Thus began an effort by Hyatt, Steinberg, and a task force of others at Kaiser Permanente-Southern California to change how their colleagues practiced, and thought about, pain management.
Taking advantage of the HMO’s massive health-data system and its status as both insurer and health provider, the Southern California Kaiser doctors set about tapering the number of patients on high doses of narcotic painkillers. They reprogrammed computer software for doctors, developed new urine tests for patients and empowered pharmacists to question potentially excessive prescriptions.
They also pushed colleagues to expand the use of non-drug options for chronic-pain sufferers: physical therapy, acupuncture, cognitive behavioral therapy, healthier diets, and increased exercise.
Five years into its initiative, Kaiser’s Southern California operation reports prescriptions of opioids have plunged.
Prescriptions of opioid pills such as Vicodin and Percocet in amounts greater than 200 tablets dropped from 2,500 a month to almost zero, according to the HMO. So, too, have prescriptions that include potentially dangerous combinations of muscle relaxants, anti-anxiety medications and opioids, as well as prescriptions of brand-name opioids in general.
Kaiser patients coming out of routine surgery no longer receive 60 Vicodin, a month’s worth of pills for what are usually a few days of pain, Hyatt says. Now “you would probably be given no more than 18” pills of generic hydrocodone.
Kaiser is deploying these strategies across the organization, and the prescription of opioids has fallen by a third since March 2015, officials at Kaiser’s Oakland headquarters said.
Researchers at the federal Centers for Disease Control and Prevention in Atlanta say in an upcoming paper that Kaiser has struck a good balance between reducing prescriptions and managing patients’ pain.
“It’s important to demonstrate that, yes, it’s possible and that action can be taken now,” said behavioral scientist Jan Losby, the paper's lead author.
But it’s not clear whether Southern California Kaiser’s approach can be adopted with success outside large HMOS. Many doctors operate in smaller clinics, under intense time pressure and without much opportunity to talk about alternative treatments. Not many have access to the kind of data Kaiser collects.
Some patients and their advocates worry about denying patients pain drugs they really need, a concern that has gained traction nationally.
“Not prescribing is as bad as over-prescribing,” said Paul Gileno, founder and president of the Connecticut-based U.S. Pain Foundation, an advocacy organization for chronic-pain patients. “We don’t want all or nothing. We want that balance.”
Kaiser patient Nancy Walter, who has experienced chronic pain since a serious motorcycle accident, agrees.