When it comes to addressing our national opioid epidemic, there are many opinions, lots of suggestions, high-minded rhetoric, an abundance of media attention, and even a Presidential Commission report replete with thoughtful analysis and recommendations.
And then there’s the on-going debate over the value of the Centers for Disease Control (CDC) Guideline for Prescribing Opioids for Chronic Pain.
It’s always best, when trying to solve a complicated problem, to start at the beginning. Determining when a physician should (per the CDC) “initiate or continue opioids for chronic pain,” is both a logical beginning and a crucial inflection point for what happens afterwards. It’s not about blame. It’s about focusing on the practice of medicine – and the important role prescriber/physicians have in solving the problem.
Admiral Hyman Rickover, the Father of the American Nuclear Navy, said, “Good ideas are not adopted automatically. They must be driven into practice with courageous patience.” Now that we have the CDC Guideline, what are we doing to infuse it into daily medical practice? Posting it on the CDC website is a good start. But it’s not enough. Suggesting it be improved and enhanced (as does the Presidential Commission) is a good idea – but have we already saturated the national opioid ecosystem with the existing guideline? Not even close. What we need to do is create a program to educate prescriber/physicians about the CDC’s 12 recommendations with a measurable goal of 100% recognition.
Is that an impossible dream? Is it really beyond our collective capabilities to (at minimum) certify that all American opioid prescriber/physicians have a basic knowledge of the CDC Guideline? After all, if doctors are to appropriately fulfill their roles as “learned intermediary,” is it too much to ask, before pen reaches prescription pad, that they have been exposed to the CDC’s suggestions for (1) determining when to initiate or continue opioids for chronic pain, (2) selection, dosage, duration, follow-up, and discontinuation, and (3) assessing risk and addressing harms of opioid use?
Having the Guideline isn’t enough. “Knowing about it” doesn’t cut it either. We must take actions that result in its use. We must work together to ensure that prescriber/physicians know what the Guideline suggests. “Best practice” is of no use unless it results in better practice. What percent of American prescriber/physicians can even say they’ve read it? We don’t know. We need to know.
Step One is a program to determine how far the Guideline has permeated the medical community. This can be done via mobile technology and it can be (indeed must be!) done swiftly to provide us with a benchmark. Our goal should be 100% awareness in 12 months. Too fast? Too slow? There are surely good arguments on both sides. But a year is a finite unit with no fudge factor. Ultimately, we can achieve success – if we want to.
Aggressive and timely physician education is also crucial to protect against the unintended consequence of having the Guideline misused as a blunt instrument to create an epidemic of denying appropriate care to patients in need. Proper “assessment” is not a synonym for denial of proper, patient-focused opioid prescribing.
What are the motivations for prescriber/physicians to become certified? There can be both positive and negative incentives. For example, the Drug Enforcement agency’s (DEA) triennial recertification for opioid prescribing could insist on CDC Guideline certification. (Through the existing REMS programs for ER/LA and IR opioids, mandatory physician (re)certification via the DEA is a potential solution). State medical boards could require it for relicensing, medical schools could include it in their core curriculum; the FDA could include a reference to the CDC Guideline on all opioid product labeling (the size of the print doesn’t minimize the importance of the language); pharmaceutical companies could “detail” the Guideline when their sales representatives visit with physicians.
What about payers? Perhaps insurance companies and Prescription Benefit Managers (PBMs) could lighten the prior-authorization load for “GC” (Guideline Certified) prescriber/physicians. What about slightly higher reimbursement rates from CMS and private payers? What about lower malpractice rates for GC prescribers?
Importantly, individual consumers and patient groups can and should shape such an approach. In the Age of Yelp, a potent tool in the “GC” arsenal would be an app-based public database that patients and caregivers could access to see whether or not a physician is Guideline Certified. Health plans could also make it a mandatory designation for “in network” inclusion.
Who creates the certification program? Who creates the “GC app?” Who launches the research project to determine current knowledge of the CDC Guideline? Who monitors progress? Who promotes the challenge? Who sits at the table? Who chairs the effort? How much will it cost? How is the Guideline reviewed and revised? There are a lot of details to work out.
Opioid abuse is an ecosystem problem that requires an ecosystem solution. To infuse the CDC Guideline into practice will take a village – and a stopwatch.
Public health illuminati, start your engines.
Peter J. Pitts is Chief Regulatory Officer at Adherent Health, LLC