Palliative Care

CDC Opens Draft Opioid Guidelines for Public Comment

Posted in opioids, Palliative Care on December 23rd, 2015 by MMS – 1 Comment
CDC Director Tom Frieden

CDC Director Tom Frieden

The Centers for Disease Control and Prevention this month released its draft guidelines for the prescribing of opioid pain medications for chronic pain.

The recommendations are designed for primary care settings, and focus on chronic pain lasting longer than three months. They do not apply to palliative or end of life care. They were published on Dec. 14 and will be open for public comment until Jan. 13, 2016.

In its public notice the CDC stated, “The guideline is not a federal regulation; adherence to the guideline will be voluntary.” However, the American Medical Association and others noted that the guidelines would likely have significant public impact. For example, a new federal law requires the Veterans Administration to adopt the final CDC guidelines as official policy.

Here’s an outline of the CDC’s draft recommendations:

  1. Non-pharmacologic therapy and non-opioid pharmacologic therapy are “preferred” for chronic pain.
  2. Providers should establish treatment goals before starting opioid therapy for chronic pain.
  3. Providers should discuss the risks and “realistic benefits” of opioid therapy before starting opioid therapy, and periodically thereafter.
  4. Providers should prescribe immediate-release opioids for chronic pain, instead of extended-release opioids.
  5. Providers should start with the “lowest effective dosage.”
  6. For acute pain, providers should prescribe the “lowest effective dosage” for immediate-release opioids, and should prescribe “no greater quantity than needed for the expected duration of pain severe enough to require opioids. It states, “three or fewer days usually will be sufficient for most non-traumatic pain not related to major surgery.”
  7. Providers should evaluate the benefits and harms of with patients within 1 to 4 weeks of starting opioid therapy.
  8. Providers should evaluate risk factors for opioid-related harms before starting or continuing opioid therapy. These risk factors include the patient’s history of overdoses and/or history of substance abuse disorder.
  9. Providers should review the patient’s prescription history using the state prescription monitoring program when starting therapy, as well as periodically during therapy.
  10. Providers should use urine drug testing before starting opioid therapy for chronic pain, and should consider ordering such tests annually.

There have been strong reactions to the guidelines, focusing on both the content and the process under which the guidelines were developed.

The CDC did not originally plan to accept public comments before finalizing the guidelines, but the American Medical Association and other groups have criticized a “lack of transparency” in the drafting process.

An AMA letter to the CDC in October also stated the guidelines are “devoid of a patient-centered view and any real acknowledgement or empathy of the problems chronic pain patients may face.”

The House Committee on Oversight and Government Reform has also launched an investigation into the drafting process.

As of Dec. 30, the CDC’s website had collected more than 1,300 public comments. The AMA is expected to submit comments on the current draft in early January.

Background information

August Physician Focus: Advance Care Planning

Posted in End of Life Care, Palliative Care, Physician Focus, Uncategorized on July 31st, 2014 by MMS Communications – Comments Off on August Physician Focus: Advance Care Planning

Physicians are increasingly recognizing the importance of advance care planning – preparation for the end-of-life –  and as the subject gains more public attention, more patients are being motivated to talk about the issues.

The August edition of Physician Focus shares the physician’s perspective on this topic with two members of the Massachusetts Medical Society’s Committee on Geriatric Medicine.

Eric Reines, M.D., (photo, center) a geriatrician with Element Care in Lynn and chair of the committee, and Beth Warner, D.O., (right) a consultant geriatrician with Cooley Dickinson Health Care in Northampton and committee member, join host and primary care physician Bruce Karlin, M.D. (left) to discuss the basics of advance care planning.

Among the topics of conversation are the importance and advantages of planning, when it should begin, how to start the process, and the physician’s role in the process. Healthcare proxies, medical orders for life-sustaining treatment, and hospice and palliative care are also included in the discussion.

Physician Focus is available for viewing on public access television stations throughout Massachusetts. It is also available online at www.massmed.org/physicianfocus, www.physicianfocus.org,  and on YouTube.

Board of Medicine Moves to Require CME Credits in Pain Management and End of Life Care

Posted in CME, End of Life Care, Palliative Care on January 12th, 2012 by MMS – 5 Comments

We learned today that the Massachusetts Board of Registration in Medicine is notifying physicians by email that effective Feb. 1, it will require continuing medical education (CME) credits on two specific clinical topics as a condition of licensure and re-licensure: pain management and end of life care.

It will require three hours of CME credits in pain management for physicians who prescribe controlled substances (Schedules I through VI). These credits qualify as either category 1 or category 2 CME, and may be counted as risk management credits. This requirement was established by the Legislature by statute in 2010.

The MMS recommends two courses to fulfill this requirement:

The Board will also require physicians to take two credits in education about end-of-life care, also effective Feb. 1.  The credits qualify as either category 1 or category 2, and may be counted as risk management credits. This is a requirement imposed by the Board very recently, following the recommendations of an expert panel on end of life care that met in 2008.

The MMS online CME center offers three courses that would fulfill this requirement:

The state’s complete CME requirements for licensure and re-licensure are available on the MMS website.

Coming Jan. 1: New Requirement for Physician Licensure

Posted in CME, Palliative Care on December 20th, 2011 by MMS – Comments Off on Coming Jan. 1: New Requirement for Physician Licensure

Starting Jan. 1, every physician applying to renew or obtain a new Massachusetts license must complete at least three credits of education and training in pain management and opioid education.

According to state regulations, such education includes “but is not limited to, training in how to identify patients at high risk for substance abuse and training in how to counsel patients on the side effects, addictive nature and proper storage and disposal of prescription medicines. These hours may be included among the required 10 hours of risk management credits.”  The requirement was outlined in state legislation passed during the summer of 2010.

Several online CME activities fulfill this requirement. The MMS offers an online program, Managing Risk When Prescribing Narcotic Painkillers for Patients, for one credit. It meets the criteria of the Massachusetts Board of Registration in Medicine for risk management study. The Boston University School of Medicine also offers a three-credit online course, Safe and Effective Opioid Prescribing for Chronic Pain.

Visit the MMS website for complete information on CME requirements for Massachusetts licensure.

Future CME Requirements
In 2014, the Commonwealth of Massachusetts will require applicants for new and renewed licenses to complete training in end of life care. In 2015, such applicants must also certify their competence in the use of electronic health records.

MOLST Expands End-of-Life Planning for Physicians, Patients

Posted in CME, End of Life Care, Palliative Care on November 3rd, 2011 by Erica Noonan – Comments Off on MOLST Expands End-of-Life Planning for Physicians, Patients

Too often, palliative care experts say, physicians are unable to carry out their patients end-of life wishes because they were contained in a document that was incomplete, too vague, not legally binding, or simply misplaced by family members.

Massachusetts is poised to join more than 14 other states with formal Physician Orders for Life-Sustaining Treatment (POLST) programs. The proposed state protocol, called Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), aims to translate patients’ goals of care into specific medical orders that travel with the patient if he/she changes health care settings.

MOLST differs from the most common type of palliative care planning – advanced directive orders, which usually include a “living will” or other expression of wishes. Those orders generally designate a surrogate decision maker, or health care proxy, to act on behalf of an incapacitated patient.

Living will instructions – when presented by a health care proxy – are generally recognized as evidence of patient preferences, but are not recognized by Massachusetts law.

In contrast, a completed MOLST form travels with the patient at all times, may be faxed or reproduced, and is an official part of a patient’s medical record.  MOLST is more comprehensive than another common end-of-life preference form, the Massachusetts Comfort Care/DNR Verification Protocol, which covers emergency hospital transport and resuscitation efforts.

The MOLST document, which is signed by both patient and physician, encompasses these procedures, as well as breathing tubes and ventilation, artificial nutrition and hydration and dialysis.   Patients or their health care proxy can change MOLST preferences at any time.

A successful MOLST pilot program in the Worcester area was completed earlier this year and the Executive Office of Health and Human Services is currently evaluating feedback from medical professionals there to shape policy. The Massachusetts Expert Panel on End-of-Life Care has recommended statewide implementation of MOLST by early 2014.

To learn more about presenting the MOLST option with patients, and how to use MOLST to facilitate conversations about end-of-life care, join us on Dec. 6 for a webinar featuring Dr. Susan Block, co-director of the Harvard Medical School Center for Palliative Care. Visit www.massmed.org/molst for more information.

–  Erica Noonan

MOLST: A New Approach for End-of-Life Care

Posted in CME, End of Life Care, Palliative Care on October 18th, 2011 by Erica Noonan – Comments Off on MOLST: A New Approach for End-of-Life Care

An estimated 75 percent of patients will be unable to make some of their own medical decisions at the end of their lives. More physicians and clinicians are now finding that advanced directives and living wills are often too vague or unenforceable to ensure optimal care for dying patients.

To ensure patients receive the end-of-life care they desire, Massachusetts is poised to join more than 14 other states with formal Physician Orders for Life-Sustaining Treatment (POLST) programs.

The proposed state protocol, called Massachusetts Medical Orders for Life Sustaining Treatment (MOLST), aims to translate patients’ goals of care into specific medical orders that travel with the patient if he/she changes health care settings.

The MOLST document, signed by both patient and physician, covers specific health care therapies such as CPR, breathing tubes and ventilation, artificial nutrition and hydration, as well as more general patient preferences about issues such as hospital transport. A patient or health care proxy can change MOLST preferences at any time.

Unlike an advanced directive, which often designates a surrogate decision maker and is not part of a patient’s file, a MOLST form travels with the patient at all times and is an official part of a patient’s medical record.

State palliative care experts say they expect MOLST to soon become part of standard patient care for many Massachusetts clinicians. A successful MOLST pilot program in the Worcester area was completed earlier this year and the Executive Office of Health and Human Services is currently evaluating feedback from medical professionals there to shape policy.  The Massachusetts Expert Panel on End-of-Life Care has recommended statewide implementation of MOLST by early 2014.

To learn more about presenting the MOLST option with patients, and how to use MOLST to facilitate conversations about end-of-life care, join us on Dec. 6 for a webinar featuring Dr. Susan Block, co-director of the Harvard Medical School Center for Palliative Care. Visit www.massmed.org/molst for more information.

–          Erica Noonan