Confronting Opioid Overprescribing Head-On
Three health systems are taking ownership of their role in the opioid epidemic with physician-led initiatives to alter pain management practices and help doctors live up to their medical commitment to do no harm.
A trio of large health systems has implemented initiatives to understand current prescribing patterns, in particular why some doctors rely on opioid drugs to manage pain rather than non-narcotic alternatives. The physician-led initiative is part of a growing movement among acute care providers to reverse a disturbing trend of opioid misuse and addiction that begins in the hospital, often in the aftermath of a surgery.
A lack of access to information—whether for benchmarking clinical practices and patient outcomes or for quantifying the shortage of primary care physicians who are available and licensed to treat opioid withdrawal—is a significant challenge. So is the sheer magnitude of the epidemic. Over 2 million Americans are addicted, and prescription-opioid overdose deaths are reported to have more than quadrupled between 1999 and 2015. Research also finds that opioids prolong hospital stays and increase the risk of complications.
Prevention is the starting point at Brentwood, Tenn.-based LifePoint Health, Nashville-based HCA Healthcare, and San Diego-based Scripps Health. At a perioperative pain management collaboration summit, hosted earlier this year by HealthTrust, a handful of representatives from each of those health systems came to recognize that opioid abuse and dependency could legitimately be described as hospital-acquired conditions.
Instituting a standardized, enterprise-wide patient care approach can be a prickly and time-consuming exercise in the best of circumstances, but addressing the reflexive overprescribing of opioids is uniquely complex. It is a clinical habit that has been decades in the making, traceable to 1996, when the American Pain Society declared pain to be the fifth vital sign—and that it was being undertreated. The Joint Commission has only recently revised its pain assessment and management standards to require hospitals to provide nonpharmacological pain treatment methods and to facilitate practitioner and pharmacist access to Prescription Drug Monitoring Program databases, which are used to reduce prescription drug abuse and diversion.
Numeric pain scales also remain in widespread use, tying the prescribing of pain medicines to patient discomfort rather than to the patient’s ability to function (e.g., trouble getting out of bed or engaging in physical therapy).
Physician leaders at LifePoint, HCA, and Scripps are advocates of pain scales that measure patient functioning. They also point to e-prescribing as a possible remedy for overprescribing that occurs to avoid inconvenience for patients and surgeons. Refilling a prescription for a narcotic painkiller otherwise requires a return trip to the doctor’s office, creating a perverse incentive to prescribe too many pills “just in case.”
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‘Because We Care’
A newly launched opioid stewardship program at Scripps Health is devoted to fundamentally changing the attitudes and expectations that prescribers, patients, and their caregivers have about pain and how it should be managed. It is modeled after an existing antibiotic program that focuses on patient education and on consistent and coherent messaging by all caregivers. Providers contact patients several times during the 90-day postoperative period to ask about continued narcotic use and offer counseling on the safe disposal of unused pills. Whether that message is delivered via print brochure, video, telephone, or in person, the “because we care” theme dominates. Patient satisfaction thus is not expected to suffer.
The initial focus is on general and gynecological surgeries that are part of a rapid-recovery protocol favoring the use of multimodal pain management. The program will expand to spine surgery and orthopedics and, ultimately, nonsurgical patients, including those going through opioid withdrawal.
Getting organized has been one of the chief challenges, given that meetings involve representatives from nearly a dozen disciplines, including primary care, palliative care, and, most recently, orthopedic surgery. Project management work falls to the clinical pharmacy director and an emergency medicine physician who self-delegate based on skill set—one compiles data and coordinates meetings while the other facilitates collaboration and writes first drafts of educational materials.
Generating before-and-after statistics on opioid utilization, specific to individual prescribers—with plans to ultimately share the data within groups to allow physicians to see where they stand in comparison to their peer group—has been slowed by data quality issues and a systemwide electronic health record conversion that will ultimately resolve the dilemma. The longer-term conundrum is where to refer patients with opioid use disorder, given the dearth of practicing addiction specialists and evidence-based treatment programs. Residency programs and fellowships in addiction medicine may be required.
The program’s official kickoff came only this past September, when the chiefs of staff and the Scripps corporate team formally blessed the program and the initiative was introduced to the medical executive committee. The system’s surgery care line co-chair, an anesthesiologist, took on the task of educating fellow physicians about the “hidden” nature of the epidemic during grand rounds. Data helped tell the story: States with more opioid prescriptions per capita also experience more drug overdose deaths, and restricted access stemming from state laws has led users to search for alternatives—notably, heroin.
In fact, prescription pain medications are a gateway drug in most cases of heroin addiction, and every type of surgery holds the potential to put patients in the downward spiral. Medical staff were immediately and overwhelmingly supportive of efforts to reduce opioid prescribing and, unprompted, began helping to raise awareness of the issue and promoting use of nonopioid alternatives for both short- and long-term pain management.
An opioid stewardship committee has been assembled to produce and disseminate patient and clinician education materials, identify patients at high risk of opioid abuse, and track outcomes related to the initiative (e.g., in-hospital opioid use and related adverse events, and readmissions or emergency room visits for subsequent opioid-related issues). Effective leadership has meant over-communicating with all stakeholders and giving them a voice on proposed changes—most especially the naysayers and curmudgeons. The disheartening statistics invariably get everyone’s immediate and undivided attention:
- One in 25 adults in the United States is opioid-dependent.
- Six percent of opioid-naïve surgical patients are still using opioids three months after surgery.
- More than 500 Americans die each week from opioid overdose (more than from car accidents).
- Seventy-five percent of heroin users were introduced to opioids through prescription medications.
- Eighty percent of opioid pills go unconsumed by the intended recipient ( 90 percent of users do not dispose of their unused pills).
- Eighty percent of nonmedical (i.e., recreational) users obtain their pills from family and friends, not from physicians.
Achieving a systemwide reboot of pain management practices begins with dialogue between providers at different points in the care continuum to spot the gaps. Are orthopedists overprescribing pills because they don’t want a patient’s supply to run out on a Saturday night, for example? Do emergency department (ED) physicians become upset with surgeons when patients present in the emergency room because they were prescribed too few pills—or don’t understand that some pain is good, helping to foster recovery? Teamwork is essential in setting reasonable expectations for opioid use for different surgeries and in reducing the wide variability in prescribing practices.
Not all participants in the opioid stewardship program are formal members, with some instead serving on a committee or in an ad hoc capacity. A family practice resident, for example, began attending meetings to provide an extra set of hands and pursue a legitimate leadership development opportunity.
Among the significant first steps taken by LifePoint is authoring a national guidance statement on responsible opioid prescribing for the EDs of its 70-plus facilities. The move reflects preexisting interest in the topic by the organization’s national ED Physician Guidance Council, where members were already working on standardizing the approach to managing painkillers and opiates. One LifePoint hospital could point to a quantitative reduction in its opioid prescribing rate after issuing similar guidance.
At the corporate level, a new multidisciplinary opioid stewardship committee is meeting monthly to maintain momentum and guide efforts moving forward. It is composed of LifePoint’s national medical director and representatives from the IT clinical team, as well as subject-matter experts from the quality department, pharmacy operations, surgical services, and the ED. The committee’s agenda includes identifying appropriate “milestones and metrics” around opioids for the ED and surgery service lines, as well as developing a multimodal pain management order set.
On the treatment side, one of the more time-consuming tasks is taking inventory of physicians who have been trained and licensed to prescribe antiaddiction medications such as methadone and naltrexone. LifePoint employs approximately 2,600 providers, half of whom are primary care physicians who rarely step foot in a hospital, including some practitioners in small groups without a designated medical director. In some markets, committee members are collaborating with physicians in director-level positions to identify who to call to obtain the information.
Collaboration across disciplines and leadership levels will continue to be critical. Hospital leaders who serve as conveners of local resources, including public health departments, are being pulled in early to ensure a full accounting of active programs that target the opioid epidemic.
Affecting a Culture Change
Orthopedic surgeons at Southern Joint Replacement Institute (SJRI) serve on the medical staff at HCA’s TriStar Centennial Medical Center in Nashville. These surgeons are actively investigating pain-reducing strategies that minimize, if not eliminate, the need for narcotics in the perioperative period. On the community level, they are focused on preventing diversion of opioids from the individual for whom they were prescribed to another person—often a loved one at home—for illicit use. The surgeons are also serving as subject-matter experts at a series of regional pain management summits that HCA is holding around the country to help its hospitals and divisions develop action plans for balancing patient comfort and safety.
With the full support of CEOs in HCA’s TriStar Division, SJRI has assembled a multidisciplinary team of physicians, nurses, and mid-level providers who are part of the prescription process for surgery patients, plus a pharmacist and addiction treatment specialist, to help identify the most effective pain management regimen for the group’s total-joint patient population. Research is underway on various perioperative cocktails and an older intravenous anesthetic, as well as alternative pain management approaches such as massage and acupuncture that are already commonplace in obstetrics and oncology. A nurse at the clinic is serving as de facto project manager.
The pharmacist on the team is with a local psychiatric hospital and already has facilitated a large in-service event to educate nurses on how to identify, diagnose, and treat opioid withdrawal symptoms. As at Scripps, patient education is viewed as the big need over the long term and will require consistent, repeated messaging by everyone involved in delivering care—with emphasis on the importance of properly disposing of unused narcotics, and how and where to do so (including year-round collection sites). Behavioral issues of patients will also need to be addressed preoperatively. Mood disorders are a knowable—and modifiable—surgical risk factor, and mental health treatment may prevent patients from “medicating” with pain medications for the wrong reasons.
Regarding diversion prevention, TriStar Centennial Medical Center recently began participating in the biannual National Prescription Drug Take Back Day, a program of the U.S. Justice Department and the Drug Enforcement Administration. The community was invited to drop off unused opioid prescriptions during a one-day “Crush the Crisis” event on the hospital campus, with complimentary t-shirts going to the first 100 attendees. The local police department served as medicine collection agents, and Centennial’s medical office staff provided refreshments. Roughly 21.5 pounds of medications was collected—a record for such events in the Nashville area.
The ability of physician leaders at SJRI to delegate responsibilities to other team members has helped make difficult work rewarding for all involved. When it comes to finding fresh ideas and plausible strategies for combating a seemingly intractable problem, every voice in the room truly counts.
About the authors:
Valerie Norton, MD, is chair of the systemwide pharmacy and therapeutics council, Scripps Health, San Diego;
John Young, MD, is national medical director, LifePoint Health, Brentwood, Tenn.;
Jeffrey Hodrick, MD, is an orthopedic surgeon with the Southern Joint Replacement Institute, Nashville.
All three authors serve as physician advisers to HealthTrust, Nashville.