Md. Medical society asks hospitals to review opioid doses

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The Maryland State Medical Society is taking action amidst the nation’s opioid crisis and urging hospitals and physicians in the state to decrease the automated controlled-substance standing orders and to prescribe a minimum amount of opioids necessary.

This epidemic is gathering attention in Maryland — Gov. Larry Hogan declared a state of emergency March 1 and committed an additional $50 million over five years to help with prevention.

The number of deaths due to prescription opioids decreased slightly — from 218 to 211— in the first half of this year over the same time period last year, Jan 1. To June 30, according to state health department data released Tuesday.

But the increase in all opioid-related deaths recent years has been sharp: From 2014 to 2017, the number of opioid-related deaths reported in Maryland between Jan. 1 and March 31 more than doubled — taking the death toll up to 473 from 226 three years earlier, according to state health department data.

In response to this crisis, the society, known as MedChi, created an Opioid Task Force to “educate Maryland physicians on safe opioid prescribing practices, how to recognize risk factors, and when to recommend alternative, scientifically-based evidence-based non-opioid treatments,” according to a release earlier this month.

Over the last decade and a half, the amount of opioids prescribed in the United States has risen sharply.

The amount of opioids prescribed per person more than tripled from 1999 to 2015, when the volume of prescriptions reached enough for every American to be medicated for three weeks straight, according to the Centers for Disease Control and Prevention.

The problem may have began in the 1990s when physicians received messages saying they were undertreating pain, said MedChi President Dr. Gary Pushkin.

The “inadequate treatment of pain” was the subject of many policy efforts in the 1990s and among these were the “increased use of opioids for acute pain and the use of long-term opioid therapy for patients with chronic pain,” according to a 2016 paper in the
American Journal of Law and Medicine.

“Doctors do have a role in the whole opioid problem, but I don’t think we are the bad guys that we are painted out to be … a majority of doctors want to do the right thing,” added Pushkin.

Now with the ongoing epidemic and continual increase in opioid prescriptions, MedChi is seeking out these smaller changes with the hopes of a larger impact.

The group is asking that physicians and hospitals review the automated controlled substance “standing orders” that are in the electronic health record systems.

These systems may be creating these standing orders automatically as the recommended dosages — even when lower dosages would be sufficient, Pushkin said.

With this initiative, MedChi is asking that if opioids are being prescribed, hospitals and physicians do not solely rely on auto-populated dosages, and instead they decide which dosage, preferably one that is more minimal, is actually necessary for the pain being treated, explained MedChi CEO Gene Ransom.

Letters have been sent to Maryland hospitals and physicians, according to Pushkin, suggesting that either, “(1) the physicians’ standing orders be reduced to the minimum dosage and quantities necessary or (2) that practices remove any automated dosage and quantity in the …ordering system.”

Ransom said MedChi has received positive responses from hospitals and physicians, and some have begun looking into enacting these changes. Many of them were appreciative that more is being done to try and solve this opioid problem, he added.

“We are very much in line with MedChi’s efforts to reduce standing orders and we know that our efforts can’t just stop there. There are many more measures we have to take on a wider basis for this issue,” Nicole Stallings, Maryland Hospital Association vice president of policy and data analytics told Capital News Service.

The association has been trying to tackle the epidemic for years — in 2015 the group created a set of opioid prescribing guidelines, which included altering standard orders, and 100 percent of Maryland hospital emergency departments signed on to using these guidelines, Stallings added.

Prescribing opioids for too many days and at too high a dose can create a problem, according to the CDC.

Even at low doses, taking an opioid for more than three months can increase the risk of addiction by 15 times, the CDC reported.

A solution may be prescribing for fewer days; for acute pain, prescriptions for three days or fewer is often enough, and more than seven days is rarely needed, according to the CDC.

“This small adjustment could help prevent patients from receiving a higher dosage or quantity than necessary, and may prevent diversion (giving drugs to other people) or other problems,” said Pushkin.

Additionally, many of these opioid prescriptions go unused and are improperly stored in the home, according to a 2017 Johns Hopkins Medicine study.

Dr. Mark Bick, associate professor of anesthesiology and critical care at Hopkins, spearheaded the study and found that 67 to 92 percent of a total of 810 patients did not use their entire opioid prescription, but still held onto them, increasing the risk of misuse.

“Our task force continues to work on solutions to this problem and we are going to keep working on it and are open to more ideas to how this can work better. It’s a common sense solution….If we can reduce just a small number (of deaths) it’s worth it,” said Ransom.

By Georgia Slater
Capital News Service

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