It’s a “public health emergency,” according to the Department of Health and Human Services. “Unprecedented” is how the Health Resources & Service Administration describes it. Indeed, the numbers are sobering:
- Overdose deaths involving opioids – both prescription and illegal --- increased fivefold between 1999 and 2016.
- More than 42,000 deaths occurred in 2016 alone, more than any previous year on record.
- Every day, on average, 115 Americans die from an opioid overdose.
For the past two years, Penn Medicine’s opioid task force – a multidisciplinary team from throughout the Health System – has been putting strategies in place to fight this epidemic on many fronts. From right-sizing opioid prescriptions and encouraging alternative approaches to managing pain, to helping those already addicted, the efforts are making a difference. Indeed, since FY2017, number of prescribed opioid tablets throughout the Health System has decreased 16.5 percent – the equivalent of nearly two million tablets!
Five Pills …. Or Less
Historically, physicians have prescribed larger amounts of opioid pain medications to keep post-surgical or acute pain at a minimum. But literature showed that, in many cases, the number of prescribed pills far exceeded the number needed and that prescribing higher opioid doses did not improve pain control. For example, one Penn study examined the use of opioids for cesarean sections and discovered that “in many cases we were overprescribing – sometimes fairly dramatically – the number of opioids for this procedure,” said Michael Ashburn, MD, MPH, of Anesthesiology and Critical Care.
To reverse this trend, the opioid task force has collaborated with several clinical departments to help them create care pathways on Penn Chart (the health system’s electronic medical record system) that follow “best practices” for specific procedures, including knee arthroscopy, joint replacement, and even spine surgery. The pathways – which are evidence-based bundles of care for providers to follow – support the use of innovative anesthesia techniques, including regional anesthesia whenever possible;
multiple pain medications, such as oral non-steroidal anti-inflammatory drugs (NSAIDs), (e.g., ibuprofen and acetaminophen); as well as early post-surgical mobilization and other recommendations of the “Early Recovery After Surgery” national effort, which have been associated with shorter length of stay, adequate pain control and less opioid use.
The care bundles limit opioid prescribing to the lowest number of tablets for the shortest period of time, based on the needs of patients undergoing that specific procedure. For most outpatient surgical procedures, it’s often five days or less. “The use of procedure-specific order sets allows providers to more easily prescribe the established multi-modal medications following surgery and avoid prescribing excessive amounts of opioids,” Ashburn said.
National guidelines encourage providers to prescribe no more than a five-day supply of opioids in the initial prescription. To help physicians adhere to these guidelines, opioid orders on Penn Chart automatically default to five days. “If a physician tries to prescribe longer than five days, an alert [aka ‘nudge’] pops up, basically asking ‘Is that the right thing to do?’” said David Horowitz, MD, associate chief medical officer of UPHS. While a physician can override the default based on an individual patient’s needs, this automatic reminder “makes it easier for people to do the right thing and harder to do the wrong thing,” Ashburn said.
Patients already on chronic opioids before surgery often experience poor pain control and longer hospital stays. Studies show that changes in anesthesia and pain management can improve pain control and patient outcomes for these patients. Ashburn said that while the best way to help these patients is to “get them down or off the opioids before surgery,” using regional anesthesia, either alone or in combination with sedation or general anesthesia – and changing the drugs that are given during the course of anesthesia – can improve post-surgical pain control.
The Power of Technology
While the opioid task force helped surgeons develop pathways to lower opioid use, Information Services made sure the impact was systemwide. By integrating order sets and pathways into Penn Chart, any Penn provider -- whether at HUP, Chester County or Princeton Health – can easily access them and make them part of their practice. “This not only spreads best practices across the Health System, but also reduces variation in care and provides an opportunity to improve patient outcomes,” said Christine Vanzandbergen, MPH, MS, PA-C, AVP of IS Applications.
The task force also teamed with IS to integrate the state’s prescription drug monitoring program (PDMP) into Penn Chart. According to Horowitz, before prescribing opioids, providers must first check the PDMP to access a patient’s prescription history within the state. Previously, this required going to the state’s website, searching for the patient’s name … and waiting for results. Now, with a single click in Penn Chart, “the system does the query for you and puts the information on the chart,” Horowitz said. Vanzandbergen said IS is now looking into integrating New Jersey’s databases into Penn Chart.
More recently, IS has made it possible for clinicians to prescribe controlled substances electronically. The prescription goes directly from the patient’s record to the pharmacy, making it both easier … and safer from fraud. Previously Penn Chart only allowed providers to electronically prescribe medications that were not controlled substances.
Monitoring the impact of these strategies requires systemwide analytics. IS created a dashboard to measure how well certain metrics -- defined by the opioid task force -- are being met. These metrics include making sure patients receiving opioids for chronic noncancer pain have signed an opioid agreement, which ensures their understanding the implications of using opioids on an ongoing basis. Others include documentation that the patient has seen a physician within three months of an opioid prescription, that a urine drug screen has been obtained within one year, and whether the patient is also receiving benzodiazepines (Valium-like medications) in addition to opioids, “a dangerous combination,” Horowitz said.
The opioid dashboard also has performance measures for acute (initial) opioid prescribing. For this, the dashboard provides information on how many patients are on opioids, the average number of days for each prescription, and total number of prescribed opioid tablets.
All of the metrics can be measured systemwide, by department/division, or for an individual provider. “The dashboard has allowed us to have almost real-time performance measures on a host of important data points,” said Charles Orellana, MD, senior medical director of Clinical Care Associates. “Both our clinicians and practice leaders can access the data so they can monitor their own performances.”
Other collaborations between the Opioid Task Force and IS include creating the Penn Medicine Opioid Stewardship site – a tremendous resource for providers – as well as a continuing medical education (CME) course on opioid prescribing on Knowledge Link which provides one of two CME credits necessary to renew a medical license.
The key to this solid partnership, Vanzandbergen said, is the multidisciplinary IT subcommittee, with representatives from IS, the office of the chief medical information officer, and providers from inpatient, ambulatory, primary care and emergency medicine practices who work together to translate what the task force wants into reality. “The comprehensive representation can be challenging but it speaks to why it’s so successful,” she said.
Getting Addicts the Help They Need
Lancaster General Health screens all inpatient, day surgery, and overnight and observation patients with a single substance question. If a patient states that he/she has opioid misuse, there is an automatic drug and alcohol consultation.
But that quick access is not the case for many addicted to opioids. Indeed, with restricted access to prescribed opiates -- and growing availability of illicit sources of heroin and fentanyl to fill the void -- the number of overdoses has skyrocketed. “We’re seeing massive increases in the number of people coming to hospitals with drug overdoses or addiction problems who need help,” said Jeanmarie Perrone, MD, of Emergency Medicine. “Visits to EDs for overdosing have tripled in the past couple years.”
The problem, she said, is that people with dependence and addiction often have nowhere to turn. But, now, Perrone has introduced into HUP a new program that uses the ED as an “open door to help.” The program provides opioid replacement therapy to people who enter the ED in withdrawal and then connects them to treatment, directly from the ED.
Perrone is working with care coordinators at the Center of Excellence at PPMC, (designated by the state Department of Human Services), who “meet the patient face to face and hand them off to a group that is ready and waiting to help them,” she said. “It’s a ‘warm-hand’ offer – we’re not just letting them dangle.” (Read more about the Center in this August 2018 blog post)
The challenge, Perrone said, is keeping the patient in the ED long enough to make the connection. “We can’t hold people very long. That’s part of the problem.” She is leading efforts to create a “new pathway that would include a longer window to get them into treatment. If we are able to give them a few doses of buprenorphine [opioid replacement therapy] and put them in an observation unit for 12 to 24 hours, we can connect with social workers in the COE program.”
Perrone said that HAP (Hospital and Healthsystem Association of Pennsylvania) is providing funding “to get these important meds into the ED and connect patients with treatment,” she said, adding that she’s like to extend the program to all EDs in the Health System.
“The ED has to be a gateway for these patients – it’s always open and it’s important for us to provide that source,” she said. “The number of people using heroin and fentanyl is only going up.”