As associate medical director at Drexel University College of Medicine in Philadelphia, PA, Jason Fodeman, MD, spearheaded the development of an opioid prescribing program for the internal medicine resident clinic. When he started his position, he discovered a lack of protocols and policies regarding the treatment of chronic pain and prescription of opioid medications. As a result, physicians' prescribing methods were more likely to fall short of meeting the CDC Guideline for Prescribing Opioids for Chronic Pain, while simultaneously sending mixed messages to patients about safe and effective chronic pain treatment.
After discussions with the medical director at Drexel, several policies for treatment of patients with chronic pain were developed, based on the CDC opioid guidelines. For example, patients on controlled substances could no longer pick up prescriptions for opioids at the front desk. Instead, patients needed to visit a physician every four weeks to discuss the management of their chronic pain and opioid usage. These visits provided additional opportunities to educate patients about the risks of opioids, to counsel them about behaviors to decrease their risk for abuse or addiction, and to discuss alternative treatments, such as physical therapy, pain management consultation, surgical consultation, psychiatry for cognitive-behavioral therapy and nonopioid-based medicines. Risk mitigation strategies were also implemented, including Urine Drug Screens (UDS) and the Prescription Drug Monitoring Program (PDMP). Importantly, prescribers were advised to have a high threshold to start new patients on opioids.
When these policies were implemented in the summer of 2016, they were presented to faculty and residents in formal presentations and via email correspondence, as well as through informal conversations with residents and faculty. Before implementation, Dr. Fodeman made efforts to listen to faculty and their thoughts on this issue. While there was broad consensus about the need to change the status quo, the main point of frustration regarding the new policies was that it was nearly impossible to do risk mitigation, patient education and counseling in a 20-minute patient visit. As a result, the visit length was increased from 20 to 40 minutes. By taking the time to gather feedback, residents and faculty were supportive of the policy changes at the time of implementation.
The new policies were also discussed with the clinic manager to make sure she understood the changes, the rationale for them, and the possible unintended consequences (e.g., decreased patient satisfaction). These conversations and the support of the administration were integral to the success of the changes once implemented.
Training was provided to faculty members and residents on how to deal with specific situations involving changes in a patient's risk profile (e.g., an unexpected UDS result or doctor shopping on the PDMP). This training helped increase their comfort and confidence in dealing with these challenging discussions. Although the impetus for the policy changes was to improve safety and minimize risk for patients, the process also provided an opportunity to improve the understanding and experience of residents regarding the treatment of chronic pain.
Given the demand for opioid medicines, there were some patient concerns about tighter monitoring. The physicians took time to address these concerns directly and explain the importance of this issue, the nature of the problem, the CDC opioid guidelines, and the efforts of federal and state governments on this front. Physicians wanted to make sure that patients understood the reason behind the changes and the risks of the medicines, and that the changes in policy were not personal. It was also important to ensure the clinic presented a unified voice on this front.
One year after implementing the chronic pain management initiative at the Drexel University internal medicine resident clinic, the effort has been largely successful. The clinic delivers more consistent messaging about risks of opioids and there is more widespread implementation of counseling, risk mitigation strategies, alternative therapies, and tapering.
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