Providers wrestle with pain management in face of opioid crisis

Public health officials want physicians and hospitals to rethink the way they manage pain as Americans become increasingly anxious about the rise of overdose deaths tied to opioid drugs.

Many of those deaths are tied to heroin use, but the Centers for Disease Control and Prevention reports more than 165,000 people died from overdoses involving prescription opioid painkillers between 1999 and 2014.

But healthcare providers say they’re put in a tough position by patients who’ve come to expect access to the powerful drugs to make them comfortable. Last week, the Obama administration responded to calls to eliminate what many have argued provides a financial incentive for hospitals to prescribe opioids: the role of pain management in Medicare’s Value-Based Purchasing Program.

The Joint Commission’s 2001 pain-management standards are credited for advancing the notion of treating pain as a “fifth vital sign,” and a series of questions about pain management were included in the subsequent Hospital Consumer Assessment of Healthcare Providers and Systems, or HCAHPS, surveys developed by the Agency for Healthcare Research and Quality and endorsed by the National Quality Forum. Now those surveys drive 25% of a hospital’s score under Medicare’s Value-Based Purchas- ing Program, which rewards or penalizes hospitals based on quality and efficiency metrics.

“Aggressive management of pain should not be equated with quality healthcare,” a coalition of public health officials and physicians wrote in a petition to acting CMS Administrator Andy Slavitt.

While Medicare officials agreed to remove the pain-management domain from the value-based purchasing score, they clearly remain dubious that the program is a factor in overprescribing, noting in a news release that “there is no empirical evidence of this effect.”

Some hospitals, the CMS says in the draft regulation proposing the change, have been disaggregating their HCAHPS scores to assess and motivate individual clinicians and specific departments. “The HCAHPS survey was never intended to be used in these ways,” the agency notes. The CMS also points out that patients diagnosed with substance abuse disorders are excluded from the scoring and that the survey “does not specify any particular type of pain control method.”

The agency is now field-testing new questions about pain management, performing statistical analysis and collecting input from stakeholders. It’s also working on new measures of concurrent prescribing of opioids and benzodiazepine in hospitals and outpatient settings and assessing how psychiatric facilities monitor adverse drug events of opioid and psychotropic drugs.