The Silent Opioid Crisis: Seriously Ill Patients Face Frequent Delays in Pain Treatment

By Pat Anson

Shortages of opioid pain medication and insurance obstacles are causing frequent delays and suboptimal treatment for seriously ill patients, according to a new study by researchers at the Icahn School of Medicine at Mount Sinai.

In a survey of 52 palliative care clinicians in Mount Sinai’s New York-based medical system, nearly nine out of ten (88%) reported frequent obstacles in getting opioids for their patients. On average, clinicians spent over an hour each day on the phone with insurance companies and pharmacies trying to gain access to limited opioid supplies. Nearly a third (31%) said this resulted in suboptimal care for their patients.

The survey findings were recently published in NEJM Catalyst Innovations In Care Delivery.

“Prescriptions are written, but patient is not able to get the correct dose or quantity at their pharmacy,” one clinician reported.

“I once had to send an oxycodone prescription to eight pharmacies,” said another.

“I spent the better part of 2 days... trying to figure out a pharmacy that would [fill] the oxycodone. Sometimes I spend more time handling access issues than actually talking to and thinking about the patient,” another palliative care clinician reported.

Patients in palliative or hospice care often have severe pain from cancer, major surgery, or a sudden emergency like a sickle cell crisis. Although they are usually exempt from opioid guidelines that limit the dose or amount, seriously ill or dying patients face many of the same obstacles getting opioids as patients with more moderate pain. Researchers say this “silent opioid crisis” has largely been ignored.

“Taken together, these findings raise alarms about a new crisis in opioid access for people with serious illness, for whom opioids are often essential pain relief medicines,” wrote lead author Rebecca Rodin, MD, Assistant Professor of Geriatrics and Palliative Medicine, Icahn Mount School of Medicine at Mount Sinai.

“Our clinicians reported that the numerous challenges in opioid access led to significant adverse effects on patient outcomes, such as uncontrolled pain, rehospitalization, and opioid withdrawal, and on clinician administrative burden. That burden included time spent contacting pharmacies and insurance companies rather than on direct patient care, which adversely affected clinician job satisfaction.”

In some cases, Rodin said clinicians changed their prescriptions to “less-than-ideal” opioid formulations and doses, a change based on the drugs’ availability rather than what is appropriate for their patients.

To improve patient access, Mount Sinai clinicians started collaborating more closely with pharmacies, finding out which opioids were in stock and improving their documentation to show why a prescription is medically necessary. Outpatient pharmacies also started delivering opioids to oncology patients before they were discharged, which helps ensure there is no disruption in pain care when they go home.  

Knowing which pharmacies have opioids in stock proved to be a critical time-saver for doctors and helped Mount Sinai develop a list of preferred pharmacies that is updated in real time.  

“Our strategies have been effective within the Mount Sinai ecosystem, but they do not address root causes of barriers which can include a number of factors, such as much broader supply chain shortages at the regional and national level, public and private coverage policies, and pharmacy stocking and dispensing practices. We need to do more to address these barriers,” said Rodin.