for the grAde ONLY

SPECIAL ARTICLE

For editorial comment, see page 269

From the Department Psychiatry & Psychology (T.A.R.) and Departmen Internal Medicine (M.C. Mayo Clinic, Rochester and Department of Inte Medicine, Mayo Clinic, sonville, FL (N.L.D.).

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How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis

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Teresa A. Rummans, MD; M. Caroline Burton, MD; and Nancy L. Dawson, MD

Abstract

The opioid crisis that exists today developed over the past 30 years. The reasons for this are many. Good intentions to improve pain and suffering led to increased prescribing of opioids, which contributed to misuse of opioids and even death. Following the publication of a short letter to the editor in a major medical journal declaring that those with chronic pain who received opioids rarely became addicted, prescriber attitude toward opioid use changed. Opioids were no longer reserved for treatment of acute pain or terminal pain conditions but now were used to treat any pain condition. Governing agencies began to evaluate doctors and hospitals on their control of patients’ pain. Ultimately, reimbursement became tied to patients’ perception of pain control. As a result, increasing amounts of opioids were prescribed, which led to dependence. When this occurred, patients sought more in the form of opioid prescriptions from providers or from illegal sources. Illegal, unregulated sources of opioids are now a factor in the increasing death rate from opioid overdoses. Stopping the opioid crisis will require the engagement of all, including health care providers, hospitals, the pharmaceutical industry, and federal and state government agencies.

ª 2017 Mayo Foundation for Medical Education and Research n Mayo Clin Proc. 2018;93(3):344-350

T here is no debate that the United States is in the midst of an opioid crisis. Between 1999 and 2014, drug

overdose deaths nearly tripled.1 In 2016, more than 60,000 people died from drug overdoses, and opioids were responsible for most of these deaths.2 For the first time since 1999, life expectancy decreased for US citizens compared with citizens of other developed countries, and opioid overdoses were a factor.3

This crisis includes both prescription and nonprescription (illegal) use of opioid drugs. Prescription opioids include natural and semi- synthetic opioids such as codeine and morphine, and synthetic opioids such as methadone, fentanyl, and tramadol. Many of the synthetic agents such as fentanyl are man- ufactured and distributed illegally. With the increased availability of both prescribed and illegally obtained opioids over the past 30 years, there has been an increase in misuse and deaths (Figure).4

Various opioids have been available for more than a century, and opioid misuse has occurred during that time. Following the Civil War, veterans who suffered severe injuries were given morphine for pain relief. In the late 1800s, pharmaceutical companies began

Mayo Clin Proc. n March 201 www.mayoclinicproceedings.org n

producing synthetic opioids, at which time heroin became available. At the same time it became clear that these derivatives of opium were addictive, and the United States restricted the importation of opium for medi- cal purposes only.5 In 1912, the United States and other countries signed the International Opium Convention, which controlled the import, manufacture, and sale of morphine.6

In 1924, because of misuse of heroin, the Heroin Act prohibited manufacturing, impor- tation, and possession of heroin, even for medical purposes.7 However, opioid problems continued to surface especially following war. Veterans were given opioids for relief of acute pain associated with combat injures but many continued to use and then misuse opioids once the immediate crisis was over. By the 1970s, additional opioids such as oxycodone and hydrocodone were developed and mar- keted for relief of acute and cancer pain.

Opioid use impacts all ages, sexes, ethnic and socioeconomic backgrounds, and espe- cially those in rural settings.8 According to a study in Annals of Internal Medicine, nearly one-third of US adults currently use prescrip- tion opioids.9 The United States leads the world in opioid use, consuming roughly

8;93(3):344-350 n https://doi.org/10.1016/j.mayocp.2017.12.020 ª 2017 Mayo Foundation for Medical Education and Research

Heroin

Any opioid

Methadone

Natural & semisynthetic opioids...

Other synthetic opioids (eg, fentanyl, tramadol)

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pe r

10 0,

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FIGURE. Overdose deaths involving opioids by type of opioid, United States, 2000-2015. From CDC/NCHS National Vital Statistics System, Mor- tality, with permission.4

THE OPIOID CRISIS

80% of all the world’s opioids.10 According to former Surgeon General Vivek H. Murthy, MD, MBA, the substance use disorder prob- lem, which includes opioids, is now more prevalent than common medical diseases such as diabetes and is 1.5 times more preva- lent than all cancer diagnoses combined.11

More people use prescription opioids than use tobacco.11 Substance misuse disorder in the United States costs $442 billion a year in health care, criminal justice costs, and lost productivity.11 The opioid crisis alone sky- rocketed to more than $78 billion a year.12

With increased opioid misuse, drug over- doses have become the leading cause of death for Americans younger than 50 years and a growing problem for those aged 15 to 24 years.3 By 2016, more die per year than from influenza, pneumonia, and kidney disor- ders, as well as from motor vehicle and firearm deaths.2 Unfortunately, only a fraction of those impacted by substance misuse, with some estimates indicating only 10%, are able to access services and get help for their condition.13

Opioids have been available for some time, so why are we now seeing a tremendous in- crease in opioid misuse and deaths? The rea- sons for this are complex. It appears that some good intentions to improve pain and suffering have contributed to some of the bad outcomes we are experiencing today with the opioid crisis.

ADDRESSING CHRONIC PAIN In the past, opioid medications were prescribed primarily for acute pain due to injury or surgery or severe pain related to can- cer or a terminal illness. Physicians were reluc- tant to prescribe opioids for other conditions because there was no evidence to support wider prescribing practices, and there was a concern for addiction. In addition, physicians feared investigation and state board disci- plinary action if they did prescribe opioids more liberally.14-16 In 1980, a 1-paragraph letter to the editors of the New England Journal of Medicine challenged the practice of using opioids only for relief of acute pain.17 The au- thors of the letter, after a retrospective review of their records, stated that only 4 of 11,882 patients who had pain and were given opioids became addicted to them. Subsequently, this

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5-sentence letter was referenced over 600 times in support of using opioids for chronic pain.18

A number of physicians and pain organiza- tions, including the World Health Organiza- tion, began advocating for more aggressive use of opioids for pain control for anyone who had “pain.”19 A study published in 1986 in the journal Pain, based on only 38 patients, concluded that “opioid maintenance therapy can be a safe, salutary and a more humane alternative to the options of surgery or no treatment in those patients with intrac- table non-malignant pain.”20 In the textbook Narcotic Analgesics in Anesthesiology, Arthur Taub similarly indicated that continuing opioid therapy in patients with nonmalignant pain was not associated with substance abuse or psychological dependence.21 Consequently, opioids were no longer limited to acute pain and pain associated with terminal illnesses but were also used to treat chronic pain.

This led to a slow but steady expansion of opioid use in the 1980s for anyone having “pain.” In 1996, the American Academy of Pain Medicine and the American Pain Society issued a consensus statement that opioids should have a role in the treatment of patients with chronic noncancer pain.22 Subsequently, many states passed Intractable Pain Acts that removed sanctions for physicians who

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prescribed long-term opioid therapy. Opioid prescribing began to increase.23 From 1990 to 1995, prescriptions for opioids increased by 2 million to 3 million each year.24 Then in 1995 OxyContin, produced by Purdue Pharma, was approved by the US Food and Drug Administration (FDA). In 1998, the pharmaceutical company began aggressively marketing the drug for the treatment of chronic pain, particularly to primary care phy- sicians.25 The company created and distrib- uted to physician offices more than 15,000 copies of the video called “I Got My Life Back” that chronicled 6 patients treated with OxyContin for chronic, noncancer pain.25

The promotional message encouraged pre- scribers to use this opioid as an ongoing treat- ment for chronic pain and highlighted the lack of side effects. Subsequently, the annual num- ber of prescriptions for OxyContin increased from 670,000 to 6.2 million between 1997 and 2002, and the total number of opioid pre- scriptions increased by 45 million.26 In 2007, a federal court found that the promotion pro- vided false information about the addiction potential of OxyContin and fined Purdue Pharma $634.5 million.27 However, the com- bination of consensus statements and decep- tive marketing had resulted in increased opioid prescribing.

With both the push for treatment of chronic pain with opioids and the promotion by pharmaceutical companies that the new opioids were safe for use in chronic pain, the number of opioid prescriptions increased from 2 million to 3 million a year in 1990 to 8 million a year in 1996, and 11 million in 1999.24 Nearly 62 million patients had at least 1 opioid prescription filled in 2016.28 These good intentions to relieve all pain led govern- ing organizations, which set and monitor stan- dards for medical practice, to develop new standards for doctors and hospitals to monitor and treat pain.

MONITORING PAIN The impetus for more aggressive pain treat- ment came from numerous studies published in the 1990s indicating that cancer and noncancer pain were ineffectively treated. In 1998, a study examining a national database of elderly patients in a nursing home with can- cer found that pain was prevalent and often

Mayo Clin Proc. n March 201

untreated.29 Another study of more than 1000 outpatients with metastatic cancer treated between 1990 and 1991 reported that 42% did not receive adequate pain therapy.30 Inadequate pain therapy was also reported in other patient populations such as ambulatory patients with AIDS and hospital- ized critical care trauma patients.31,32

In 2001, the Joint Commission, an organi- zation that monitors quality and sets standards for hospitals and medical centers, announced new standards for monitoring and treating pain that emphasized the need to perform sys- tematic assessments of patients’ pain levels regularly and frequently while hospitalized. It advocated for pain to be monitored similarly to how vital signs are monitored. Conse- quently, pain monitoring increased dramati- cally and became known as the “5th vital sign.” With “pain” increasingly surveilled and endorsed, opioid administration increased. Although the Joint Commission later revised and then in 2009 deleted these recommenda- tions in response to concerns of overtreat- ment, the practice continued.33 The good intention to closely monitor and treat pain on the basis of patients’ direct input increased the use of opioids, which has further contrib- uted to today’s opioid crisis.

Using Patient Satisfaction as a Proxy for Quality Care In 2001, the Institute of Medicine (IOM) in Crossing the Quality Chasm: A New Health Sys- tem for the 21st Century stated that the “US delivery system does not provide consistent, high-quality medical care to all people.” The IOM called for improvement in 6 areas: safety, effectiveness, patient centeredness, timeliness, efficiency, and equitableness.34 The IOM called for processes to monitor and track these 6 aims at improving the patient experience for which patient satisfaction became a proxy.34

Shortly thereafter, Congress directed the Center for Medicare & Medicaid Services (CMS) and the Agency for Healthcare Research and Quality to create the Hospital Consumer of Healthcare Providers and Systems (HCAHPS)35 Survey that incorporated patient satisfaction data and became a proxy for qual- ity care. Three of the 25 survey questions concerned pain control, intended to measure how well hospital providers manage patients

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with pain. The laudable goal to measure and improve patient experience was well intended, but no evidence existed that equates patients’ perception of their health care including pain control with quality of care.

REIMBURSING FOR PATIENT SATISFACTION The Deficit Reduction Act of 2005 required hospitals to participate in the HCAHPS Survey by submitting the results of the survey as a part of the Inpatient Prospective Payment System. The hospitals that submitted patient satisfaction data received full annual payment; those that did not incurred a 2% penalty for nonsubmission.36 By 2010, the Patient Protec- tion and Affordable Care Act of 2010 expanded the role of patient satisfaction as a payment incentive by including the HCAHPS Survey scores as a part of the Hospital Value Based Purchasing program.37 This program was intended to reward hospitals for high- quality care by requiring measures of clinical processes, outcomes, and patient experience. The patient experience domain comprised 30% of the total performance score in this calculation. Therefore, the scores on the patients’ perception of pain control had a big influence on reimbursement under the Inpa- tient Prospective Payment System.

Although there is some evidence that patient satisfaction with care is correlated with adherence to treatment recommenda- tions, multiple studies show that patient expe- rience scores do not relate to quality of care or to significantly improved outcomes.38-42 In spite of this, reimbursement from CMS was in part related to patient satisfaction and pain control. The 3 questions included in the HCAPS Survey were as follows: (1) During this hospital stay, did you need medicine for pain? (2) During this hospital stay, how often was your pain well controlled? (3) During this hospital stay, how often did hospital staff do everything they could to help you with your pain?43 As a result many clinicians felt obliged to address patients’ pain more aggressively to satisfy the patient.44,45 Opioids were now given in situations involving acute pain from minor procedures as well as for chronic pain.

On the other hand, many conscientious physicians received poor patient satisfaction scores for not providing opioids and other

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controlled substances when requested. A recent study showed the denial of a patient request for pain medication was associated with lower patient satisfaction scores.46 This has discouraged some of the best and most caring physicians who try to provide quality care. Although the Joint Commission, IOM, and CMS had good intentions of involving patients in their care, some of the ramifications were that patients received more opioids and other controlled substances when requested.

PROVIDING LARGER AMOUNTS AND MORE POTENT PAINKILLERS Pharmaceutical companies, medical governing agencies, insurance companies, and retail pharmacies also had good intentions of improving patient care and decreasing cost, but these intentions also indirectly contributed to the opioid crisis. Physicians and dentists wrote prescriptions for larger supplies of opioids after procedures to not only aggres- sively treat pain but also limit refill requests. Some retail pharmacies and insurance com- panies inadvertently contributed to the opioid problem by charging less for prescriptions of larger numbers of pills rather than smaller ones that would require refills to obtain the same number of pills. In addition, some insur- ance companies restricted higher priced, less addictive agents to control pain, leading providers to prescribe opioids when nonop- ioid pain medications may have been just as helpful.47 A recent study published in JAMA indicated that there was no clinical or statisti- cal difference in pain reduction for acute extremity injury between opioid and nonop- ioid pain medication.48 As a result of this pre- scribing practice, many patients received large amounts of potent opioids when only a few or none were needed.

This prescribing practice increased the risk for dependence. A study showed that 80% of opioid abusers had a prescription for opioids before the start of the addiction.49,50 When patients could no longer obtain prescription refills, the illegal opioid market was available with more potent and cheaper agents such as heroin and fentanyl. Even if patients did not take all the prescribed medication, the remain- ing pills could be misused by other family members, become a target for theft, or sold illegally. Fifty percent of opioid abusers who

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did not have a previous opioid prescription had a family member who did.49,50

Opioid prescribing rose at alarming rates from 1995 until 2012. In 2006, 72.4 opioid prescriptions were written per 100 people. This rate continued to increase annually until 2012. By 2016, it declined to 66.5 opioid pre- scriptions per 100 people, but despite this drop, the death rates from opioid overdoses did not decline. Although prescription opioid pain relievers were initially driving the crisis, by 2015 there were an equal number of deaths caused by illicit, synthetic opioids, which included heroin and fentanyl as well as meth- adone. As prescription opioid deaths level off, deaths from the illicit, synthetic agents continue to rise.28 Unfortunately, the good intentions to improve patient satisfaction, reduce the need for refills, and reduce medica- tion costs have inadvertently contributed to the opioid crisis.

SUMMARY Many good intentions leading to specific actions contributed to the opioid crisis. It began with underestimating the addictive potential of opioids in treating chronic pain and the advocacy of opioids to treat all pain issues. The implied message was that pain, which is part of the human condition, is a vital sign that should be treated similar to abrupt changes in temperature and blood pressure. Concurrently, pain control assessments included in patient satisfaction surveys became a measure of patient-centered care. The financial incentive for both doctors and hospitals to have high patient satisfaction scores only escalated the growing opioid crisis. Finally, the less expensive cost of opioids compared with that of less addictive agents to treat pain fueled an already smoldering problem. There is no single group or organiza- tion that is responsible for what has occurred over the past 30 years. Together we created the opioid crisis that exists today and together we must address it.

POSSIBLE NEXT STEPS To address the opioid crisis, there are a num- ber of groups attempting to set goals, guide- lines, and regulations including the IOM, the Joint Commission, the Department of Health and Human Services, the CMS, the FDA, the

Mayo Clin Proc. n March 201

Centers for Disease Control and Prevention, and other federal and state government agencies. In 2011, the IOM published “Relieving Pain in America,” which advocates for a multidisciplinary and multimodal approach to pain management, and includes emphasis on prevention, not just treatment.51

Over the past decade, the Joint Commission reexamined and modified its view of the stan- dard of pain management starting with the elimination of assessments as a fifth vital sign in 2009.33 The Department of Health and Human Services and the CMS worked together to set priorities including addressing opioid prescribing practices and implementing more effective person-centered and population-based strategies to reduce risk of opioid disorders, expanding use of naloxone, increasing use of medication-assisted treat- ments to reduced opioid disorders, and encouraging the use of evidence-based prac- tices for acute and chronic pain manage- ment.52,53 The CMS also is transitioning to new questions regarding pain in the HCAPHS Survey. Starting in January 2018, the new questions are as follows: (1) During this hospi- tal stay did you have pain? (2) During this hos- pital stay did the hospital staff talk with you about how much pain you had? and (3) Dur- ing this hospital stay, how often did hospital staff talk with you about how to treat your pain?52

Many are recommending investment in research to better understand the neurobi- ology of pain and opioid use disorders to find better nonopioid treatments and other in- terventions that identify unique factors for specific opioid using populations.54 The Cen- ters for Disease Control and Prevention has developed guidelines for prescribing opioids for chronic pain.55 States are also addressing the crisis. Most states have databases that can be accessed by providers that show previous opioid prescriptions dispensed to patients. This measure is associated with a modest and sustained decrease in opioid prescriptions as has been found by the mandatory prescrib- ing drug monitoring program on opioid pre- scriptions by dentists in New York.56,57 In April 2017, federal legislation was introduced to limit the supply of opioid prescription for acute pain to 7 days.58 By August 2017, 24 states have enacted legislation with a limit,

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guidance, or requirement related to opioid prescribing.59

Despite these advances, there are still gaps that need to be addressed. Reimbursing physi- cians and hospitals for patient pain control and satisfaction data, that neither reflect quality nor consistently reward those who are providing the best care, needs to be reevaluated. Insur- ance companies and retail pharmacies should also reassess how opioid medications are sup- plied to patients and how the cost of opioid versus nonopioid pain medications is deter- mined. Potent, synthetic illegal opioids such as heroin, carfentanil, and many others entering the United States from outside mar- kets must be eliminated.

CONCLUSION Over the past 30 years, the intentions to address and control pain and to have patients directly involved in their care were well- meaning, but the measures taken to achieve these goals contributed to the opioid crisis. Pain is not an opioid-deficient condition but a human, multidimensional disorder often involving more than just physical pain. Because it encompasses emotional, social, and spiritual, as well as physical components, it cannot be eliminated by a single drug. If we continue to approach pain in a unidimen- sional way, the current opioid crisis will likely continue, and the suffering will persist. Suffering will be alleviated only when, in addition to physical pain relief, emotional turmoil is calmed, social conflicts are lessened, and spiritual peace is found.

Abbreviations and Acronyms: CMS = Centers for Medi- care & Medicaid Services; FDA = Food and Drug Admin- istration; HCAHPS = Hospital Consumer Assessment of Healthcare Providers and Systems; IOM = Institute of Medicine

Potential Competing Interests: The authors report no competing interests.

Correspondence: Address to Teresa A. Rummans, MD, Mayo Clinic, 200 First St, SW, Rochester, MN 55905 (rummans.teresa@mayo.edu).

REFERENCES 1. Rudd RA, Seth P, David F, Scholl L. Increases in drug and

opioid-involved overdose deaths d United States, 2010e2015. MMWR Morb Mortal Wkly Rep. 2016;65:1445- 1452.

Mayo Clin Proc. n March 2018;93(3):344-350 n https://doi.org/10.1 www.mayoclinicproceedings.org

2. Hedegaard H, Warner M, Miniño A. Drug overdose deaths in the United States, 1999-2016. https://www.cdc.gov/nchs/ products/databriefs/db294.htm. Accessed January 16, 2018.

3. Fenelon A, Chen LH, Baker SP. Major causes of injury, death and life expectancy gap between US and other high income countries. JAMA. 2016;315(6):609-611.

4. CDC/NCHS. National Vital Statistics System, Mortality, CDC Wonder; Atlanta, GA: US Department of Health and Human Services, CDC, 2016. http://Wonder.CDC.gov/. Accessed January 16, 2018.

5. Hodgson B. In the Arms of Morpheus: The Tragic History of Laudanum, Morphine, and the Patent Medicines. Buffalo, NY: Firefly Books; 2001.

6. Wright H. The international opium conference. Am J Int Law. 1913;7(1):108-139.

7. The National Alliance of Advocates for Buprenorphine Treat- ment. Learn about the laws concerning opioids from the 1800s until today. http://www.naabt.org/laws.cfm. Accessed January 16, 2018.

8. Sullivan A. The opioid epidemic is this generation’s AIDS crisis. New York Mag. March 16, 2017; Daily Intelligencer.

9. Lasser KE. Prescription opioid use among U.S. adults: our brave new world. Ann Intern Med. 2017;167(5):351-352.

10. Manchikanti L, Singh A. Therapeutic opioids: a 10-year perspec- tive on the complexities and complications of the escalating use, abuse and nonmedical use of opioids. Pain Physician. 2008;11(2, Suppl):S63-S88.

11. Murthy VH. Surgeon General’s report on alcohol, drugs and health. https://addiction.surgeongeneral.gov/surgeon-generals- report.pdf. Accessed January 16, 2018.

12. Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States. Med Care. 2016;54(10):901-906.

13. Center for Behavioral Health Statistics and Quality. 2016, Keys substance use and mental health indicators in US: results from 2015 National Survey on Drug Use and Health, HHS Publica- tion No. SMA 16-4984, NSPUH Series H-51, http://www. samhsa.gov/data/. Accessed January 16, 2018.

14. Substance Abuse and Mental Health Services Administration, Rockville, MD, https://tandfonline.com/doi/abs/10.1300/Jo88v 01n01_05. Accessed January 16, 2018.

15. Joranson DE, Cleeland CS, Weissman DE, Gilson AM. Opioids for chronic cancer and non-cancer pain: a survey of state med- ical board members. Fed Bull. 1992;79(4):15-49.

16. Turk DC, Brody MC, Okifuji EA. Physicians attitudes and prac- tices regarding the long-term prescribing of opioids for non- cancer pain. Pain. 1994;59(2):201-208.

17. Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.

18. Leung PTM, Macdonald EM, Stanbrook MB, Dhalla IA, Juurlink DN. A 1980 letter on the risk of opioid addiction. N Engl J Med. 2017;376(22):2194-2195.

19. World Health Organization. Cancer Pain Relief. Geneva: World Health Organization; 1986. www.who.int/iris/handle/10665/ 43944. Accessed January 16, 2018.

20. Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986;25(2): 171-186.

21. Taub A. Opioid analgesics in the treatment of chronic intrac- table pain of non-neoplastic origin. In: Narcotic Analgesics in Anesthesiology. Baltimore, Md: Williams and Williams; 1982: 199-208.

22. Haddox JD, Joranson D, Angarola RT, et al. The use of opioids for the treatment of chronic pain: a consensus statement from the Academy of Pain Medicine and the American Pain Society. Clin J Pain. 1997;13(1):6-8.

23. Gilson AM, Joranson DE. Controlled substances and pain management: changes in knowledge and attitudes of state medical regulators. J Pain Symptom Manage. 2001;21(3): 227-237.

016/j.mayocp.2017.12.020 349

MAYO CLINIC PROCEEDINGS

350

24. Volkow N. America’s addiction to opioids: heroin and prese- cription drug abuse. May 2014. https://www.drugabuse.gov/ about-nida/legislative-activities/testimony-to-congress/2016/ americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed November 27, 2017.

25. Meier B. Pain Killer: The Extraordinary and True Story of OxyCon- tin. Emmaus, PA: Rodale Press; 2003.

26. Prescription Drugs: OxyContin Abuse and Diversion and Ef- forts to Address the Problem. GAO Report to Congressional Requesters; United States General Accounting Office, Wash- ington, DC: December 2003.

27. Associated Press. Purdue Pharma, Execs to pay $634.5 million fine in OxyContin case. 2007. http://www.cnbc.com/id/ 18591525.

28. Centers for Disease Control and Prevention. Annual surveil- lance report of drug-related risks and outcomes. 2017. http:// www.CDC.gov/drugoverdose/PDF/pubs/2017-CDC-drug- surveillance-report.pdf. Accessed January 16, 2018.

29. Bernabei R, Gambosi G, Lapane K. Management of pain in elderly patients with cancer. SAGE Study Group. Systematic Assessment of Geriatric Drug Use via Epidemiology. JAMA. 1998;279(23):1877-1882. Erratum in JAMA. 1999;281(2):136.

30. Cleeland CS, Gonin R, Hatfield AK, et al. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med. 1994; 330(9):592-596.

31. Breitbart W, Rosenfeld BD, Passik SD, McDonald MV, Thaler H, Portenoy RK. The undertreatment of pain in ambu- latory AIDS patients. Pain. 1996;65(2-3):243-249.

32. Whipple JK, Lewis KS, Quebbeman EJ, et al. Analysis of pain management in critically ill patients. Pharmacotherapy. 1995; 15(5):592-599.

33. Baker DW. History of the Joint Commission’s Pain Standards: lessons for today’s prescription opioid epidemic. JAMA. 2017; 317(11):1117-1118.

34. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Acad- emy Press; 2001.

35. Centers for Medicare & Medicaid Services. HCAHPS fact sheet (CAHPS Hospital Survey). 2013. http://www.hcahpsonline.org/ files/August%202013%20HCAHPS%20Fact%20Sheet2.pdf. Published August 2013. Updated September 5, 2013. Accessed August 25, 2017.

36. Centers for Medicare & Medicaid Services. HCAHPS: Patients’ perspectives of care survey. http://www.hcahpsonline. org%2fglobalassets%2fhcahps%2ffacts%2fhcaphps_fact_sheet_ november_2017a.pdf. Accessed January 16, 2018.

37. Hospital Value Based Purchasing. Washington, DC: Depart- ment of Health and Human Services, Center for Medicare & Medicaid Services; September 2015.

38. Jha AK, Orav EJ, Zheng J, Epstein AM. Patients’ perception of hospital care in the United States. N Engl J Med. 2008; 359(18):1921-1931.

39. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their health care are not associated with the technical quality of their care. Ann Intern Med. 2006;144(9):665-672. Erratum in Ann Intern Med. 2006;145(8):635-636.

40. Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians: linking patients’ experiences of care to clinical qual- ity and outcomes. J Gen Intern Med. 2008;23(11):1784-1790.

41. Lee DS, Tu JV, Chong A, Alter DA. Patient satisfaction and its relationship with quality and outcomes of care after acute myocardial infarction. Circulation. 2008;118(19):1938-1945.

42. Lyu H, Wick EC, Housman M, Freischlag JA, Makary MA. Pa- tient satisfaction as a possible indicator of quality surgical care. JAMA Surg. 2013;148(4):362-367.

Mayo Clin Proc. n March 201

43. Centers for Medicare & Medicaid. Hospital Consumer Assess- ment of Healthcare Providers and Systems (HCAHPS): Cen- ters for Medicare & Medicaid Services. http://www. hcahpsonline.org/HospitalVBP.aspx. Published 2015. Accessed November 29, 2017.

44. Calcaterra SL, Drabkin AD, Doyle R, et al. A qualitative study of hospitalists’ perceptions of patient satisfaction metrics on pain management. Hosp Top. 2017;95(1):18-26.

45. Kelly S, Johnson GT, Harbison RD. “Pressured to prescribe”: the impact of economic and regulatory factors on South- Eastern ED physicians when managing the drug seeking patient. J Emerg Trauma Shock. 2016;9(2):58-63.

46. Jerant A, Fenton JJ, Kravitz RL, et al. Association of clinical denial of patient requests with patient satisfaction. JAMA Intern Med. 2018;178(1):85-91.

47. Thomas K, Ornstein C. Amid opioid crisis, insurers restrict pricey, less addictive painkillers. New York Times. September 2017. https://www.nytimes.com/2017/09/17/health/opioid-painkillers- insurance-companies.html. Accessed January 16, 2018.

48. Chang A, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a single dose of oral opioid and non opioid analgesics on acute extrem- ity pain in the emergency department. JAMA. 2017;318(17): 1661-1667.

49. National Institute on Drug Abuse. Opioid overdose crisis. June 2017. http://drugabuse.gov/drugs-abuse/opioids/opioid-crisis. Accessed January 16, 2018.

50. Shei A, Rice JB, Kirson NY, et al. Sources of prescription opioids among diagnosed opioid abusers. Curr Med Res Opin. 2015; 31(4):779-784.

51. Institute of Medicine Report: Relieving Pain in America: A Blue- print for Transforming Prevention, Care, Education and Research. Washington, DC: The National Academies of Sci- ences Engineering and Medicine; 2011.

52. Centers for Medicare & Medicaid Services (CMS). Opioid Misuse Strategy 2016. January 2017. https://www.cms.gov/ Outreach-and-Education/Outreach/Partnerships/Downloads/ CMS-Opioid-Misuse-Strategy-2016.pdf. Accessed January 16, 2018.

53. Worcester S. Report: opioid epidemic fight must increase sub- stantially and immediately. Intern Med News. July 13, 2017. https://www.mdedge.com/internalmedicinenews/article/142546/ pain/report-opioid-epidemic-fight-must-increase-substantially. Accessed January 16, 2018.

54. King NB, Fraser V, Boikos C, Richardson R, Harper S. Determi- nants of increased opioid-related mortality in the United States and Canada, 1990e2013: a systematic review. Am J Public Health. 2014;104(8):e32-e42.

55. Dowell D, Haegerich TM, Chou R. CDC Guideline for pre- scribing opioids for chronic paindUnited States. JAMA. 2016; 315(15):1624-1645.

56. Rasubala L, Pernapati L, Velasquez X, Burk J, Ren YF. Impact of mandatory prescription drug monitoring program on prescrip- tion of opioid analgesics by dentists. PLoS One. 2015;10(8): e0135957.

57. Bao Y, Pan Y, Radakrishnan S, et al. Prescription drug moni- toring programs are associated with sustained reductions in opioid prescribing by physicians. Health Aff (Millwood). 2016; 35(6):1045-1051.

58. https://www.mccain.senate.gov/public/index.cfm/2017/4/ senators-mccain-gillibrand-introduce-bill-to-combat-opioid- addiction-abuse. Accessed November 29, 2017.

59. National Conference of State Legislatures. Prescribing polices: states confront opioid overdoes epidemic. http://www.ncsl. org/research/health/prescribing-policies-states-confront-opioid- overdose-epidemic.aspx. Accessed November 29, 2017.

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