2/20/2019. Source: Source:

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1 The misuse of and addiction to opioids including prescription pain relievers, heroin, and synthetic opioids such as fentanyl is a serious national crisis that affects public health as well as social and economic welfare. The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement. In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive. Opioid overdose rates began to increase. In 2015, more than 33,000 Americans died as a result of an opioid overdose, including prescription opioids, heroin, and illicitly manufactured fentanyl, a powerful synthetic opioid. 1 That same year, an estimated 2 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers, and 591,000 suffered from a heroin use disorder (not mutually exclusive). 1

2 Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them. Between 8 and 12 percent develop an opioid use disorder. An estimated 4 to 6 percent who misuse prescription opioids transition to heroin. About 80 percent of people who use heroin first misused prescription opioids. Opioid overdoses increased 30 percent from July 2016 through September 2017 in 52 areas in 45 states. The Midwestern region saw opioid overdoses increase 70 percent from July 2016 through September Opioid overdoses in large cities increase by 54 percent in 16 states. The U.S. Department of Health and Human Services (HHS) is focusing its efforts on five major priorities: Improving access to treatment and recovery services Promoting use of overdose-reversing drugs Strengthening our understanding of the epidemic through better public health surveillance Providing support for cutting-edge research on pain and addiction Advancing better practices for pain management The National Institutes of Health (NIH), a component of HHS, is the nation's leading medical research agency helping solve the opioid crisis via discovering new and better ways to prevent opioid misuse, treat opioid use disorders, and manage pain. In the summer of 2017, NIH met with pharmaceutical companies and academic research centers to discuss: Safe, effective, non-addictive strategies to manage chronic pain New, innovative medications and technologies to treat opioid use disorders Improved overdose prevention and reversal interventions to save lives and support recovery 2

3 In April 2018 at the National Rx Drug Abuse and Heroin Summit, NIH Director Francis S. Collins, M.D., Ph.D., announced the launch of the HEAL (Helping to End Addiction Long-term) Initiative, an aggressive, trans-agency effort to speed scientific solutions to stem the national opioid public health crisis. Within 3 5 years, HEAL research investments are expected to deliver: Implementation strategies demonstrated to significantly increase initiation of MAT and retention in treatment beyond 6 months, and decrease rates of opioid addiction and overdose death. Biological signatures to predict which patients are at risk for developing chronic pain, guiding precision medicine approaches to reduce patient transition to chronic pain and thereby reducing reliance on opioids. A comprehensive dataset for the research community to reveal factors that predict transition or resilience to chronic pain. Identification of novel targets associated with spinal and peripheral pain pathways. A clinical trials network poised for the rapid testing of new pain therapies. New evidence-based approaches to inform previous practice-based approaches and improve care for infants with NOWs. Evidence for the non-pharmacological management of multiple acute and chronic pain conditions. In over 5 years, HEAL will deliver: Pharmaceutical programs leading to 15 Investigational New Drugs (INDs) and Investigational Device Exemptions (IDEs), with the goal of 5 New Drug Applications (NDAs) or 510K/premarket approvals for devices submitted to the FDA for: Overdose reversal agents. More flexible and new medications for the treatment of OUD. New interventions against respiratory depression to stop overdose death. Novel medications to treat withdrawal, craving, and relapse. 3

4 Increased options for small molecules, biologics, and neuromodulation devices for the treatment of pain without the use of opioids. A pipeline of novel non-opioid therapies that can be further developed and tested for the treatment of acute and chronic pain. Understanding of the lasting effects of early exposure to opioids on children and young adults. Opioid use is defined in ICD-10-CM under the category F11 Opioid related disorders, which is further categorized by patterns of use, abuse, and dependence. As with other drug use and dependency codes, these codes may specify with intoxication, with induced psychotic disorder, and with other induced disorder. documenting-opioid-dependence-and-abuse/ The diagnosis of Opioid Use Disorder can be applied to someone who has a problematic pattern of opioid use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period: Taking more opioid drugs than intended. Wanting or trying to control opioid drug use without success. Spending a lot of time obtaining, taking, or recovering from the effects of opioid drugs. Cravings opioids. Failing to carry out important roles at home, work, or school because of opioid use. documenting-opioid-dependence-and-abuse/ 4

5 Continuing to use opioids, despite use of the drug causing relationship or social problems. Giving up or reducing other activities because of opioid use. Using opioids even when it is physically unsafe. Knowing that opioid use is causing a physical or psychological problem, but continuing to take the drug anyway. Tolerance for opioids. Withdrawal symptoms when opioids are not taken. documenting-opioid-dependence-and-abuse/ According to the CDC, the majority of drug overdose deaths (more than six out of 10) involve an opioid. Documentation improvement aides coding specificity and allows stakeholders to generate quality data that could potentially save lives. documenting-opioid-dependence-and-abuse/ In response to HHS declaring the opioid epidemic a public health emergency, AHIMA recently released a documentation tip sheet that introduces seven characteristics of high-quality clinical documentation related to opioid use and abuse. These characteristics, while important when documenting all patient records, are especially important for tracking the specifics of opioid use. 5

6 When provider documentation is illegible, it affects not only the accurate coding of an encounter but also patient care. If a patient is being treated for a condition and any piece of diagnostic documentation is illegible, treatment could be jeopardized. A 65-year-old male patient has a follow-up visit for COPD. The provider documentation mentions that the patient is being treated for the COPD and he should continue his methadone therapy. However, there is not a diagnosis anywhere in the record that correlates with the methadone therapy. As a result, the patient's record would be considered unreliable. By adding a diagnosis of OxyContin addiction, the reliability characteristic would be met. The more details a provider can document about the patient's condition, treatment, and patientprovider interaction, the more precise the record will be. A diagnosis of drug abuse without documenting the type of drug that is being abused is a perfect example of imprecise documentation. 6

7 Complete documentation is imperative to ensure the patient's continuity of care. Providers must not only offer topnotch documentation to guarantee the completeness of the medical record, they also must authenticate every entry with their signature and date. When a provider documents that the patient had abnormal laboratory findings related to a drug screening but fails to document what those findings were, the record is considered incomplete. For a record to be considered consistent, there should be no conflicting documentation. For example, suppose the attending provider documents "39-year-old male patient was admitted for opioid use. This is the second admission for opioid abuse in the last two weeks for her." Is it opioid use or abuse? Is the patient male or female? Even little details matter for consistency. Clear documentation means leaving no room for interpretation and being as informative as possible. For example, a provider knows his patient, admitted with fatigue and lethargy, is addicted to heroin but fails to document the addiction. This leads to ambiguous documentation and can possibly be detrimental to the patient's continued care. 7

8 Documentation often becomes a low priority. However, if a diagnosis or a treatment is not documented, the patient is put at risk. A 25-year-old male was admitted to the emergency department with an accidental heroin overdose. He has been opioid dependent for three years. T40.1X1A, poisoning by heroin, accidental (unintentional), initial encounter. F11.229, opioid dependence with intoxication, unspecified. 8

9 A 57-year-old female is seen by her primary care provider for a follow-up related to cirrhosis. The provider documented a history of alcohol dependence and heroin abuse with alcoholic cirrhosis. K70.30, alcoholic cirrhosis of the liver without ascites. F10.21, alcohol dependence, in remission. F11.11, opioid abuse, in remission. 9