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What Should Doctors Do When They Know Patients Are Seeking Pain Meds?

pain medicineSteve Diaz, an emergency medicine doctor at Augusta’s MaineGeneral Health, says he knows what patients want when they come to him in pain. Drugs. And preferably strong ones.

“The only thing they think of is, ‘Do I get a pill?’” he said.

And with abuse of prescription painkillers like OxyContin, methadone and Percocet soaring, the instinct, public health experts say, should be to say no. Or at least, not necessarily. The Centers for Disease Control and Prevention put out a new guideline this spring, advising doctors to prescribe the highly addictive drugs, known as opioids, in smaller doses and only when truly needed.

But another federal policy — a provision of the 2010 federal health law linking hospital payments to patient satisfaction surveys — may be complicating efforts to curb opioid prescribing as part of the nation’s effort to address the painkiller abuse epidemic.

As part of these surveys, amidst questions about night-time noise levels and hospital staff proficiency, patients can evaluate how doctors managed their pain, and if clinicians did all they could to treat it. That’s setting up a system, doctors say, where physicians’ ratings can get caught between patient demands and sound medical judgment.

It’s something Diaz says he sees play out in his own hospital, where he’s also a senior vice president and chief medical officer.

“The patient says, ‘I’m in pain, and you’re not meeting my needs.’ And [doctors] might say, ‘I’m being graded on this. I’ll give this patient something, to get them over the hump,’” he said. “No one will overtly say, ‘I’m doing this to not get a bad score. But in the back of their mind … and knowing they’ll be publicly rated, I think it leads to making that subconscious decision.”

Now, as advocates seek an all-hands-on-deck response to the nation’s opioid crisis, many physicians are calling on federal authorities to change these satisfaction surveys.

Doctors “feel like they’re getting mixed signals,” said Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association. On one hand, “they’re getting this signal [from the CDC] to not prescribe opioids. And on the other, they’re getting this signal to manage patient pain so it’s zero.”

And that second signal can create expectations that ultimately feed into the problem. When patients get painkillers in the emergency department or hospital, they often expect that treatment to continue. The drugs are highly addictive. Researchers believe unnecessary prescribing may be a key factor in fueling abuse.

In 2014, the most recent year for which data is available, about 2 million Americans abused prescription painkillers, according to the Centers for Disease Control and Prevention. More than 14,000 died from overdosing on them.

With that concern, more stakeholders are pushing for action. This spring, organizations such as the American Hospital Association and the advocacy group Physicians for Responsible Opioid Prescribing called on the Centers for Medicare & Medicaid Services, the responsible federal agency, to eliminate the questions, rephrase them or disconnect them from hospital payments. But the evidence on how meaningful that change might be remains scant.

CMS is now testing different phrasing, said Jonathan Gold, a spokesman at the Department of Health and Human Services. Changes in the questions would look at how clinicians discuss pain with patients, rather than how they treat it.

That builds on a statement agency officials published in a May JAMA opinion piece. Officials said they were “exploring how best to measure” experiences including how patients’ pain is treated.

Meanwhile, on a separate track, a group of Senators has introduced legislation to eliminate the pain questions from the official hospital survey.

Without a fix, doctors face pressure on two fronts, said Joan Papp, an emergency physician in Cleveland, who has advocated removing pain management as a factor in assessing patient experience. She compared the concern about painkiller prescribing to antibiotics — a third of antibiotics given aren’t necessary, she said, and can in fact cause negative public health consequences. But doctors give them because they think patients expect more than just advice like bed rest, hot tea and time.

With painkillers, that same pressure to do something is compounded by financial stakes, she said.

“Not only are we seeing patients, but the federal government, pushing to prescribe, sometimes inappropriately,” she said.

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