The misuse and abuse of both prescription and illicit opioids has increased dramatically in recent years and the resulting side effects of addiction have become a major public health concern in the U.S. Many factors have contributed to the opioid crisis and a multipronged approach is needed to address the situation moving forward with input from all stakeholders, including patients, governmental and regulatory officials, the community at large, and health care providers.
Policymakers at both the federal and state levels are struggling with the fallout of this increase in opioid abuse. Most recently, at the federal level, the U.S. House of Representatives considered more than 70 opioid-related pieces of legislation, culminating in the creation of one larger opioid package—the Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment (SUPPORT) for Patients and Communities Act (H.R. 6). The House passed this bill June 22 with a bipartisan vote of 396–14, and, at press time, it was expected to be the main legislative vehicle for opioid-related legislation in the Senate.
This article reviews the American College of Surgeons’ (ACS) efforts to work with Congress to develop legislation that helps to quell the opioid abuse crisis, while allowing surgeons to provide their patients with appropriate pain relief. It also highlights key provisions in the SUPPORT for Patients and Communities Act and informs Fellows about how they can get involved in this and other advocacy efforts.
ACS advocacy efforts regarding opioids
The College maintains that physicians have a responsibility to minimize their patients’ pain while also meeting the societal imperative to avoid overprescribing.
Throughout the years, payors and state legislators have placed widely varying limits and restrictions on prescribers. Many of the proposed policies will significantly affect patient safety and the way surgeons prescribe opioids, which may expose specific patient populations to unnecessary suffering.
Through sustained advocacy efforts on Capitol Hill, the ACS has focused on ways to avoid overprescribing and opioid misuse through patient and provider education, continued research into nonopioid pain treatments and other alternative remedies, and how to reduce the number of individuals who improperly or unnecessarily receive opioid prescriptions through enhancements to prescription drug monitoring programs (PDMPs).
The ACS has been advocating for a patient and provider education-focused approach to address the opioid crisis and limit one-size-fits-all legislative mandates on prescribers. ACS congressional advocacy efforts have involved working with members of the Congressional Bipartisan Working Group, the House Committee on Ways and Means, and the Senate Finance Committee.
In addition, John Daly, MD, FACS, Co-Chair of the ACS Patient Education Workgroup, moderated a panel at the 2018 Leadership & Advocacy Summit, which included representatives from the U.S. Food and Drug Administration (FDA) and the Drug Enforcement Administration (DEA) and focused on regulatory and enforcement tactics that the federal government is using to address the opioid crisis.
Specific activities can be summarized as follows.
Congressional Bipartisan Working Group
The ACS facilitated a November 2017 meeting for Dr. Daly with the Congressional Bipartisan Working Group to discuss the opioid crisis. At the meeting, Dr. Daly discussed the public health concerns related to the opioid epidemic. He also described his experience as the Co-Chair of the ACS Patient Education Committee in order to provide insights regarding pain control for the surgical patient and how to best address the opioid crisis while also ensuring that physicians can provide appropriate pain relief to their patients.
Dr. Daly highlighted several of the informational tools the ACS has developed to educate both patients and prescribers about opioids, including the ACS Statement on the Opioid Abuse Epidemic; ACS’ patient education guide, Safe and Effective Pain Control After Surgery; and the August 2017 opioid-focused issue of the Bulletin.*
House Ways and Means Committee
In March 2018, the ACS responded to a House Ways and Means Committee request for information on the use and misuse of opioids. The ACS response included a comprehensive outline of the College’s work to develop and disseminate patient and provider opioid-related educational materials and examples of how best to address the epidemic on the legislative and regulatory front. In addition, this comment letter reinforced the ACS’ opposition to federal mandates that would affect prescribing limits or Continuing Medical Education (CME) requirements.
The ACS suggested that Congress consider creating a Healthcare Common Procedure Coding System (HCPCS) code for physicians who counsel their patients on the risks associated with opioids. Utilization of a HCPCS code for opioid-related counseling would be similar to how physicians counsel their patients regarding smoking cessation. This proposal was included as a study in one of the Ways and Means opioid packages, but was not adopted in the SUPPORT for Patients and Communities Act.
Senate Finance Committee
In February, the ACS responded to a Senate Finance Committee request for information regarding the opioid epidemic. The response included a comprehensive outline of the College’s efforts to improve patient and provider opioid-related education and examples of how best to address the misuse and abuse of opioids. Overall, the ACS letter reiterated the points of the ACS Statement on the Opioid Abuse Epidemic and called for fully functioning and interoperable PDMPs, the ability for prescribers to electronically prescribe opioids, and the need for any opioid-related CME to be specialty-specific.
Other ACS activities on Capitol Hill
In addition, the ACS provided written statements regarding ACS’ policy positions on opioids to the House Committee on Energy and Commerce in July 2017 and the Senate Health, Education, Labor and Pensions (HELP) Committee in September 2017. The statements can be accessed at facs.org/advocacy/federal/opioids. The College also has monitored dozens of opioid-related Congressional hearings and offered input to members of Congress on legislation.
The ACS’ approach to advocacy
The College has been advocating in partnership with Congress and other health care providers to find solutions that both facilitate the physician-patient relationship and help to end the cycle of opioid abuse.
The ACS has developed several educational guides and courses to assist with both patient and physician opioid-related education. Patient and physician education is paramount to ensuring patients receive the most appropriate pain management and appropriate doses of opioids, nonopioids, and therapies for side-effect management. The ACS has been active in developing ways to educate both patients and surgeons on the safe and appropriate use of opioids. Advocacy efforts included sharing the College’s Safe and Effective Pain Control After Surgery patient education brochure with members of Congress.
The College has requested that Congress provide grant funding for opioid education and awareness, as well as specialty-specific and team-based CME on proper opioid prescribing protocols, nonopioid alternatives, the management of high-risk patients susceptible to opioid use disorder, and the transition of care for chronic pain patients. The ACS recognizes that the Centers for Disease Control and Prevention (CDC) has issued prescribing guidelines, but maintains that this directive is just a first step, as the guidelines were developed for primary care providers and focus on long-term, chronic pain. As such, they provide limited information on treating patients with the acute pain that surgical patients experience. The ACS has requested that Congress work with the CDC to further define these guidelines to accurately reflect the needs of the surgical patient.
The ACS maintains that any opioid-related training or CME should come directly from medical specialty societies and be regulated by the physician’s state licensing board. The surgeon is ultimately responsible for both the surgical care that a patient receives and the pain control options presented and therefore is best able to craft an individualized pain control plan.
PDMPs and prescribing
The ACS supports the use of fully functioning PDMPs as a health care and research tool to assist physicians and other prescribers. At present, the functionality and accuracy of PDMPs vary widely from state to state. For example, some states restrict PDMP login to physicians. Not only do these parameters disrupt the day-to-day clinical workflow, but they also restrict the availability and accessibility of PDMP information to other health care professionals who might be in a position to prevent abuse. When both physicians and/or physician designees can access these programs, this burden is decreased. Therefore, the ACS strongly supports the use of governmental grant funding to enhance these programs and make them accessible to appropriate members of the health care team.
In addition, the data in PDMPs must be interoperable across states and with electronic health records (EHRs) to streamline workflow and accessibility. The data in PDMPs should be available in real time to ensure accuracy. Finally, the ACS strongly maintains that use of PDMPs should be voluntary, the information should not be used for law enforcement purposes, and PDMPs should be updated as frequently as possible to ensure accuracy, particularly for partial-fill prescriptions.
The ACS encourages members of Congress to work with the Centers for Medicare & Medicaid Services (CMS) to reevaluate pain control methods reimbursed in certain bundled services. Some bundled surgical procedures include opioids as the preapproved pain control method, whereas other nonopioid treatments relieve pain just as effectively with far fewer short- and long-term side-effects. Unbundling Medicare reimbursement for nonopioid medications and removing obstacles to multimodal pain management techniques should be part of any legislative initiative.
Reducing the risk in opioid prescribing involves both an assessment of addiction risk and accommodation of that risk into the perioperative plan for pain control. The ACS recommends establishing new HCPCS codes to appropriately reimburse surgical practitioners for the additional opioid risk screening.
Alternative pain treatments
The ACS advocates for the use of nonopioid treatment options. These include local anesthetics, nonopioid medications (acetaminophen/NSAIDs [nonsteroidal anti-inflammatory drugs]), nerve blocks, ice therapy, and nonmedical treatments (exercise/relaxation techniques) and other alternatives. The College supports the use of a patient outcomes database related to safe and effective pain control. Additionally, the ACS is actively promoting educational materials on home care training for patients and caregivers. Together, these initiatives could have a meaningful impact toward reducing opioid dependence and abuse.
SUPPORT Patients and Communities Act
Among other provisions, the House-passed SUPPORT for Patients and Communities Act includes provisions focused on treatment and prevention, safe disposal of opioids, PDMP enhancements, and electronic prescribing for controlled substances under Medicare Part D. Details are as follows.
Treatment and prevention
The legislation establishes a demonstration project to increase provider treatment capacity for substance use disorders and increases the maximum number of patients that health care professionals may initially treat with medication-assisted treatment. Furthermore, the bill expands prescribing of buprenorphine to certain mid-level health care professionals, such as certified nurse midwives, clinical nurse specialists, and nurse anesthetists, which raises potential scope of practice issues. The ACS is monitoring new developments as the legislation works its way through the Senate.
Furthermore, the act allows patient health care teams to have access to patients’ substance use disorder records, and establishes an action plan for CMS to study inherent disincentives for prescribers for prescribing nonopioids.
Education (patient and provider)
The legislation requires the establishment of drug management programs for at-risk beneficiaries within Medicare. It also requires the initial examination for new enrollees in Medicare to include an opioid use disorder screening.
Development and use of nonopioid alternatives
The bill calls for extending the eligibility of Hospital Outpatient Prospective Payment System Pass-Through Payments for the development of nonopioid medications.
The SUPPORT for Patients and Communities Act requires coverage for services provided by certified opioid treatment programs and creates a demonstration project for an Alternative Payment Model for treating substance use disorder.
The act establishes baseline standards for PDMPs, requires PDMP use to be integrated into the physician workflow, and requires PDMP use within the Medicaid system.
The act requires prescription drug plan sponsors to establish drug management programs for at-risk beneficiaries and mandates e-prescribing for Medicare Part D patients.
The legislation establishes and expands programs to support increased detection and monitoring of fentanyl and other synthetic opioids.
At press time, the Senate had not acted on its version of opioid-related legislation but is expected to take up a package similar to the House bill before the end of 2018. The College will continue to monitor and advocate on the opioid package and other opioid-related legislation as they continue through the legislative process.
How to get involved
Congress, policymakers, and state legislatures make decisions daily that have the potential to affect the surgical profession, such as responses to the use and misuse of opioids. To have a robust, effective advocacy program, it is essential that all surgeons and Fellows of the ACS join together with a united voice to engage congressional leaders and public officials in support of patients with conditions that cause both acute and chronic pain.
The ACS suggests the following activities for Fellows to support these advocacy efforts:
- Attend the Leadership & Advocacy Summit, March 30–April 2, 2019, in Washington, DC
- Learn more, take action, and explore tools and resources available to surgeon-advocates online at addition to engaging via social media (@SurgeonsVoice)
- Host your federal/state legislators at your facility/practice
- Meet with members of Congress in your home district or in Washington, DC
The ACS Division of Advocacy and Health Policy is available to assist with these efforts and can help you prepare for a successful meeting, event, or facility tour.