Prescribers, including both newly trained and experienced waivered providers, will need additional support to ensure they are comfortable with best practices in pain management and medication-assisted treatment (MAT). Health plans can support their provider networks by developing a support system with mentors and experienced pain management specialists to help newly trained waivered providers. Health plans can also disseminate the latest pain management research and techniques via academic detailing and training. In this section we provide suggested topics for mentor meetings and links to supportive programs and resources for providers.
How to Do It
- Develop support system (e.g., mentors and trainings) for waivered providers to encourage prescribing at all points in the health care system (primary care, mental health, hospitals, emergency departments, residential treatment, etc.).
- Create opioid safety curriculum/training program for provider network and provide incentives for participation, with the curriculum including:
- Prescribing guidelines for pain management, including when and how to taper safely to lower doses; involuntary tapers and tapering unstable patients should be avoided as they may cause harm
- Overview of medication-assisted treatment
- Guidelines for co-prescribing naloxone
- Nonpharmacologic (family-centered) neonatal abstinence syndrome treatment
- Conduct academic detailing for outlier prescribers.
- Connect providers to specialists through telehealth.
Health Plan Stories
Blue Shield of California
Kaiser Permanente Southern California
KPSC also invested heavily in reeducation efforts to counter decades-old beliefs that led to liberal prescribing habits. Clinical pharmacists and physicians provided high-volume prescribers with academic detailing — brief in-person educational sessions focused on evidence and the need for changing practice. Get more information about academic detailing.
Clinical champions held educational sessions at medical centers and department meetings, and KPSC required all clinicians at the time to attend an educational program developed by the University of California, San Diego. All new physicians and residents were required to complete a three-hour online continuing medical education session within their first year. KPSC has also continued frequent communications to clinicians to reinforce messages about appropriate opioid use.
Partnership HealthPlan of California
PHC leaders wanted to respond to the public health emergency — as opioid overdose deaths were also highest in their counties — while avoiding unintended consequences of tapering patients too quickly or too aggressively (such as the risk of pushing patients to illicit drug use and potentially even increasing overdose deaths). A 2017 Department of Veterans Affairs study showed rapid tapers led to increased suicidal ideation and increased use of mental health crisis services.
PHC invited Andrea Rubinstein, MD, a local pain medicine expert from Kaiser Permanente, to give presentations at several provider convenings, and heavily promoted her educational lectures — “The Art and (very little) Science of Tapering Opioid Medications” and “Rational and Irrational Use of Opioids” — to its entire provider network.
PHC attributes its success — an 87% drop in members on high-dose opioids — partly to the organization’s efforts to educate its provider network on the value of patient-centered tapers, with careful assessment for each patient to ensure the benefits of tapering exceeded the risks (17% of patients were too medically or psychiatrically unstable to taper). PHC created a Tapering Toolkit (PDF), which covered some of the key lessons in Rubinstein’s approach:
- The goal of tapering is to make life better — for the patient. Not for the doctor, not for the health system, and not with an arbitrary goal. Many patients are on unnecessarily high doses. Dose reduction reduces risk and improves the quality of life while commonly having little effect on their levels of pain, or at times reducing hyperalgesia.
- Look at the whole picture — not just dose level. Understand the impact of the opioid regimen on mental health, medical conditions (such as sleep apnea, bone density), pain, and function. Looking at the real risks and harms of opioids helps win patients over to the benefit of tapering — for them.
- Tapering must be customized to succeed. Tapering plans never go as expected. Adapt as you go.
- A few patients are too unstable to be tapered. Don’t taper if the patient will get worse. Stop the taper and stabilize if the patient’s function is worsening instead of improving. But most of those at very high doses can tolerate a degree of tapering to safer levels.
- Don’t aim to taper to zero. Most patients on high-dose opioids, when on them long enough, can never tolerate total opioid cessation — for the same reason that overdose risk is high for patients with opioid use disorder who are made to be abstinent. Tapering to a lower, safer dose, or tapering to buprenorphine (which has a much safer profile), should be considered a success.
San Francisco Department of Public Health
University of Southern California
Emerging Treatment Options for Neonatal Abstinence Syndrome
Download this infographic: Emerging Treatment Options for Neonatal Abstinence Syndrome (PDF).
- American Society of Addiction Medicine: The ASAM National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use (PDF)
- Bree Collaborative: Prescribing Opioids for Postoperative Pain (PDF)
- California Health Information Association: State Health Information Guidance (This explains when, where, and why mental health and substance use disorder information can be exchanged, and provides clarification of state and federal laws.)
- Centers for Disease Control and Prevention
- County of Plumas: Primary Care Guidelines Flowchart
- Kaiser Permanente: Patients on Chronic Opioid Therapy for Chronic Non-Cancer Pain Safety Guideline (PDF)
- Mentorship and conference scholarship resources: Medical Education and Research Foundation for the Treatment of Addiction
- Partnership HealthPlan of California: Provider Education Letter (PDF)
- Prescribe to Prevent
- Providers Clinical Support System
- San Francisco Department of Public Health: Naloxone for Opioid Safety: Providers Guide (PDF) and Naloxone for Opioid Safety: Patient and Caregiver Guide (PDF).
- San Francisco Health Plan: FAQ Guide for the 7-Day Limit on Initial Opioid Rxs (PDF)
- Turn the Tide: Prescribing Opioids for Chronic Pain (PDF) (flyer)
- UCSF: Warmline (855.300.3595) and Clinician Consultation Center Substance Use Resources
- American Academy of Family Physicians: Pain Management and Opioid Misuse
- California Health Care Foundation
- NEJM Catalyst: “The Physicians’ Quandary with Opioids: Pain versus Addiction“
- SafeRx Lake County (sample county strategy)
- Yale New Haven Children’s Hospital: “An Initiative to Improve the Quality of Care of Infants with Neonatal Abstinence Syndrome” (Pediatrics) and “Reconsidering the Standard Approach to Neonatal Abstinence Syndrome” (video).