Do incentives nudge physicians to prescribe opioids for pain?

Humans have used opioids to treat pain, both physical and mental, to over 3,000 years . ancient Egyptian documents as the Ebers Papyrus recommend the use of a poppy seed extract to soothe crying children. In the “Odyssey” of Homer describes a drug “to soothe all pain and anger and bring forgetting all pain.”

Both the analgesic and addictive properties of these drugs have been recognized, and the tension between relief and dependence is now in the heart of opioid epidemic in our country . Opioids are effective in relieving pain, but the number of deaths from opioid overdose quadrupled since 1999 , and a new report from the Centers for Disease Control and Disease Prevention shows that an estimated 24,000 babies a year born opioid-dependent .

There is plenty of blame to go around, but a central concern is whether doctors prescribe opioids -. And if you could inadvertently providing incentives to do so

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The Centers for Medicare and Medicaid currently makes incentive payments to hospitals based in part on how well they do in patient satisfaction surveys. These surveys asked patients how they feel their pain was controlled and if suppliers did everything possible to relieve pain.

Critics have argued these incentive payments are worsening the problem – “he told hospital staff everything he could to ease his pain” questions like, set unrealistic expectations and encourage more aggressive opioid prescribing by doctors to avoid economic sanctions.

Last month, CMS announced a proposal divorce incentive payments of responses to surveys pain, while at the same time arguing that these payments are a “connection very limited “to study the answers. The proposal comes from the hand of Promotion Act Responsible Prescription Opiate a bipartisan bill introduced in February, which, if approved, would have a similar effect.

Our work as physicians and as researchers in health policy suggests that the measure could help – a little. But to really curb opioid epidemic in the nation, while ensuring that the pain of patients adequately controlled, you also need a clearer picture of how to frame and when to prescribe opioids, definitive way to accurately measure doctors prescribe them and the responsibility of these measures.

On the surface, payments linked to pain scores are relatively small. Pain management less than 5 percent of Medicare incentive payments. (About 30 percent of the total score for the performance of a hospital is determined by scores of patient satisfaction, only an eighth of which is based on pain management.) However, quantification of the amount assigned to specific survey questions money can ignore the enormous influence that these results may have on the psyche of prescribers. Some surveys have found that between means and three quarters doctors feel greater pressure to prescribe opioids because of issues related to pain in patient surveys.

very difficult tests for surveys of patient pain actually lead to more opioid medications – or withholding of opioids results in satisfaction scores of patients under – is limited and mixed. But a recent study by one of us (A. J.) offers some new ideas and a possible way forward.

in this study, more than half a million Medicare beneficiaries hospitalized were evaluated, none of which recently had been prescribed opioids. Nearly 15 percent of them left the hospital with a new prescription opiates. More than 40 percent of the prescriptions were still being filled 90 days later, suggesting that hospitalization may be an important risk factor for opioid dependence. Interestingly, even taking into account the patient’s diagnoses and severity of the disease, the rate of prescription opioid varies dramatically between hospitals -. Some were twice as likely than others to send patients home with a prescription for these potentially addictive analgesics

Hospitals with better scores pain control in surveys of patient satisfaction were more likely to have prescribed opioids, but the strength of the association was small. That tells us that break the link between pain scores and incentive payments may be worthwhile, but it is unlikely to cause a major impact on prescribing opioids.

The patient satisfaction scores did not create the epidemic of opioid, or are eliminated to solve it. However, the elimination of payments for pain control can be an important step because even the perception that financial incentives are linked to pain scores may contribute to prescribing opioids.

Creating a gold standard

The central problem of this research highlights is that we lack a gold standard for the definition of “proper use” of opioids. Without one, there is no way to systematically measure the underuse of opioids and overuse.

In health care, the variation in the frequency of use of a treatment – as some hospitals prescribe opioids twice more than others – often signals overuse by some suppliers and underutilization others. But identifying that is what can be challenging.

If we want to ensure that people who need to get opioids while reducing the risk of dependence on others, we need tools that measure the underuse of opioids and validated overuse. This would allow the prescription of opioids to be used as a measure of hospital quality – like the door-to-balloon angioplasty and placement of cardiac stents time is for people who have heart attacks – and CMS to offer incentives smart prescription opioid instead of more prescribing opioids.

a deeper understanding of prescribing appropriate opioids would also pave the way for the creation of public reports validated patterns of opioid prescribing by hospitals and systems health, together with the respective ranges. These reports are available in www.hospitalcompare.hhs.gov and other sites for things like hospital-acquired infections and readmission of 30 days or after being treated for a heart attack death.

CMS support the proposal to unlink the incentive payments from patient surveys pain control. But still a deeper problem. How to measure appropriate versus inappropriate prescribing of opioids

Opioids are necessary in some situations, dangerous in many, both necessary and dangerous in others. You can only clearly identify where in the spectrum of each patient falls can we effectively and safely treat pain during hospital stay and prevent tragedies related to addiction later.

Dhruv Khullar, MD, is a resident at Massachusetts General Hospital and Harvard Medical School doctor. Anupam Jena, MD, is an economist, physician and associate professor of health policy at Harvard Medical School.

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