Pennsylvania to roll out opioid prescribing guidelines for doctors
HARRISBURG — Pennsylvania doctors may soon have a new set of state-specific guidelines to consider when prescribing patients highly addictive painkillers like OxyContin and Vicodin.
The Corbett administration, the state’s largest physician advocacy group and a new state House task force are all focusing on developing opioid prescription guidelines as part of a broader attempt to curb the prescription drug abuse problem that has been deemed a public health crisis.
“Everybody realizes the urgency in setting up something to deal with what has been deemed an epidemic of opiate abuse,” said Carbon County state Rep. Doyle Heffley, who authored the House resolution that formed a new joint task force to study the problem. “We can do something. We can do better. But everybody has to really work together.”
More Americans now die from drug overdoses than motor vehicle crashes, with at least 38,000 drug-induced deaths reported in 2010, or 105 per day, the Centers for Disease Control and Prevention reports. Opiate-based painkillers are linked to more overdoses than any other drug. They’re also tied to climbing heroin use, with prescription drug abusers turning to heroin as a cheaper alternative to get a similar high.
Efforts in the commonwealth to address the problem at the prescription level would follow similar moves by other states, with the Vermont Medical Practice Board among the most recent to issue a new set of opioid prescribing rules.
Opioid prescribing guidelines for Pennsylvania are being tackled on at least three fronts: Gov. Tom Corbett’s Safe and Effective Opioid Prescribing Practices and Pain Management Task Force, co-chaired by Physician General Dr. Carrie DeLone and Secretary of Drug and Alcohol Programs Gary Tennis; a panel of doctors within the Pennsylvania Medical Society; and, most recently, a panel of four lawmakers appointed to a new task force established by the House Joint State Government Commission.
After a three-hour meeting last week, the governor’s work group approved tentatively its set of opioid prescription guidelines, which have not yet been made available to the public.
Then on Monday night, the Pennsylvania Medical Society’s internal group reviewed the latest draft, said Scott Chadwick, legislative counsel for the society, which represents about 20,000 physicians and medical students. He said that overall, the multi-specialty panel of doctors was pleased with the document, which closely resembles guidelines now in place in Ohio.
“We’re very excited that there’s so much governmental interest in addressing the problem of opiate abuse,” said Scott Chadwick, legislative counsel for the Pennsylvania Medial Society. “How it all comes together is the $64,000 question.”
Taking a ‘pause’
The final guidelines will likely encourage doctors to screen patients for histories of alcoholism, mental illness and various dependency and substance abuse problems that could put them at higher risk of getting hooked on opiates.
Doctors should also be advised to “press pause” and re-evaluate a treatment plan once a patient’s prescription reaches a certain threshold of opiate use, said Dr. David Talenti, vice chair of the Pennsylvania Medical Society’s Board of Trustees. Ohio’s guidelines called for using an 80 milligram morphine equivalency as its “trigger threshold.” The Pennsylvania Medical Society’s group recommends a 100 milligram threshold, based on new medical research that came out after Ohio’s rules went into effect, Talenti said.
Research shows that doses above that amount stop providing additional therapeutic effects while increasing the likelihood of addiction and side effects of long-term opioid use, Talenti said.
“When they see that a patient gets to that level, they take a pause and say, ‘Whoa, wait. I’ve got guidelines here … it’s time for me to take a step back and ask a few questions,'” said Talenti. “‘Do we need specialty help with either a pain medicine specialist, a psychiatric medicine specialist or an addiction specialist to help this person out?'”
The Pennsylvania Medical Society’s work group has asked that any guidelines be voluntary, so as not to replace a physician’s individual clinical judgment.
“They would provide a road map without mandating that you follow exactly the route prescribed,” Chadwick said.
The doctors’ group also emphasized the guidelines should not be too lengthy or complicated.
“The group felt that it was very important that the guidelines be concise, easy to follow, easy to understand,” Chadwick said. “We didn’t want something that was 20 or 30 pages long that users could get lost in. We wanted something short, clear and useful.”
Next steps
More than two dozen stakeholders were asked to submit comments before the document gets finalized, with the Pennsylvania Medical Society and other groups planning to weigh in formally by May 15, Chadwick said.
“A concern is that the Corbett administration will issue one set of guidelines and the Legislature, based on whatever comes out of the Joint State Government Committee, will issue a separate set of guidelines,” Chadwick said. “We would all be confused.”
Heffley, one of the four lawmakers on the Joint State Government Committee’s new task force, isn’t worried about their work leading to competing sets of rules. He noted that many of the 29 individuals that will be advising his legislative task force have also been involved in the governor’s work group. Heffley also personally attended the April 15 meeting of the governor’s group.
“I thought it was a great group of individuals with a lot of knowledge, and a lot of really good recommendations,” said Heffley, such as the call to take into account a patient’s history before prescribing opiates for non-cancer pain. “It was a great conversation, and I’m really looking forward to working with them.”
The new House task force includes Heffley and Reps. Joe Hackett, Marty Flynn and Pam Snyder. Its charged with studying the opiate abuse problem over the course of year, and rolling out prescribing guidelines within two months.
“Just because a doctor prescribes it doesn’t make a drug any less dangerous or addictive,” Snyder, a Greene County Democrat, said in a statement. “It is staggering that an estimated 70 percent of drug abusers are getting their drugs from family and friends who take old prescriptions being stored in family medicine cabinets.”
Other recent efforts to reduce opiate abuse include increasing the number of drug take-back programs to dispose of old prescriptions, and establishing an electronic prescription drug monitoring database to thwart patients from doctor-shopping and flag potential addicts.
“Just the fact that a primary care doctor can look and see some things that are showing this person may have an addiction problem and getting them the right help that they need, that is huge,” Talenti said.
“That is absolutely huge in making sure these patients don’t go onto other things, whether it be heroin or escalated doses of the prescription that can get them into bad problems like overdoses and other opiate side effects.”
Another partial remedy could be better coordination of care and team-based approaches to medicine, so that all of a patient’s health care providers are collaborating on the overall treatment plan.
Natasha Lindstrom can be reached at nlindstrom@calkins.com.