Curbing abuse and overdoses through opioid stewardship

https://www.addictionnow.com/2017/01/30/curbing-abuse-overdoses-opioid-stewardship/

http://the-stewardship.org/metaphors.htm

“The steward, or “keeper of the hall”, was the official in a medieval household responsible for its management. Under the feudal system, it was the lord who had all of the legal authority. The steward had only a delegation of that authority, and a mandate to administer the estate. His stewardship of the estate was all-inclusive, from the broadest policies to the most trivial details. For the estate to function properly, the steward needed to hold himself accountable for all that took place in the household. He might delegate; but he would maintain an interest in all happenings, make it his business to know all of the operational details, and know when to intervene and when to concentrate on other matters.”

Last December, the Centers for Disease Control and Prevention (CDC) updated its website with information about antibiotic stewardship — a practice that describes a coordinated effort to reduce unnecessary prescriptions for antibiotics. The overarching goal, the CDC stated, was to provide the best standard of care and minimize the spread of antibiotic-resistant bacteria.

According to the CDC, at least 30 percent of antibiotics prescribed in an outpatient setting are unnecessary, and the amount of inappropriate antibiotic use may be close to 50 percent in outpatient settings.

Would establishing a standard for opioid stewardship reduce the rates of overprescription and, in turn, the rising rates of opioid overdoses?

Last year, the CDC urged primary care physicians to turn to physical therapy, over-the-counter medication and exercise before writing a prescription for opioids for pain management.

Dr. Tom Frieden, former CDC director, said in an interview that the risks for addiction and death related to opioid painkillers are “very well documented.”

With opioid prescriptions in the U.S. reaching all-time highs, the concept of opioid stewardship is beginning to gain traction among key stakeholders.

The problem of opioid overprescription is not unique to the United States.

Canada has become the world’s second largest opioid consumer in recent years. The Institute for Safe Medication Practices Canada (ISMP) created an Opioid Stewardship Program to help key stakeholders become more aware of the risks of overprescribing opioids.

In November, the ISMP released a safety bulletin for community practitioners titled Safer Decisions Save Lives, which recommended best practices for opioid prescriptions. Among their suggestions were not prescribing potent opioids for minor pain, reserving chronic opioid therapy for patients who have chronic pain that impedes daily functions and have not responded to non-opioid treatments, treating an opioid regimen as a therapeutic trial, educating patients about the risks and potential of overdose, and recognizing opioid use disorder before writing a prescription.

Establishing a standard for opioid stewardship requires a collaborative effort from gatekeepers.

“We have to come together as health care professionals and governments to collaboratively work on the issue,” said Phil Emberley, director of professional affairs for the Canadian Pharmacists Association. “The first is we have to improve our drug information systems that pharmacists have access to, and we also have to give pharmacists the ability to adapt prescriptions in order to better manage their patients’ pain.”

Education is also an important component of creating a standard for opioid stewardship. Pennsylvania’s Physician General Dr. Rachel Levine said that there are efforts underway in her state to…

work with medical schools in establishing a set of core competencies related to opioid prescriptions and create continuing education programs for physicians and other health care professionals. The state has also written specialty- and location-specific prescribing guidelines, which have been submitted to respective medical boards for review, acceptance and affirmation.

Technology can also play a role in opioid stewardship. Prescription Drug Monitoring Programs (PDMP) allow medication dispensers such as pharmacists to input information about a patient into a statewide database, which physicians can be required to access before writing a prescription. The benefit of a PDMP is the access to information about a patient’s history with a controlled substance that a physician may not have previously had. The information available through a PDMP would give a physician a more complete profile of a patient, which can be taken into consideration before writing a prescription.

According to the CDC, PDMPs are among the most “promising state-level interventions” to improve overprescription rates of opioids.

“Opioids are essential medications in our medical toolbox, but we have to use them more carefully and more judiciously,” Levine said. “And we need to make sure that we moderate the prescriptions, the length of the prescriptions and the doses.”

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