Issues with pain management, in particular opioids, continue to be at the center of policy debates, media headlines, and new initiatives to protect public health and patient safety. Given this context, the CSA Committee on Pain Medicine is moving forward with a variety of activities to help ensure that the voice of physician anesthesiologists is heard and establish CSA as the subject matter expert when it relates to appropriate pain management treatment considerations. Without our leadership on this issue, the Legislature will continue to look for misguided solutions that legislate the practice of medicine when it comes to opioids.
The Committee is pursuing opportunities for public education – through the CSA website, social media, and traditional media outlets. Timely subject areas include CDC guidelines for opioid prescribing, the Medical Board of California Death Certificate Project, the role of alternative pain management techniques that minimize the role of opioids, and the need for better alignment of patient expectations with the reality of pain management throughout the perioperative spectrum.
Of particular note, the “Death Certificate” project is deeply concerning. Medical Board staff are conducting a retroactive review comparing coroners’ reports to CURES data – if opioids were identified as the cause of death, the prescribing physician on record is at risk of being investigated or sanctioned. The project was launched due to political pressure to stem the tide on opioid deaths and a desire to identify and punish “over-prescribing” doctors. However, there are multiple challenges with implementation – coroner toxicology screening methodologies differ along with their definitions of opioid overdose, and there will undoubtedly be a lack of full information available regarding the deceased patient and whether they were properly following prescription guidelines or accessing medications from multiple sources – legal and/or illegal. In some cases, there may have been significant time between when the prescribing physician saw the patient last, and when the patient suffered an overdose.
Given the desire to find someone at fault, physicians are at risk of being blamed for patient deaths in situations beyond their control. The negative outcome will be that a high-risk patient population become more stigmatized, with physicians unwilling to treat them for fear of being subject to investigation or sanction. The project could also escalate a “witch hunt” mentality, with associated hysteria, spreading misinformation about opioids, and an inaccurate portrayal of “overprescribing physicians”. The CSA Pain Committee will be coordinating with CMA in reaching out to Medical Board staff regarding the problems with this project and seeking ways to shape the enforcement process.
The CSA Committee on Pain Medicine, in conjunction with the CSA Legislative Affairs Committee, is also keeping an eye on legislation that has been recently adopted or is currently moving through the CA State Capitol. One of the many bills last year, AB 1753 (Low) was adopted, which created stringent requirements for prescription pads used to issue controlled substances such as opioids. There have been technical challenges with compliance given that the law requires certain types of serialized pads that are not yet widely available to physicians.
Although the bill is technically in effect, the Governor’s Office, Medical Board and California Board of Pharmacy have acknowledged the need for discretionary leniency, while at the same time there is currently a new bill moving through the Legislature to delay implementation. This new bill, AB 149 (Cooper), delays implementation until 2021 or before if/when the California Department of Justice determines there is enough access to the new serialized prescription pads – it is sponsored by CMA and strongly supported by CSA. Our letter to the Legislature stated, in part:
“AB 149 (Cooper) is urgently needed in order to ensure patients continue to receive lawful controlled substance prescriptions and to assist us in providing the most efficacious and medically necessary pain medicine treatment.”
On March 11, Governor Newsome signed AB 149 into law and because of the urgency clause, it will take effect immediately.
The CSA Committee on Pain Medicine is also trying to sort through the medical and legal implications of AB 2760 (Wood), which passed last year, and now requires that healthcare providers offer a Naloxone prescription along with an opioid prescription when certain patient criteria are met. Physicians should specifically document in the patient record that they have made a good faith effort to educate the patient about the safe use of opioids and associated risks, and made available a Naloxone prescription if necessary. CSA committee members have found the requirement somewhat disconnected from the reality of patient interactions and worry that co-prescribing Naloxone could send mixed signals to patients.
There is frustration that this bill forces a one-size-fits-all approach to deal with opioid prescription discussions with patients, regardless of their unique needs, whether they are suffering from chronic pain or acute pain. Naloxone serves an important role in harm reduction and can help save lives – but physicians must continue to use their training and expertise to prescribe opioids and/or Naloxone based on their individual assessment of the individual patient need. With AB 2760 (Wood) now in place, it is important however to document in the record your efforts to educate patients about opioid risks and offer Naloxone if needed. While this can be done with smart text or other shortcuts in the electronic medical record, it doesn’t negate the need for high-quality discussion with individual patients.
Given all the attention on opioids, the CSA Committee on Pain Medicine is exploring an effort to create a CSA-branded patient education video. The goal is to create an informational video for patients after surgery, with access to the video through their hospital TV system or on an iPad or mobile device. The video will provide an overview of expectations for managing post-surgical pain, pain management options, the appropriate role of opioids including risks, signs to be aware of, and tips on how to take to take them safely, considerations for caregivers, and how to properly dispose of unused medications. Once the video is completed it will be pushed out through CSA channels and we will ask CSA members to help secure opportunities to distribute/display the video to patients at their hospitals and surgery centers.