Penn Medicine Confronts the Opioid Crisis

The Penn Medicine Opioid Task Force was established in 2017 as a system-wide program in response to the nationwide opioid crisis. The principle objectives of the Task Force are to align opioid guidelines across Penn Medicine, reduce the total number of opioid doses prescribed, diminish dependence on opioids, and raise the standard of care for patients with acute and chronic pain.

Pain management is problematic in any medical locale, but is particularly complicated in academic medicine, where complex chronic conditions and disease are more common than in the community setting. Beyond this consideration are the needs and expectations of a patient population that has come to see pain management as a right, but is increasingly vulnerable, by all indications, to addiction and its devastating effects.

Given these circumstances and what is now clearly a nationwide calamity in terms of opioid overdose deaths, the Opioid Task Force at Penn Medicine recently engaged colleagues across the spectrum of care – including Orthopaedics – to design an algorithm for opioid prescriptions that would confront the crisis head on.

The Penn Opioid Task Force in Action

Among the specialists leading this effort were Michael Ashburn, MD, MPH, MBA, Director of Penn Pain Medicine and Palliative Care, and Eric L. Hume, MD, Joint Replacement surgeon at Penn Orthopaedics with specialization in chronic bone diseases.

“What Drs. Ashburn and Hume proposed was that we consider other options for pain management,” says Penn Orthopaedics nurse navigator Krista Tarducci, MSN, RN. “They suggested, for example, that we limit the pill count and prescription term for opioids, eliminate certain extended-release opioids altogether, and substitute NSAIDS instead to prevent overuse.”

“Penn Orthopaedics Provider Erin Nardella, PA-C did a study in the summer of 2018 that found many patients needed fewer than 60 pills after discharge for their pain management,” says Hannah Lacko, Director of Quality and Patient Safety at Penn Orthopaedics. “For these patients, the count was reduced to 30 pills, with a single refill of 20 additional pills.”

A second study is underway to follow up with patients using fewer pills to determine, if possible, whether they are free of pain and to rate their satisfaction with the new program.

Patient Education

In addition to updating the actual order sets, pain management specialists at Penn Medicine were enlisted to put together a patient letter that is placed in the surgery consent packet. The specific benefit of the letter is to educate patients about their prescription, set appropriate expectations for their adherence and instill in them the concept of responsible self-care.

“The letter spells out exactly what medications a patient is going to be prescribed post-op,” says Tarducci. “Patients are required to sign this letter, so they know which prescriptions they’re going to have after surgery before they arrive.”

To further ensure patient adherence to the opioid prescription management program, the Prescription Drug Monitoring Program (PDMP) is available to all prescribers; the PDMP tracks patients to ensure they’re not visiting multiple prescribers.

“It’s very thorough – it tells you who prescribed, when, and how many tablets, and because the PDMP is now integrated into EPIC, physicians don’t even need to open a new window to use it.” — Hannah Lacko

Handling Addiction

The designers of the pain protocol at Penn Medicine didn’t ignore the reality that some patients would be addicted to opioids at the inception of care.

“We’re very attentive to these patients,” Tarducci says. “Everyone gets a drug screen, and patients that need to wean down before surgery are managed.”

Individuals unable to wean from opioids entirely prior to needed surgery are titrated down from their prescribing dose, adds Tarducci.

“We may give these patients a low dose, say five mg, to help them through until they can see their pain management doctor or primary care doctor,” she explains. “They’re well aware that they have to go to another source for their meds from that point on, however.”

Pain protocol evaluation at Penn Orthopaedics

The dilemma of pain management is perhaps nowhere better represented at Penn Medicine than within the Department of Orthopaedic Surgery, where Dr. Eric Hume and Dr. Michael Ashburn led the implementation of the Multi-modal Perioperative Pain Protocol, or MP3, used to manage pain for joint replacement patients.

Adopted several years ago, MP3 was developed to address the significant pain management needs of hip and knee replacement. Because MP3 predates the current Opioid Task Force, Penn Orthopaedics has been ahead of the curve in their approach to managing opioid usage. The MP3 protocol has been reviewed consistently, however, to ensure its alignment with the wider program with regard to opioid prescription behavior and pain management goals and to identify opportunities for improvement.

“What brought about the MP3 protocol was our surgeon’s sense that a balance was needed between prescribing too much, with its known risks, and prescribing too little, with the possibility that patients would be in pain,” Tarducci said recently. “Given this challenge, Drs. Hume and Ashburn sought in the MP3 protocol to find the means in the short-term to alleviate pain without establishing the foundation for addiction.”

Pain protocols across every section of orthopaedic surgery have since been evaluated, revised and optimized to coincide with the principles of Penn’s Opioid Task Force. By keeping these the goals of optimal pain management and dependency avoidance at the forefront of each pain management plan, Penn believes we will be able to turn the tide on the opioid epidemic.