Heroin

[45dotACP]

Didn't the AMA just publish a study that showed similar efficacy between narcotic pain meds and conventional OTC stuff for breaks, sprains etc?

Sent from my XT1585 using Tapatalk

[YVK]

Late 90s and early 2000s saw a number of publications and statements, from here and Europe, stating safety of chronic opioid use. Both accuracy and implementation of these findings are a subject of intense criticism these days.

Breaks and sprains are considered an acute pathology, not chronic pain conditions that are associated with opiate abuse. I am not aware of acute diseases being a risk factor for that.

[Sensei]

I don't necessarily disagree with pain specialists or pain clinics - but I think you are misinterpreting family practitioners motive behind managing chronic pain. I don't disagree that the patients are mismanaged - and that goes into the whole need for better guidelines. But a family doc gets paid like $25 per visit - they're not getting kickbacks from Pharma - and these patients are often the bane of their existence. No physician sees a chronic pain patient on their clinic schedule and thinks "Cha-ching!" So yes, these patients are mismanaged because it is way easier in 15 minutes to give them refills and get them out the door than spend 60 minutes to go over a withdrawal strategy or alternative solutions. But to say that family docs are mismanaging out of greed is frankly sensational and wrong. They have 40 patients a day, 15 minutes per patient, and get reimbursed poorly by Medicare. Just because the office sends you a bill for $150, doesn't mean that's what that doc is pocketing. You're clearly in healthcare, so you know what I'm saying.

Even if they bill a 99214, which I doubt - that is equal to 1 wRVU, which on average is maybe $45. So the physician gets credit for $45 in his production box. Do you think that motivates him/her to push opiods? It wouldn't motivate me. It's more likely that it's just the easier thing to do - just like pediatricians giving the high maintenance parent antibiotics, rather than taking the extra 10 minutes to assure her that it's a viral URI and will resolve.

Your are correct - I'm a physician. Been doing it for about 15 years with a mixture of private practice, military, other federal, and now academics. Here is what I've seen happen since I finished residency. The use of incentive based compensation that over relies on patient satisfaction has been one powerful financial motivator for physicians to over utilize diagnostic testing, antibiotics, and controlled substances. This largely mirrors the ascendancy of large contract management groups and an over emphasis on surrogate markers of quality such as CMS core measures and patient sat.

For example, I left a lucrative practice after 7 years when our group was acquired by a large contract management group that utilized a compensation model where quarterly bonuses were predicated on 90th percentile patient satisfaction scores. While I believe that patient sat is important and I understand that no study has correlated going home with controlled substance prescriptions with good scores (that study will never be done), most of my partners adopted predictable maladaptive practice patterns when it came to resource utilization. Because one or two bad surveys in a quarter meant no bonus, my partners massively increased their controlled substance prescribing in an irrational fear of not meeting every patient's expectations. I vividly recall after having a quarter where my scores slipped and I sacrificed $10K in bonus, my own prescribing of antibiotics and controlled substances went up. That is when I realized that financial pressures were being used to drive me outside of my comfort zone and it was time to move on. I actually left medicine for 3 years to pursue other employment options because I was seeing this phenomenon across my speciality.


So, the majority of the problem is not just primary doctors churning out Level 3 visits as a some sort of quasi pill mill, although those physicians do exist and are significant. It is also not just doctors taking the "easy way out" and writing a script instead of taking the time to explain an alternative treatment plan (BTW, that is unethical as hell too). No, the lion share of prescription opiates are out there because physicians are responding to a multitude of financial pressures such as core measures, patient sat, etc. that increases their controlled substances prescribing.

So, if you want to see this drop really fast, just have CMS create a Core Measure that financially penalizes whoever they deem as over-prescribers. We both know the fastest way to change physician behavior is not through rigorous studies, but CMS core measures that affect our reimbursement.

[Sensei]

Didn't the AMA just publish a study that showed similar efficacy between narcotic pain meds and conventional OTC stuff for breaks, sprains etc?

Sent from my XT1585 using Tapatalk

It was the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) Trial. It studied opiates and non-opiates for chronic pain and found no difference functional outcome at 12-months and marginally more pain in the opiate group. Predictably, the opiate group had more drug related adverse reactions.

[Sensei]

So what else happened in 2000 where the data shows an uptick. Did it take 10 years for the opiates to take hold or just trickle down to PCP’s handing them out like candy so to speak?

I’m mixed on the whole legalization thing as I’m pretty sure that the actual impact it would have in the numbers of users and abusers would be minimal in the long term. Addiction is a symptom and not generally a root cause. At least in my experiences in dealing with addicts. What we are doing isn’t working. It’s costing trillions of tax dollars and eroding many of our freedoms and rights. Not sure if that’s a fair trade. Not sure what the solution is, but at some point I think we will need to let Darwin do it’s thing to these repeat idiots.

A bunch of stuff was happening around that time. A lot more types of prescription opiates hit the market (if you make it they will take it), the ascendancy of patient satisfaction as part of incentive based compensation for physicians, etc.

[DocGKR]

"The use of incentive based compensation that over relies on patient satisfaction has been one powerful financial motivator for physicians to over utilize diagnostic testing, antibiotics, and controlled substances......No, the lion share of prescription opiates are out there because physicians are responding to a multitude of financial pressures such as core measures, patient sat, etc. that increases their controlled substances prescribing."

This is a huge issue which should not be underestimated.

Chronic pain patients are difficult to manage and often need a team approach with multiple specialties to successfully treat.

Acute pain (post-surgery or post-trauma) patients are much easier to care for.

[Qaz98]

Don't disagree with any of that. Your original statement was that physicians were lining their pockets by promoting opioid usage. That suggests a financial motivation. Everyone knows that Press Ganey is a joke. But giving opioid to avoid bad patient scores, (which would lead to loss of a bonus), is way different than "lining" one's pockets.

Sent from my SM-G935V using Tapatalk

[45dotACP]

It was the Strategies for Prescribing Analgesics Comparative Effectiveness (SPACE) Trial. It studied opiates and non-opiates for chronic pain and found no difference functional outcome at 12-months and marginally more pain in the opiate group. Predictably, the opiate group had more drug related adverse reactions.

That's the one. Must've been confused because my hospital has absolutely zero IV morphine and somehow we're managing well...patients are still saying we've been managing their pain effectively, even in ICU/post-op patients.

Sent from my XT1585 using Tapatalk

[YVK]

So, if you want to see this drop really fast, just have CMS create a Core Measure that financially penalizes whoever they deem as over-prescribers. We both know the fastest way to change physician behavior is not through rigorous studies, but CMS core measures that affect our reimbursement.

That leaves no alternative for the primary docs, they will either be penalized for over-Rx or penalized for low satisfaction scores. The outcome will be primary docs dropping their DEA licenses and referring out to pain specialists who will be much harder to bracket into over-prescribers.

[willie]

See this link. You may find out what your doc is doing. projects.propublica.org/docdollars