No hospital is safe from the effects of an opioid epidemic that’s raging across America, and neither is any patient. An estimated 44 people die every day in the United States from overuse of powerful prescription painkillers, from teens to senior citizens, in isolated rural towns and large cities alike.
The year 2014 set a new high for the number of overdose deaths from opioids — including commonly prescribed oxycodone and hydrocodone, alongside illegal drugs like heroin — at 28,647, according to the Centers for Disease Control and Prevention. The epidemic is clearly worsening, the agency believes, with the number of opioid deaths quadrupling since 2000. As a result, President Obama last month proposed adding $1.1 billion in federal funding to address the problem, with $1 billion going toward expanded access to treatment and $90 million toward supporting drug overdose prevention strategies.
The health care field is working to reverse the trend and raise awareness. “I don’t think it’s getting the attention that it needs to get on a national stage, and I’m worried about a generation here that is at risk,” says Peter Holden, president and CEO of Beth Israel Deaconess Hospital in Plymouth, Mass. “We have had overdoses in our emergency room from the ages of 13 to 69, in three-piece suits or cutoff blue jeans. This knows no age barriers, no class barriers, no racial barriers. It’s just hideous.”
The commonwealth has been ravaged by opioid use, with nearly 1,300 drug overdose deaths in 2014, an uptick of 19 percent compared with the previous year, making it one of 14 states where the problem is growing the fastest, according to the CDC.
To combat the problem, the Massachusetts Hospital Association helped to form a field task force that has found some early success with nine recommended best practices for managing opioids in the emergency department. The guidelines include everything from refusing to replace lost or stolen controlled substances, to counseling ED visitors on how to store and dispose of medications properly. All 51 MHA member EDs have put the nine recommendations in place, and some, such as Beth Israel Plymouth, believe they’re starting to move the needle on opioid use. In the five months after implementation, the number of such painkillers prescribed has dropped by 25 percent. They’re now moving on to Phase 2, developing the same best practices for every other area of the institution where prescriptions are written — surgery, inpatient, etc.
A nationwide effort
That type of collaboration among hospitals is taking place across the country, says Evelyn Knolle, senior associate director of policy at the American Hospital Association. Provider organizations are desperately seeking guidance on the safe prescribing of opioids for pain, and the association in January urged the CDC to move swiftly to finalize guidelines the agency released in draft form in December. “As your data so clearly show, the dangers are substantial and the need for sound guidance to steer clinical activities is urgent,” the AHA wrote in its comment.
In the meantime, the association is gathering best practices from the field on how to address the epidemic and properly manage pain without causing harm. It planned a March 8 webinar with Holden and other Massachusetts trailblazers to discuss their “groundbreaking efforts,” which is available at www.hpoe.org.
Hospitals must find a way to strike a balance between undertreating chronic pain and overprescribing opioids, and the AHA is compiling tools and education to help hospitals and doctors do so, Knolle says. “It’s a big problem,” she says. “Our members are seeing it every day on the front lines, and they are engaged in many different ways to help fight it.”
Among the health systems taking a concentrated approach to ensuring that opioids are prescribed properly and that patients addicted to opioids get appropriate treatment is Gundersen Health System, La Crosse, Wis., Boston Medical Center and Spectrum Health, Grand Rapids, Mich.
Before a prescription is written
Gundersen Health System has been at it for years. In 2008, a pain med specialist with the system set about ensuring that primary care doctors understood patients who were battling chronic pain and had systematic guidelines in place to treat them, says Holly Boisen, R.N., a project manager and Lean specialist with Gundersen.
What bubbled up was a committee of like-minded folks aiming to address the epidemic, including everyone from the legal department to primary care, pain management and information technology. The committee members devised a standard list of operating procedures for how every clinician would care for patients who are coping with chronic pain, outlining responsibilities of each member on the patient care team and stricter guidelines for long-term opioid use.
Today, Gundersen patients must sign a three-page “opioid agreement” before obtaining their pills. Those who break the agreement — whether because they are facing criminal charges, failed a urine screening or missed an appointment — will lose their prescriptions. The system also established a chronic pain registry for patients using Schedule II opioids, with a high potential for abuse, for six consecutive months.
One of the key lessons learned by Gundersen early on was the importance of involving all stakeholders in its chronic pain committee, including patients, Boisen says. Once a hospital’s efforts start to gain momentum in dropping opioid use, the committee must continue to convene, even after hitting its goals. Several years after the initiative launched, the hospital’s pain experts continue meeting regularly because medication standards and patient populations can always change.
Provider resistance was a hurdle as Gundersen worked to standardize prescribing practices. Some doctors didn’t want to believe a urine screening was necessary, and were shocked when trusted patients tested positive for methamphetamines or cocaine. That’s why the hospital continues to stress the importance of education and is exploring making opioid training mandatory for all who write prescriptions. Doctors’ first inclination is often to ease patients’ pain and improve their experience, but opioids don’t always do that, Boisen says.
More meds, more problems
While prescriptions for opioids have skyrocketed — quadrupling since 1999, according to the CDC — there hasn’t been a corresponding drop in pain, Boisen believes. A study by Danish researchers, she notes, even found that patients with chronic pain who were liberally prescribed opioids reported worse pain, higher health care utilization and lower activity levels than those who were not prescribed liberal amounts of opioids.
“The evidence is out there to say that more opioids is not always a good thing,” Boisen says. “We’re giving more people more problems by just giving them more medication.”
A lack of training and standards for doctors was one reason the CDC started developing guidelines, says Deb Houry, M.D., director of its injury center. She says the emphasis in med school when learning about pain often centered around aggressive use of pharmaceuticals and improving patient satisfaction.
Health care’s drive toward value, population health and prevention of disease also helped to propel the CDC toward creating recommendations on curbing opioid use. One of the most important takeaways for hospitals in the new guidelines, Houry says, is to not start with opioids as the first line of defense against chronic pain. The CDC’s strategies, which she hopes will be finalized in the spring, include several steps to take before a doctor even issues a prescription — weighing non-medication alternatives, considering how therapy will be discontinued if a drug fails and discussing the risks of using opioids.
Houry hopes the CDC moves quickly with its recommendations, because dozens of lives are lost every day it waits. “During the 30-day comment period, there were about 1,500 overdose deaths, so we understand the urgency,” she says.
For some, heroin is next step
About 55 percent of those who use prescription painkillers for nonmedical reasons attained them for free from a friend or relative, a 2010 study by the Substance Abuse and Mental Health Services Administration found. Others, cut off from prescription painkillers, are turning to heroin, which is high in purity and cheaper than pills, according to the CDC. Heroin-related deaths skyrocketed by 26 percent year over year in 2014, up to 10,574 deaths, and the strongest risk factor for heroin initiation, the CDC says, is past abuse of opioids.
One would assume that an opioid overdose might be a moment to retool a patient’s care plan and move him or her toward other treatments. However, of those who overdosed on prescription opioids for chronic pain, 91 percent continued to receive a supply of pills, according to a December study by the Boston Medical Center. About 70 percent received that next prescription from the same doctor who wrote the original order. Plus, at two years of follow-up, patients who kept taking a high dose of opioids following that initial overdose were twice as likely to experience another overdose compared with those who discontinued the drug.
It’s possible that the original prescribing physician wasn’t even aware of the overdose if it took place at a different hospital, notes Marc LaRochelle, M.D., a physician in internal medicine with Boston Medical Center and leader of the study. That’s why it’s essential hospitals facilitate easy communication between ED physicians, primary care doctors and clinicians at other outpatient facilities. There are prescription-monitoring programs in 49 states, the study notes, which could be leveraged to help bolster such communication. Or, LaRochelle asks, why not use the public health reporting system for infectious diseases to track addiction waves? Researchers also suggest — because health plans keep track of hospitalizations and prescriptions — that providers require prior authorization before a patient can pick up his or her next bottle of opioid pills after experiencing an overdose.
Beyond interoperability, BMC also has its own more traditional means of treating addiction. Its project ASSERT (Alcohol & Substance Abuse Services, Education and Referral to Treatment), started in 1994, connects emergency department visitors with a variety of services — linking them with primary care, finding a detox program, or even assisting an individual who needs shelter or a ride to a follow-up appointment. More recently, the hospital started an addiction consult service so that anytime someone arrives at the hospital from an overdose, it triggers a mandatory consultation to engage patients with treatment, or notify providers if any concerns pop up in the hospital’s prescription monitoring program. The ED is the engine driving BMC’s opioid strategy, but it’s important that every piece of the hospital plays a role in such efforts.“It’s tough to throw the entire burden onto a busy emergency room provider, but there are ways you can build systems within your hospital to try to respond effectively,” LaRochelle says.
Spectrum Health also is pursuing ways to reach upstream and treat addiction before patients show up in the ED with an overdose. The 12-hospital system recently began requiring its hundreds of employed primary care physicians to screen patients for addiction by asking a couple of simple questions, and testing the urine of those who are pregnant or who reveal signs of drug abuse in their answers. Doctors then use the results to decide whether to refer patients to behavioral therapy and other care, rather than to filter them away from a primary care practice. The goal is to have all 350 employed primary care doctors performing the screen by the end of September, says R. Corey Waller, M.D., an addiction, pain and emergency medicine specialist and medical director of the Spectrum Health Medical Group Center for Integrative Medicine.
Early on, physicians feared that the organization wouldn’t have the resources to treat all the problems that manifested; in the early stages, Waller was the only board-certified addiction doctor in a $5 billion system. But it has since hired other physicians and specialists to the treatment team, doubling his clinic in capacity to meet patient needs as they found them. Worries or stigmas about addiction started to dissipate.
“We’ve seen a lot of resistance go away and now, interestingly enough, a lot of primary care physicians who were worried about having to deal with ‘those patients’ are now feeling empowered to learn more about it and actually treat this no differently than hypertension or high cholesterol,” Waller says.
The first phase was seeking out those who were already addicted; next, Spectrum wants to determine how to prevent future opioid abuse. Leaders plan to build dashboards into the electronic health record so that physicians can compare prescribing habits, both in the system and across the nation, and educate them on how to wean patients off of opioids, and other pain treatment methods. Waller hopes to start training and testing for the next phase in August.
Waller wears many hats, including head of the advocacy committee at the American Society of Addiction Medicine and member of the Michigan Prescription Drug and Opioid Abuse Task Force. He also works with the Robert Wood Johnson Foundation and Camden Coalition of Healthcare Providers in producing more than 50 hours of free video training on pain addiction and behavioral health scheduled to go live in June on a special website, www.complex.care.
Unlike Gundersen, Spectrum didn’t determine its opioid strategy with a formalized committee. Rather, it started with a few nurses and doctors and, eventually, patients, “angry,” Waller says, over the fact that opioid misuse was harming some patients. They began to meet on a regular basis and nailed down a vision and mission. Spectrum leaders recognized the recommendations as “the right thing” but had to figure out how to fund them in a climate in which payers don’t always cover addiction abatement and treatment.
“At the end of the day, once the system coalesced on that focus, then these things just started to drop like dominoes and it was really pretty fun,” Waller says. “When the CFO and the CEO and the strategic development people all understood that this was, in the end, just doing the right thing for every patient who walked in our door, that seemed to be the moment that everybody stopped pushing back and started helping in every way they could.”
12 Ways a Primary Care Team Can Fight Opioid Overuse
The Centers for Disease Control and Prevention recently released a draft proposal for best practices for primary care providers to follow in prescribing opioid pain relievers to adult patients. The guidelines are geared toward those with chronic pain, defined as lasting more than three months, or past the typical time of healing, in patients outside of cancer and end-of-life care.
1. Therapies that don’t use opioids or other pharmaceuticals for chronic pain are preferred. Only consider using opioid therapy if the expected benefits for pain relief will likely outweigh the risks to the patient.
2. Before starting a patient on opioids for chronic pain, set treatment goals with patients related to pain relief and function. Don’t start opioid therapy without first deciding how it will be discontinued if the meds fail, and only continue therapy if clinically meaningful improvement of pain and function is made that outweighs risks to patient safety.
3. Prior to opioid therapy, doctors must discuss known risks, realistic benefits and both parties’ responsibility to manage care.
4. When starting a patient on opioids, prescribe those of the immediate-release variety, rather than extended or long-acting release.
5. Start by prescribing the lowest effective dosage possible, use caution and implement precautions when increasing dosage.
6. Prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three or fewer days are typically sufficient for most non-traumatic pain not tied to major surgery.
7. Weigh the benefits and harms with patients within one to four weeks of starting a patient on opioids. Then evaluate benefits and harms with patients at least every three months, and if those are outweighed by potential harm, work to reduce dosage toward eventual discontinuation.
8. Incorporate into the treatment plan strategies to mitigate risk to the patient, including considering offering naxolone when a patient displays factors that increase risk for opioid overdose.
9. Review the patient’s history of substance use by tapping into the state prescription drug monitoring program to determine whether he or she is receiving high opioid dosages or dangerous combinations that create a higher risk for overdose.
10. Drug test patients before initiating opioid use, and continue such testing at least annually to watch out for other prescribed medications, along with other illicit drugs that show up in screenings.
11. Where possible, avoid prescribing opioid pain meds for those who are receiving benzodiazepines.
12. Offer or arrange evidence-based treatments for patients with an opioid disorder.