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As the opioid epidemic rages, doctors and hospitals should consider these tips and strategies employed by other organizations.
With addiction to opioids and other pain-relieving medications reaching record levels in the United States, at 2 million in 2015-according to the American Society of Addiction Medicine, it’s important for providers to employ strategies to avert dependence. From 1999 to 2015, more than 183,000 people died in the United States from overdoses related to prescription opioids, the CDC reported. Here’s a look at what healthcare providers are doing to decrease dependence.
With the burden of coordination for pain care management following inpatient procedures such as orthopedic surgery typically falling on the surgeon, it’s important to carefully coordinate a patient’s narcotic prescriptions with the primary care physician, says Greg Sullivan, MD, who is board-certified in internal medicine and addiction medicine. “Prescription monitoring of every patient for six months after discharge is particularly important, in that post-discharge, patients are often seen for follow-up by multiple providers, with overlapping prescriptions for narcotics quite common,” he says. “It’s best to pick a single physician source for pain medication, and particularly effective to allow the provider that is also formulating rehabilitation plans to provide that pain medication.”
Patients who take opiates for two months have a marked increase risk of continuing those opiates chronically, says Sullivan, who is also a clinical investigator focused on safer alternatives to full-agonist opioids, and is chief scientific officer of pharma start-up Bridge Therapeutics. “These patients find it difficult to wean from those medications after an illness or surgical episode has resolved, and they are unable to get off the medications because of withdrawal or other dependence issues. Providers should have a definite exit strategy that involves weaning patients off of pain medications to less addicting agents early on, to help with the process of returning the patient to a normal livelihood without the need for chronic opiates.”
To prevent opioid misuse in both chronic and acute care patients, Allina Health, a large healthcare system based in Minneapolis, Minnesota, evaluated how it managed acute noncancer pain in the outpatient setting, particularly among opioid-naïve patients.
Nicole M. Kveton, RN, MHA, vice president, quality, value, and nursing at Allina Health Group, says data analysts used the Health Catalyst Analytics Platform and Data Warehouse to obtain data on prescribing patterns for the acute pain committee to review, including data for specific medications, differences in prescribing patterns between and among specialties, and data on each provider’s prescribing practices.
Following the data review, the committee identified opportunities to reduce the number of patients prescribed more than 20 pills in one prescription for acute pain. “This would lower the risk of long-term use or abuse and reduce the potential for opioids being diverted into the community,” Kveton says. “The committee then developed a comprehensive guideline for the appropriate use of opioids in patients with acute pain, and has plans to develop a chronic pain guideline as well.” All providers were required to complete a newly developed education program.
To support providers in following the new guidelines, Allina revised its electronic health record system, developing a structured order set and progress note to aid in adherence to the chronic pain management guideline. “In this order set, providers have all the tools needed to guide them in the proper protocol for prescribing opioids, including access to the state’s Prescription Monitoring Program, a link to Allina’s guideline, risk assessment tools, a calculator for confirming appropriate opiate dosage, and a link to the Minnesota Board of Medical Practice pain management guidelines,” Kveton says.
Providers and care team members need to have conversations with their patients, setting clear expectations and encouraging shared decision making on the best approach for managing pain, including possible alternative treatments, such as acupuncture, massage, and non-opioid medication, Kveton says. As a result Allina developed education materials to enable providers and care team members to have effective conversations.
As a result of the above Allina initiatives, 980,527 fewer opioid pills were prescribed in the outpatient setting in 2016, a 12% reduction, says Kevton.
Ira B. Fox, MD, cofounder, Tamarac, Florida-based Anesthesia Pain Care Consultants, says the best way to treat chronic pain is to properly identify the source. At his facility, providers obtain a patient’s medical history, review radiography, conduct a physical exam, and perform a medication reconciliation. Patients also complete a survey about the origin and intensity of their pain. Physical therapy and conservative treatments are initially recommended; new radiography is prescribed as needed.
In addition, Fox uses interventional pain management techniques such as administering injections under fluoroscopy to determine the actual source of pain based on a patient’s response. “This enables us to treat the pain at its origin, making it less necessary to administer pain medications over time,” he says.
For patients with the most serious chronic pain conditions such as late stage metastasized cancers or spinal cord injuries, Anesthesia Pain Care Consultants has had great success with implanting intrathecal pain pumps, which deliver pain medications directly into the spinal canal-often reducing dosages by up to 99%.
Myrtle Hilliard Davis Comprehensive Health Centers in St. Louis, Missouri, which is affiliated with Logan University, in Chesterfield, Missouri, introduced chiropractic care in an effort to curb opioid prescription rates. “The medical doctors at this facility can refer patients in-house for a trial of conservative care before resorting to prescribing opioids,” says chiropractor Ross Mattox, DC. “The chiropractor can identify complicating factors during treatment, such as behavioral health issues or diabetic foot problems, and refer patients to other providers who specialize in those conditions.”
Some patients get better with the trial of conservative care and never need an opioid prescription. Others report that after starting chiropractic care, they no longer feel the need to take the opioids they were previously prescribed. “Because we are working in an integrated setting, it is easy to communicate between doctors and share notes on a patient’s progress or lack thereof,” Mattox says.
In an effort to battle the epidemic, the Accreditation Association for Ambulatory Health Care developed and released an opioid stewardship toolkit derived from CDC guidelines.
Naomi Kuznets, PhD, vice president and senior director of quality improvement for the institute, says using standardized pain scales to accurately assess pain pre- and post- prescribing can ensure that if opioids are prescribed, they decrease pain satisfactorily.
But she says most important tool may be communication with the patient. “This includes not only helping patients understand the benefits and dangers of opioid use, but also helping patients set realistic expectations with regard to pain control and teaching them about non-opioid medications or therapies,” Kuznets says.
Sullivan says providers should be re-educated that the goal of “zero pain” for patients is not a realistic one. Pain can be managed adequately without overprescribing, he explains. In addition, tools such as the SOAPP-R and CAGE-AID opioid risk scales can identify patients who may be at risk for opioid addiction so that they can be monitored closely.