Addiction is a powerful, complicated disease. Genetic, environmental, and psychosocial characteristics all factor into a person’s risk for dependency. When it comes to opioid addiction, who your doctor is also influences whether or not you will become addicted to these powerful pain medications.
That’s because some doctors write opioid prescriptions more often, and for longer, than other doctors. But research shows that the likelihood of chronic opioid use increases with each additional day of medication supplied; and taking opioids for just five days — days, mind you, not weeks or months — can lead to long-term use. So when a doctor writes an initial prescription for nine days instead of three, that doctor is increasing his or her patient’s risk of opioid addiction.
Of course, there are many people who need opioids for pain management and for whom opioids are a legitimate treatment option. But easy availability and a lack of appreciation for the true risk of addiction have contributed to the opioid epidemic. We need to curb overprescribing to loosen opioids’ grip on America. But when it comes to opioids, many physicians don’t have a good sense of what constitutes appropriate use. Helping physicians navigate this minefield is an important next step in controlling the nation’s opioid epidemic.
The medical community is beginning to see guidance on responsible prescribing. The Centers for Disease Control and Prevention released guidelines for primary care clinicians who prescribe opioids for chronic pain. The American Society of Interventional Pain Physicians has issued guidelines for responsible opioid prescribing for treating chronic non-cancer pain. Many hospitals have also adopted their own guidelines.
But the available guidance is typically high level and designed to avoid blatant misuse. What is missing is contextual relevance. As a physician, how do I know if I’m overprescribing for my specific patient population? What if some of the surgical procedures I perform are more involved than others, and those patients legitimately need that extra day of pills?
To shed light on what constitutes the appropriate use of opioids for a given procedure or a specific patient population, I am working with Dr. Marty Makary, a surgeon at Johns Hopkins and a national leader in patient safety, on a new initiative to give physicians visibility into standard prescribing practices. Through a detailed analysis of claims data from more than 100 insurance companies, collected over a five-year span, we were able to assess opioid prescribing patterns for specific procedures and specific types of patients. From there we were able to develop “appropriateness measures,” as we call them, which show the range of prescribing patterns and identify the average number of pills prescribed for this procedure or that type of patient.
These measures are grounded in detailed conversations with specialists from across the country — interviews conducted to develop a sense of what range of prescribing behavior could be considered extremely inconsistent with the practice of peer physicians, and thus potentially harmful to patients. The appropriateness measures also incorporate a thorough review of the clinical literature. They are intended to serve as actionable guideposts for physicians, helping them understand how their own prescribing patterns in a given situation compare to the standard practice of their peers, locally and nationally.
When we compare physicians’ practices, even within a single hospital system, we see wide — sometimes shocking — variation. For example, our analysis shows that the national average length of an opioid prescription after a routine caesarean section is less than five days. Yet individual physicians prescribe them for zero to 10 days.
The doctor who prescribes significantly more opioids than his or her peers is not lazy or a bad doctor; more likely, he or she simply does not have a clear understanding of what is suitable. But now, with appropriateness measures, we can empower individual physicians and health care organizations with the data they need to identify outliers and to curb the high rates of unnecessary opioid prescriptions.
My company, Oliver Wyman, is using this information to develop a tool designed for sale to large medical groups, health systems, and insurers that will evaluate the appropriateness of physicians’ opioid prescribing patterns.
Arming physicians with appropriateness measures can help them determine whether their prescribing behavior for opioids is consistent with peer-developed guidelines. The measures can also help administrators identify physicians whose prescribing patterns routinely fall outside the best-practice range. They could then connect those physicians with pain specialists and other experts to develop individual prescribing standards based on the latest best practices.
Appropriateness measures do not seek to second guess a physician’s clinical judgment on individual cases. But when a provider’s clinical judgment, manifested by his or her treatment patterns, consistently deviates from standard practice, it becomes an issue of patient safety as well as one of quality and cost. In the case of opioid prescribing, it puts people’s lives and livelihoods at risk.
Our initiative is focused on bringing transparency to opioid prescribing behavior in a way that does not threaten the doctor-patient relationship. Instead, we are giving physicians the data they crave to understand their own and their peers’ practice patterns. This approach of holding a mirror into physicians’ own practicing patterns has been shown to spark meaningful behavior change without bringing a physician’s clinical judgment into question.
This effort to develop appropriateness measures is an entirely doctor-developed, home-grown solution, one that uses the wisdom of clinicians to put actionable and relevant data into the hands of physicians. Doctors may have contributed — however unknowingly — to the current opioid crisis. And doctors can help bring us back from it.
Bruce Hamory, M.D., is a partner and chief medical officer in the health and life sciences practice of Oliver Wyman, an international management consulting firm. The appropriateness tool described in the article will be sold as a product by Oliver Wyman.