is our own Food and Drug Administration’s policy that allows drug manufacturers to advertise opioids as safe and effective for “moderate to severe pain” without further qualification. On July 25, 2012, PROP filed a citizen petition with the FDA calling for opioid label changes. Many names on that petition were familiar to Summit attendees: Jane C. Ballantyne, Roger Chou, Gary Franklin, Andrew Kolodny, Roger Rosenblatt, and Michael Von Korff. Specifically, the petition asked for three actions by the FDA: Strike the term “moderate” from the indication for non-cancer pain; add a maximum suggested daily dose, equivalent to 100 milligrams of morphine for non-cancer pain; and add a suggested duration of 90 days for continuous (daily) use for non-cancer pain. The proposed label change would not prohibit off-label prescribing of opioids for longer than 90 days or at doses above 100 milligrams morphine equivalent dose, but it would prohibit drug companies from marketing for prescribing practices that have not been proven safe and effective. The FDA is currently considering the PROP petition.


Has the Cultural Transformation Begun?

The National Summit on Opioid Safety provided two excellent models for control of the epidemic, both from Washington state.Group Health Cooperative (GHC) accepted the challenge in 2010, developing a biopsychosocial approach to complex chronic pain management for all of its physicians.Claire Trescott, MD, Medical Director of Primary Care, detailed the process Group Health leadership undertook to achieve that cultural transformation. GHC invested in developing clinical guidelines with organization-wide buy-in. Beginning from the advantageous perspective of an integrated medical home with standardized care planning processes already in place, Group Health used lean management, strong and consistent leadership, and the engagement of both patients and staff to carry out the improvement process.

Leadership defined the “what,” after which the staff involved defined the “how.” The result was a new Chronic Opioid Treatment (COT) process flow supported by standard processes and monitored by metrics and visual outcomes displays. Accountability is now tracked on five tiers: the front-line team view; the clinic view; the primary care leadership view; the divisional view; and the organizational (executive leadership team) view.

The results Dr. Trescott was able to report to the Summit were encouraging, to say the least: near universal EMR-documented COT care plans; a more open, respectful care process; decreased patient complaints; increased efficiency for clinicians and staff; increased provider confidence and satisfaction, with reduced stress; fewer patients on high doses; increased urine drug screening; improved urgent and emergent care; and expectations of future reductions in morbidity and mortality.

Additional representatives of GHC detailed the carefully orchestrated process by which COT was finalized and rolled out for implementation. Grant Scull, MD, Associate Director of the Group Health Family Medicine Residency, explained the extensivetraining program put in place: eight-hour training for chiefs and “champions”; 1.5-hour course for all clinicians; two-hour training in new processes for the entire team; and the placement of coaches in all clinics to mentor and assist with difficult conversations related to COT management.

Rivka Klaff, PharmD, Clinical Pharmacy Coordinator of Primary Care and Pharmacy IT, gave a riveting account of the unique relationship among patient, prescriber and pharmacist in the management of COT. Her data showed a decline in the GHC prescribing of both Oxycontin and Methadone. She concluded with this advice for prescribers: Set expectations with your patients; write prescriptions in seven-day increments; add something to the sig that easily identifies COT patients to the pharmacy; and always alert the patient in advance about any prescription change or denial.


Through the Eyes of a Young Physician

Perhaps the most touching presentation came from a brutally honest, clearly mission-driven young physician, Dr. Hannah Burdge, a family physician for Group Health Permanente since 2008. Her presentation was on avoiding dose escalation and tapering when indicated. She told her story through the composite profile of a prototypical complex patient with fibromyalgia and low back pain, among other problems, already taking a startling array of drugs when Dr. Burdge “inherited” her case. Her patient panel when she started her first “real job” as a doctor included 12% on chronic opioid therapy, a significant number of which were on high dose regimens.

Dr. Burdge reviewed for the audience the time pressures she experienced as she tried to prudently address daunting opioid management issues in visits lasting 10-20 minutes each, while striving to remain responsive to patient needs. She described clinical encounters in which she struggled to hold the line on safe prescribing with distraught and sometimes angry patients. According to Dr. Burdge, the mixed messages she was receiving from the medical community (“Treat the pain!” “Don’t be unsafe!”) only made her situation more difficult. The tapering process Dr. Burdge described for patients on unsafe drug regimens reflected the guiding principles of the Summit. She began with a pain contract; wrote prescriptions for refills in intervals of 7, 14, 21 or 28 days; applied an accepted scale to measure functionality and PFQ-9 or Beck’s Anxiety Scale; and referred for consults with specialists, behavioral health, and pain specialists as indicated.

Using “I” statements and “safety” statements, Dr. Burdge introduced a tapering plan, keeping in mind that tapering is not an emergency and can be slowly done over time on a trial basis. She explained to patients the boundaries she intended to set and how she would augment their therapy with non-opioid solutions as needed. While she wanted to tell us her profile patient was now off all opioids and functioning wonderfully, the actual level of success was generally more modest, but one that gave her confidence as a physician. In her example, the patient was tapered to 90 morphine equivalents a day and was completely tapered off benzodiazepines. While the patient remained unhappy and distressed, she was no longer using a dangerous combination of drugs. In summary Dr. Burdge said, “It is much easier to avoid escalation than to taper.”


Washington State Gets Tough

Finally, Gary Franklin, MD, MPH, (of the “hair on fire” comment) concluded the formal presentations as a representative of both the Washington State Department of Labor and Industries and the Agency Medical Directors’ Group. His report provided simple guidelines with documented positive outcomes. Dr. Franklin first observed the results of Big Pharma’s profit-driven promotion of opioids: By the late 1990s, he explained, 20 states had passed new laws, regulations or policies moving from what was once near prohibition of opioids to use without dosing guidance. Washington State law stated, “no disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.” He agreed with other presenters that such laws were based on weak science and good experience with cancer pain. “By 2006, over 10,000 Washington citizens were taking over 120 mg/day MED,” he said.

As Washington State Worker’s Compensation saw opioid-related deaths climb steadily, Dr. Jane Ballantyne and others warned that patients on medium-to-high opioid doses uniformly become dependent and that tolerance is unlikely to be overcome by dose escalation. In 2007 Washington’s Agency Medical Directors’ Group implemented strong opioid dosing guidelines developed with the help of clinical pain experts. It was an “educational pilot,” not a new standard or rule. The dosing guidelines were in line with everything heretofore presented at the Summit: first establish a treatment plan; screen for substance abuse and depression; use random drug screening judiciously; do not use concomitant sedative-hypnotics; track pain and function, watching for signs of tolerance; and seek help if the dose reaches 120 mg without improved pain relief and function.

By 2012, Washington state was bending the opioid curve. The average daily dosage in Washington workers began declining when the dosing guidelines were piloted. From 2009 to 2010, opioid-related deaths dropped 60%. Unintentional prescription opioid overdose deaths dropped steadily from 2008 to 2010, and the percent of patients who became chronic users began a steady decline as soon as the guidelines were issued. On March 25, 2010, Governor Gregoire signed into law new legislation on opioid treatment with specific guidance on dosing, consultations, assessments and tracking. Subsequent regulations indicated the importance of a single pharmacy and a single prescriber as well as a prescription-monitoring plan.

Dr. Franklin noted that Washington physicians do not always have ready access to pain specialists, and interventional anesthesiologists generally will not assist with opioid issues. The proposed solution is advanced training for primary care providers to increase their proficiency, telephonic or video consultation with experts such as with Project ECHO, and incentives from public payers to offer non-opioid best practices such as cognitive behavioral therapy, graded exercise, activity coaching, interdisciplinary care, and care coordination.

Dr. Franklin reviewed data from a study of 1843 workers with acute low back injury with at least four days’ lost work time. After one year, 14% of them were on disability. If they had received opioids for more than seven days, with at least two prescriptions OR if they were on 150 mg MED or more, their chances of being still disabled after one year doubled after adjustment for pain, function and injury severity. In 1954, 4% of the nation’s workers aged 25-54 were unemployed; in 2010, 20% of men in the same age range were unemployed. Paraphrasing David Leonhardt in the New York Times of April 8, 2011, Dr. Franklin said that Workers’ Compensation is likely contributing to a large proportion of the permanently unemployed or disabled to state, federal and private disability program. Since 2001, the average workers’ time loss has grown by 38%!

Dr. Franklin offered very specific advice to overturn the problem:

—  Track high MED (morphine equivalency dose) and their prescribers

—  Reverse permissive laws and set dosing standards for chronic, non-cancer pain

—  Implement the Agency Medical Directors Opioid Dosing Guidelines

—  Implement Prescription Monitoring Programs

—  Encourage/incentivize use of best practices

—  DO NOT pay for office-dispensed opioids

—  Identify high prescribers and offer assistance

—  Incentivize community-based Rx alternatives (activity coaching and graded exercise early, opioid taper/multidisciplinary Rx later)

—  Offer assistance (academic detailing, free CME, ECHO)


He cautioned that attempts to reverse bad policy will incur pushback, but the doctors on the front lines of healthcare delivery welcome assistance, tools and knowledge of best practices. He believes Washington prescribers are much more concerned about dependence and addiction than about regulatory scrutiny.


Revised principles

Following the expert presentations, the entire gathering rotated through small breakout groups to consider the initial proposed principles in light of the information presented. Following are the final principles, fully articulated, that the summit attendees agreed to promote as guidelines for working with chronic pain patients.


Principles for All Chronic Non-Cancer Pain Patients

Self-care is the foundation for effective chronic non-cancer pain care - Patient efforts to remain active and sustain rewarding life activities usually matter more than treatments prescribed for chronic pain.


Your relationship with the patient supports effective self-care - Listening, empathy, and encouraging patients to remain active and sustain rewarding life activities characterizes excellent care for patients with chronic pain.

Guide care by progress toward resuming activities - To track outcomes, have patients rate their ability to participate in rewarding life activities that pain makes difficult on a 0-10 scale (where 0 is “no difficulty” and 10 is “extreme difficulty”). Monitor return to work. For sedentary patients, consider tracking gradual increases in walking. Guiding care by changes in pain intensity should not be the primary indicator of successful care.

Prioritize long-term effectiveness over short-term pain relief - Differentiate treatments offered for short-term pain relief from steps patients take to resume activities. Short-term pain relief can be helpful, but long-term benefits of medications for chronic non-cancer pain are often modest, and risks may outweigh potential benefits.


Principles When Considering Long-term Use of Opioids

Put patient safety first - Find common ground with patients by emphasizing their safety. Risks of long-term opioid use are significant, while benefits are typically modest. Possible adverse effects include addiction, overdose, dependence, depression, cognitive impairment, chronic constipation, motor vehicle accidents, and serious fractures due to falls, among others. 

Think twice before prescribing long-term opioids for axial low back pain, headache and fibromyalgia - The long-term benefits of opioids for these conditions are unproven, while risks of addiction, overdose and other serious adverse effects are significant.

Systematically evaluate risks - Do not consider a therapeutic trial of opioids for chronic non-cancer pain before assessing risks of opioid misuse and abuse by taking a thorough history, reviewing the medical record, and checking Prescription Drug Monitoring Program data. Ask about past or current alcohol, tobacco and drug abuse, and mental health problems. Do not overestimate your ability to identify high risk patients. Risks of long-term opioid use are substantial, so be cautious when considering chronic opioid therapy, especially for higher risk patients.


Consider intermittent opioid use - Continuous use of long acting opioids has not been proven more effective or safer than intermittent use of short-acting opioids. Time-scheduled opioid prescribing has not been proven to reduce risks of opioid misuse or addiction. Higher doses with around-the-clock use may increase risks. Consider PRN prescriptions of short acting opioids to minimize risks of tolerance, dependence and dose-related medical risks of opioids. When opioids are prescribed for short-term pain management, set clear expectations for duration of use. Prescribe no more than needed for acute pain management--often a few days to a one week supply.

Do not sustain opioid use long-term without decisive benefits – Initial evaluation of long-term opioid use should be based on a therapeutic trial lasting no more than 90 days, preferably less. Long-term use of opioids should only be continued if decisive benefits are observed during the trial. Opioids should not be continued if improved function is not sustained. Involve the patient in determining functional goals for therapy. Continually monitor the benefit-to-harm ratio as benefits may decrease while harms accrue over time. 

Keep opioid doses as low as possible - Reaching doses of 50 to 100 milligrams morphine equivalents or higher should trigger re-evaluation of the therapy. Risks increase with dose, but benefits of higher doses have not been established. Discontinuation is substantially more difficult at high dose. 

Principles for Patients Using Opioids Long-term

Clearly communicate standardized expectations to reduce risks - Opioids have important hazards for patients, for family members, and for the community. Set clear expectations for use to reduce patient risks and for protecting others from unintentional or intentional diversion. Expectations should be standardized across all clinicians in your practice setting and communicated to patients verbally and with simple written materials. 

Adhere to recommended precautions - Close and sustained monitoring of chronic opioid therapy is the standard for care. This includes asking about potential opioid misuse and about adverse behavioral, psychological and medical effects of opioids. Check urine drug screening results and Prescription Drug Monitoring data periodically. These precautions should increase in frequency and stringency for patients on regimens of 50 to 100 milligrams morphine equivalent dose or greater, and for patients with risk factors for opioid misuse. These safety precautions do not guarantee patient safety, so vigilance and caution are essential.     

Avoid prescribing opioids and sedatives concurrently - Concurrent use of opioids and other CNS depressants increases risks of overdose and other adverse effects. Prescribing opioids and sedatives concurrently is not recommended.

Revisit discontinuing opioids or lowering dose - Regularly reassess whether doses can be reduced or opioids discontinued entirely. Many patients using opioids long-term are ambivalent about opioid use. Patients may be open to a trial of a slow taper. Opioids should be tapered when problems arise or if decisive benefits for function are not sustained. If a patient is diverting or engaging in high risk opioid misuse, discontinuation is mandatory. Non-fatal overdose should prompt immediate reduction of opioid dose or tapering off completely.


Identify and treat prescription opioid misuse disorders – When identified, patients with prescription opioid abuse or addiction should be treated rather than discharged from care. Know locally available referral options for addiction treatment including buprenorphine/naloxone treatment, methadone maintenance and counseling. Detoxification is not the standard of care, and is not supported by evidence, as the primary option for prescription opioid addiction.    


NWRPCA’s advice to member health centers

Northwest Regional PCA is committed to helping the community health centers of the Northwest identify and effectively respond to challenges that impact their mission fulfillment and business success. While the Primary Care Association considers measures it might take to help health centers address the opioid prescribing issue over the next year, these are the steps NWRPCA recommends individual health centers take right now in the interests of immediate improvement:

  1. Commit to setting aside adequate staff time, if you haven't already, for discussing the opioid-prescribing issue and complex chronic pain management within your own health center.
  2. Identify a project lead to evaluate your current status as opioid prescribers and pain managers.
  3. Compare your health center’s approach to the guiding principles stated above and start to identify general areas for improvement.
  4. Follow the links in this report, particularly the presentations provided by Group Health leaders, as a model for implementing a program of improved chronic opioid therapy, and identify specific processes and procedures you would like to consider adopting in your own health center.
  5. As appropriate, seek help and advice from the experts who have provided their contact information at the end of their presentations (linked to this document).
  6. Offer suggestions and requests for help to NWRPCA to inform our planning and programming on your behalf.


You may view the slides from all the Summit presentations by clicking here.

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