Monday, March 4, 2013

Opioid related deaths


Deaths related to the abuse of prescribed opioid analgesics are undoubtedly a momentous concern in North America.  A recent article published in JAMA (JAMA. 2013;309(7):657-659) highlights the scope of the problem: seventy-five percent of deaths related to pharmaceutical overdoses are attributed to opioid analgesics.  While troubling, this figure has, in fact, been steadily rising over the past 11 years with no end in sight. 

Complicating the matter is a new focus in health care in the USA; customer service.  Treating patients with customer service in mind is not a bad idea, per say. Centers for Medicare and Medicaid Services will be withholding 1% and going up to 2% of Medicare reimbursement to hospitals with the potential to “earn” the money back in a program called Value-Based Purchasing.  There are several areas each hospital will be evaluated upon, one of which being patient satisfaction assessed through a Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. In one of the key questions, patients are asked to rate their satisfaction with how their pain was treated while in the hospital.  Importantly, this will help guide our treatment strategies to make sure pain is addressed. 

A blind focus on improving HCAPS scores could further the problem of opioid dependence and abuse.  Few analgesics are capable of relieving pain as rapidly as opioids. Considering HCAPS, “here is your Dilaudid” sounds more “satisfying” than “here is your acetaminophen you already took at home but did not relieve your pain, followed by a ultrasound guided regional block with lidocaine and some gabapentin.”  Importantly, patients are going to require outpatient pain relief upon discharge, leading to more opioids.  With that said, there are many other meaningful points to address including educating patients regarding what to expect in terms of pain control.

Yes, we do need to do a better job treating pain in the ED and hospital wide. Yes, we do need to reduce the amount of deaths related to opioids. I fear the big picture is being missed because these discussions are being held in two separate silos.  I also understand this is an extremely complex issue to which I have no answers. Nevertheless, the discussion needs to come together or we’ll be looking at a 12th consecutive year of increased opioid related deaths.

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