Prescription for Success
By MELANIE KILGORE-HILL
Med Law Advisory Partners Training Providers in Smarter Prescribing Practices
Evolving opioid prescription guidelines, coupled with a nationwide overdose epidemic, have created a regulatory firestorm for providers, particularly those in rural areas.
Helping clinicians care for patients while meeting increasingly stringent guidelines has become the mission of Alicia Davis, RN, LNCC, president and CEO of Med Law Advisory Partners. The medical-legal consulting firm assists healthcare providers in identifying opioid prescribing requirements and developing safe prescribing protocols that will help improve care and mitigate risk for the organization.
Davis, who previously founded the medical-legal consulting firm ALN Consulting, recognized the need for such a service while working a large opioid prescription investigation during inception of the Appalachian Regional Prescription Opioid Strikeforce. The government-led taskforce is dedicated to identifying individuals contributing to prescription misuse, responsible for over 67,000 drug-related deaths in the United States in 2018.
"It really opened my eyes around how some patients with chronic pain are being managed," said Davis. "The care long-term pain patients were receiving had them on a hamster wheel. I saw how they were coming in month after month with very little improvement in quality of life and function and little movement in the amount of meds they were being prescribed."
Davis also observed that prescribing regulations were a moving target in each state, with guidelines changing rapidly. "I was seeing a lot of providers in rural communities really not understanding what they needed to do to be in compliance; they were just doing the best they could," she said. "I could see a segmented group of providers who weren't participating in egregious fraudulent scams related to billing and opiates. They were doing what they'd always done with the limited resources they had."
Davis refocused her practice to help healthcare systems and providers at risk for being flagged as over-prescribers adopt a preventative approach through smarter prescribing practices. The proactive approach means she and her team of experienced nurse consultants step in before a provider's license is threatened - a welcome contrast to the reactive cases she's worked for years.
Adopting the old "an ounce of prevention" adage, Davis is creating safeguards by educating prescribers on simple steps to keep them off the radar. And while she fully supports crackdown efforts to deter opioid misuse, she said the industry-wide focus merely on prescription numbers can be disheartening to well-meaning providers, particularly those in rural areas.
"A lot of bad apples are being shut down, but the unfortunate problem we see continues to be access to appropriate healthcare for patients with chronic pain," she said. "Regulatory environment dictates weaning patients off opioids with a pain management system, but a lot of patients don't have access to a pain clinic, or it can take months to get in."
She continued, "We have to consider if we're going to take care of those high-risk patients without access to a specialized level of care, we must manage them using a different algorithm. And we step it up with regard to monitoring and conversations, making sure they have the right prescription and oversight and understand overdose prevention measures." Davis said providers can continue to manage those patients but have to be able to show ongoing assessment of the risk versus benefit of continued therapy and have measures in place to prevent drug diversion.
Davis is concerned for chronic pain patients, as providers are often tempted to forgo narcotic prescribing altogether. "Some are just saying, 'We don't want to mess with it,' but that's problematic for patients, especially in rural areas," she said. "We're seeing providers pull back, but the middle ground is applying risk management principals, taking time to understand their state's regulations and putting safe prescribing guidelines in place."
Working with a provider's EMR and practice workflow, Davis's team creates algorithms for safeguards and triggers to connect moving parts and ensure safe prescribing practices are implemented. "If we're going to manage this on a chronic basis, we have to have checks and balances in place," she stated. "When a patient falls within a window, we know what to do and questions to address with them. We're not just putting patients on a dose of a drug and keeping them on it forever."
Today's hyper focus on COVID-19 is causing providers to push overdose prevention efforts to the back burner, and patient anxiety and isolation are compounding the issue, as well. And while telemedicine has shown promise in expanding treatment options, Davis said opioid overdoses are still on the rise.
"Telemedicine is helpful but doesn't replace one-on-one interaction with patients, especially those with substance use disorder who benefit from face-to-face care and accountability," said Davis. "Our concern is we don't know how long we'll be so focused on COVID, and it's taking attention from the opioid epidemic as providers concentrate on managing the 'new norm' within their patient population. They've had to shift time and resources to the pandemic, so I'm concerned overdose numbers will continue to rise."
Davis urges providers not to take their eyes off the opioid problem, even amid an industry-wide resource shortage. "I encourage them to be diligent in their opioid stewardship efforts, setting aside some of their limited resources to make sure safe prescription practices are in place and their patients on chronic opioid therapy are followed closely," she said. "We have to make sure patients are getting the touch points they need now more than ever and ensure oversight doesn't slip."
She added the task might feel like tackling an elephant, but it's really not. "It can be done quickly with minimal resources but must be prioritized, and that will be an investment in your patients and your practice," Davis concluded.