Personal Reflections on Opioid Prescribing Reforms
Leading Change in Opioid Prescribing:
Process vs Patient Outcomes
Like many practices in the 2000s, Clallam County saw significant increases in opioid prescribing which peaked in 2012 with one of the highest numbers of opioid pills prescribed per capita in Washington state.[1] I entered the scene as a young physician right out of residency. Caught in the early throes of course-correction, we were trained to reel back prescribing while most of my colleagues in practice had been pushed to accelerate prescribing. I remember the times with some angst: prescribing massive opioid doses, chasing pain scores, navigating chaotic refill processes (particularly on Fridays and weekends), difficult conversations, and the demise of many patients sucked into dependency. A large effort at reform ensued as the CDC released recommendations in 2016 on opioid prescribing. States enacted mandatory CME, strict prescribing limits and other rules. Physicians, both empowered by law and now also in fear of it, started off-loading patients to pain specialists, discontinuing medications, and implementing strict protocols. In rural areas where pain specialists were sparse, primary care continued to shoulder the load and struggle with how to best help patients on opioids for chronic pain.
The evolution of the opioid epidemic was complex, but one could argue that focus on pain scores was part of the original problem. Unfortunately, opioid prescribing has been since centered on reforming processes over patient outcomes. Like many institutions, our practice implemented a protocol around expectations for prescribing to ensure compliance with CDC guidelines. Protocols included urine drug screening, medication agreements, avoiding co-prescribing of opioids with benzodiazepines, checking the prescription monitoring system, and using templated visits. Change was slow and difficult. Patients balked or resigned to it, and many felt punished by a few ‘bad actors.’ More than one patient attempted to manipulate me, stating if I didn’t give them a prescription they would be forced to buy it on the street. Chemical dependence on opioids, lack of accessible alternatives, and the emotional toll on physicians to have difficult conversations created significant barriers to sustaining inertia in reducing prescribing. Physicians overtaking the panels of physician retirees often inherited many legacy patients on opioid medications, increasing the number of challenging conversations to be held. Many patients with chronic pain to this day remain on opioids, some in risky combinations with benzodiazepines, which they have used for years. And although medication-assisted treatment for opioid use disorder provided an avenue to reduce opioid prescribing, training in opiate-dependency was on the fringe at the time. In my career, much has changed for patients with opioid use disorder and I’ve matured in my knowledge and approach as well.
I applaud the support and effort given to this important issue by leaders. However, the strategy for the opioid epidemic has been largely focused on reducing risk and prescribing, accounted for by a series of process measures. For example, at the state level, the Washington State Medical Association sends bulletins to providers showing prescriptions in compliance and compares prescribing to local peers. Toolkits focus primarily on adhering to state rules, which albeit, is important. On the local level, our organization attempted to tackle opioids in their strategic plan: “Assure best practices are followed for use of opioids, reduce reliance on opioids when appropriate.” How did a widespread strategy focusing on processes affect operations? We doubled-down on box checking and audits, strengthening compliance with enacting medication agreements, urine drug screening, and other prescribing protocols. We discussed some functional outputs for patients, but it certainly wasn’t our focus. As a clinical leader, I saw minimal progress and felt unsure about what to do next.
What outcomes did patients experience from our efforts to reform opioid prescribing? Despite hundreds of hours of process effort, I would argue that we do not know. We don’t know which patients were harmed through under-treatment of pain or helped by shifting to alternative pain relief measures or simply ignored because we had already checked the box. Although measuring process was a good first step, I understand now that it fell far short of measuring patient-oriented outcomes. In 2022, the CDC revised their opioid prescribing recommendations to focus more on patient functioning and shared decision-making. Our local strategic plan goal should have been re-written as patient-oriented: patients with acute and chronic pain will progress in their functional goals while minimizing short and long-term adverse effects from opioid treatments. A strategic focus on patient outcomes would have directed us to measure what matters to the patient – improving functioning and reducing adverse effects of opioid medications, suffering, unintentional overdose, mortality, and hospitalization rates.
I’m reminded of a recent routine visit I had with a patient on chronic opioids. Daily doses of opioids had been her treatment for years, and she was compliant with the quarterly protocol-prescribed visits. She was holding down a job and managing her family, but noted her sleep was poor. Had I only focused on process compliance, I could have checked the boxes for an ‘easy’ visit and moved on. The patient would have likely found it to be a ‘useless’ visit, adding little to her journey with chronic pain. Instead, I introduced some coaching-type questions around her functioning. She was surprised the conversation went beyond the usual pat items but at the end, thanked me for addressing her sleep. It was a pertinent example of how the ‘right’ process measures do not ensure that we are helping the patient, and even small efforts to address patient outcomes can yield important results.
Unfortunately, clinics, states and societies have not sufficiently changed their approach. Process-orientation is the “go-to” for medical administrators and was for me in the past as well. I now see with greater clarity the downstream effects of process orientation rather than patient orientation. I look back at patients we fired from the practice, the ones we cut off opioids, and the tremendous time and effort that could have been spent to produce better patient outcomes but was put into process. Sadly, I have little proof that compliance with our process really helped patients. If I were to do it over again, I would first focus on patient outcomes without abandoning process. The opioid epidemic is far from resolved, and I see a loss of momentum for clinicians who manage chronic pain and prescribe opioids. It’s easy to think that we’ve cleaned up our processes so it must be all we can do. There is no less pain in our society, and illicit opioids are more easily available than ever. Measuring patient outcomes will propel us further towards helping patients who are suffering more than any process measure could. Focus on the patient outcomes and you will adapt your processes until you get the right results. It isn’t easy to do, but patient outcomes are why we are here.
[1] Rich, Steven, Mood, Paige, Schaul, Kevin. September 2023. How deeply did prescription opioid pills flood your county? See here. Washington Post. https://www.washingtonpost.com/investigations/interactive/2023/opioid-epidemic-pain-pills-sold-oxycodone-hydrocodone/
