The national opioid epidemic, years in the making, will require more than the effort of government agencies to alleviate.
Deaths from drug overdose last year escalated to an all-time high of more than 63,000 nationwide – killing more Americans than car accidents. These deaths were largely driven by a five-fold increase in deaths involving illicit opioid drugs such as fentanyl and heroin, according to data released by the Centers for Disease Control and Prevention (CDC) in December 2017. Some of the steepest increases have been in Florida, where Gov. Rick Scott last year declared a public health emergency to draw on federal funding for statewide prevention, treatment and recovery services.
This national opioid epidemic has been years in the making and mitigating its effects will take the effort of more than government agencies. The University of South Florida’s academic medical center has joined medical schools across the country in evaluating and strengthening education and prevention measures needed to help derail the devastating toll taken by the opioid crisis.
Boosting pain management education
In Florida, the USF Health Morsani College of Medicine (MCOM) plays a leading role in providing faculty, residents and students with the tools to address the opioid crisis while caring for patients in acute and chronic pain. USF’s medical college is among nine across the state working together to educate the next generation of physicians in pain management best practices, including appropriate opioid prescribing. MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group, along with Diane McKay, PsyD, director of behavioral health and assistant professor of psychology at Lake Erie College of Osteopathic Medicine, which has a branch campus in Bradenton, FL.
The group, including members from the state’s six public and three private medical schools, coordinates with Florida’s Surgeon General, policymakers, the state’s allopathic and osteopathic medical associations, and others. Participants are developing a set of core competencies that can be readily integrated into existing curricula to better prepare Florida’s medical students and residents to manage different types of pain, to recognize the risks for addiction and mental health conditions affecting substance abuse, and to safely prescribe opioids when appropriate while keeping pace with changing practice guidelines for pain management.
MCOM Vice Dean for Education Bryan Bognar, MD, co-chairs the Council of Florida Medical School Deans’ Pain Management Working Group.
“All our medical schools are already addressing substance abuse and pain management to some extent,” Dr. Bognar said. “Our goal is to fill in any gaps that we find, and also assess that students achieve these competencies, whether through test modules or standardized patient simulations.”
The Florida group has built upon initiatives in Pennsylvania and Massachusetts, states where medical schools have already gone through the exercise of creating core competencies to strengthen pain management education for undergraduate and graduate medical students, Dr. Bognar said.
“Pain management education is an incredibly important pillar in addressing the opioid epidemic,” Dr. Bognar said. “At USF Health, we are teaching future physicians and other health care professionals to be skilled in best practices, so it is incumbent upon us to be part of the solution to this pervasive public health problem.”
“The misuse and abuse of opioids is a serious public health problem because the numbers of individuals, families and communities affected are staggering and the costs are borne by society,” said Donna Petersen, ScD, dean of the USF Health College of Public Health. “Solutions will require a team-based approach to bring various disciplines around the same table for discussion.”
Within a core course taken by all USF public health master’s degree students, Dr. Petersen teaches a new segment on the opioid epidemic that encompasses surveillance of narcotic-related risks and outcomes, effects of opioids on the brain, prescribing practices, roles of law enforcement and the medical community, and changing the conversation of addiction as weakness toward chronic illness.
Donna Petersen, ScD, dean of the USF College of Public Health, says addressing opioid misuse and abuse will require a team approach.
With a focus on interprofessional collaboration among its colleges of medicine, nursing, public health and pharmacy and school of physical therapy, USF Health faculty members are also looking for ways to bring students together as teams to learn about the complexities of substance abuse and pain management within the context of the opioid epidemic. Led by Tricia Penniecook, MD, MPH, vice dean for education at the College of Public Health, an Interprofessional Education Workgroup on Opioids was recently formed at USF Health to develop and implement common teaching modules to address the issue comprehensively.
Taking the lead in opioid prescribing practices
The Morsani College of Medicine is one of the first medical schools in Florida to develop clinical practice guidelines for opioid prescribing, said Charles J. Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine.
The current opioid crisis emerged following substantial increases in per-capita frequency and dosages of prescription opioids, a trend begun in the late 1990s. Researchers hypothesize that this increase was due in part to palliative care experts seeking to address the burden of chronic pain without sufficient evidence of either the long-term effectiveness or risks of opioid dependence. The Joint Commission’s classification of pain as a “fifth vital sign” contributed to hospitals and physicians seeking to improve patient satisfaction scores through aggressive pain relief – sometimes without managing patient and family expectations of a pain-free experience.
Charles Lockwood, MD, senior vice president for USF Health and dean of the Morsani College of Medicine, has written editorials on opioid abuse and how obstetrician-gynecologists can help prevent it for February and March 2018 issues of Contemporary OB/GYN. Dr. Lockwood is editor-in-chief of the publication. | Photo by Sandra C. Roa
While doctors now prescribe opioids less often, the overall rates remain high and vary substantially across the country, a recent CDC surveillance report indicates. In 2016 prescribers wrote 66.5 prescriptions for every 100 people, down from 72.4 in 2006; however the prescribing rate remains three times as high as in 1999 and the average days of drug supply for each opioid prescription continues to trend upward. The explosion of opioid prescribing in this decade has contributed not only to rising emergency department and hospital admissions and overdose deaths — but also to far-reaching psychosocial ills. A USF-led study published in the January 2018 issue of Health Affairs found an association between the rate of opioid prescriptions in Florida and the alarming number of children placed into foster care.
“Physicians can play a critical role in curbing the epidemic by returning to our traditionally stringent criteria for opioid prescriptions, using a multimodality, non-opioid approaches to chronic pain management and by better understanding opioid pharmacology,” said Dr. Lockwood, who, as editor-in-chief of Contemporary OB/GYN, has written editorials on opioid abuse and how Ob-Gyns can prevent it for the publication’s February and March 2018 issues.
The USF Health proposed guidelines clearly lay out for all practitioners who “prescribe, administer or dispense” controlled substances — including opioid medications such as OxyContin, morphine and fentanyl, to name a few — evidence-based standards for safely treating pain. Among other provisions, they specify recommended prescribing limits and exceptions, strongly encourage practitioners to complete approved continuing education training on pain management and addiction, and recommend that conservative and non-drug alternatives be considered to control non-cancer pain.
Mark Moseley, MD, chief medical officer for USF Health Care, says the new guidelines are intended to reinforce prescribing and practicing in a safe and thoughtful way.
The executive board of USF Health Care, the university’s multispecialty faculty practice group, is expected to approve the guidelines in February. Mark Moseley, MD, chief medical officer for USF Health Care, and Kevin Sneed, PharmD, dean of the USF Health College of Pharmacy, led development of the guidelines with input from faculty leaders in neurology, psychiatry, pharmacy, nursing, physical therapy and legal counsel.
Creating a culture of patient safety
“Our intent is to reinforce evidence based prescribing and practicing in a safe and thoughtful way, given that these (opioid) drugs can be highly addictive in some,” Dr. Moseley said.
“At USF Health we are creating a culture of safety and putting the patient first, and these guidelines are important in setting that expectation,” Dr. Sneed said. “Ultimately, we have to be mindful about not creating an unintended problem while trying to treat a (pain-related) problem. Opioids are not a long-term solution for managing chronic pain.”
When prescribed prudently opioids are useful in helping physicians relieve pain, especially extreme pain or the chronic pain suffered by cancer patients at the end of life. But research on the long-term effectiveness of these agents for chronic pain relief has been inconclusive or suggests ineffectiveness, and some studies indicate misuse and abuse of the prescription painkillers has led to a rise in addiction and overdose deaths from heroin.
Kevin Sneed, PharmD, dean of the USF College of Pharmacy, says opioids are not a long-term solution for managing chronic pain.
“Opioids as a class of medications are an important tool in our full armamentarium of pharmacological agents,” said Dr. Moseley, an emergency physician. “If you come into the emergency room with a broken bone, I need to have that as an option to give some immediate relief… but for a patient with back pain there may be more appropriate and effective options than prescribing three months of highly potent opiate medication.”
Both Dr. Moseley and Dr. Sneed agree that non-medication alternatives like exercise, physical therapy and biobehavioral treatments should be considered and discussed when evaluating an individual’s condition.
“Patients want their physicians to have an open discussion with them about how to best manage their pain,” Dr. Moseley said. “Most are pretty agnostic of the modality used if you can help alleviate the pain.”
CRNA advanced pain management fellowship among nation’s first
A USF Health College of Nursing postgraduate program for practicing certified registered nurse anesthetists (CRNAs) was granted accreditation in August by the Council on Accreditation of Nurse Anesthesia Educational Programs.
The distinction makes the nursing school’s Simulation-Based Academic Fellowship in Advanced Pain Management one of four such specialty fellowship programs for nurse anesthetists in the United States and the only one in Florida, said John Maye, PhD, CRNA, the fellowship program’s coordinator. The program, combining online courses with an intensive simulation clinical experience at the USF Health Center for Advanced Medical Learning and Simulation (CAMLS), will graduate its first class of 25 fellows this spring, including some from rural areas of America hit hard by the opioid epidemic.
John Maye, PhD, right, coordinator of the USF College of Nursing’s Simulation-Based Academic Fellowship in Advanced Pain Management, with Erik Rauch, DNP, center, and Alan Todd, DNP — all members of the college’s nurse anesthesia faculty. In this simulation exercise they are evaluating vertebral column anatomy. | Photo by Ryan Noone
CRNAs work with physicians to provide anesthesia and related care to patients before, during and after diagnostic, surgical or obstetric procedures. They can order and administer controlled substances based on state law and/or facility-specific protocols.
New research reported last year in JAMA Surgery cited an under-recognized complication of perioperative care among certain patients who never used opioids before surgery – whether they undergo minor or major procedures, some prescribed these painkillers for postsurgical relief may face a risk for developing opioid addiction.
Health care practitioners traditionally receive minimal exposure to the science of pain medicine, yet education is a “huge part” of preventing or reducing pain without inadvertently promoting opioid dependence, Dr. Maye said. “Our fellowship program focuses on educating CRNAs to understand the transmission of pain within the central and peripheral nervous systems and how specific drugs other than opioids can be used to help control that pain perioperatively.”
