Controlling Controlled Substances

Technology to Fight Opioid Diversion

The opioid epidemic has grabbed national headlines in recent years. But the problem has actually been a pressing one for more than a decade, spurring new regulations across healthcare, says Mark Walsh, PharmD, director of clinical pharmacy strategies for HealthTrust.

Mark Walsh

For instance, it has been 18 years since York Hospital in York, Pennsylvania, organized a team to focus on ways to treat pain that minimizes the potential for opioid addiction. “Our pain team has always focused on recognizing that every patient has the potential for addiction,” says Robert Patti, PharmD, manager of clinical pharmacy services. “We try to consider a variety of ways to treat pain beyond opioids, including the use of non-addictive drugs like ibuprofen and therapies such as music, massage or visual distraction.”

While opioids have their place in the treatment of pain, until recently, few facilities have been able to keep a tight rein on their usage. Increased attention and regulation were aimed at fighting opioid addiction, but loopholes in the system allowed patients access to more pills than they needed. This created a surplus that was prime for diversion, which can happen at any point in the drug supply chain—from manufacturing to retail to healthcare professional and down to the patient level.

“People have been sent home from surgeries and hospitalizations with way too many pills, and for a long time this practice was a blind spot for facilities and health systems in the effort to curb opiate addictions,” Walsh explains.

Robert Patti

Because pain management had become an important part of HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores, facilities were incentivized to put a high focus on controlling patients’ pain levels, Walsh adds. But those efforts might have contributed to opioid misuse.

Today, new technologies are available to help track and trace opioid prescriptions and prescribers in an effort to curb diversion, with an increasing number of facilities joining in with innovative practices. Consider these four examples:

1. RFID chips. After the FDA approved prescription pills that contain RFID microchips in 2012, this technology was used to study the utilization habits of patients who were prescribed opiates in certain settings. According to Walsh, “The RFID chips could show whether the patients actually ingested the pills or not, and the data showed that most patients just needed two or three days’ worth of opioids after surgery. This was an important revelation as, historically, many patients were sent home post-surgery with up to a 30-day supply.”

Given that data, physicians are decreasing the number of pills prescribed to patients—with some facilities also requiring a decrease. This move helps ensure that the prescribed pills will be used and not diverted to others without prescriptions.

2. Narcotic audits. Until recently, York Hospital had relied on a tedious manual process to compare its automated medication dispensing system transactions to the electronic medical record (EMR). Now, the hospital is leveraging its new EMR data to streamline monthly narcotic audits. While it’s still a work in progress, the technology is allowing hospital personnel to “eliminate the noise and focus on the transactions that send up red flags,” says Mary Crerand, R.Ph., quality assessment manager for York’s inpatient pharmacy services.

To get a detailed narcotic audit, York is using these reports:

• Inpatient unreconciled dispenses report, which looks for undocumented medication administration or returns.

• Undocumented wastes report, which examines partial doses pulled from the automated dispensing system that are not wasted during removal.

• Activity report of overrides, which looks for every medication pulled on override, including those not captured in the inpatient unreconciled dispenses report.

After reviewing these reports, Crerand’s team compiles a list of highlighted transactions and forwards the results to individual nurse managers for follow up and documents the occurrences in the master file. In addition, the group runs several monthly anesthesia audits comparing the automated dispensing system’s pull of 100 medications to what is recorded in the anesthesia record.

Even when York Hospital was using a manual process, “because we were looking, we found suspicious activity,” Crerand explains. “Working with a team from human resources, employee health and nursing, we could protect our patients and get staff the help they needed.”

3. E-prescribing systems. “It’s almost impossible to track prescribing patterns with paper prescriptions, but as more healthcare facilities move to electronic prescribing systems, they’re able to evaluate the patterns of their particular providers,” Walsh says. “Facilities and hospital systems can begin to use this data to evaluate providers and look for trends and responsible prescribing of opioids.”

Health systems that use e-prescribing can look at the data and score providers against each other to see if there are any outliers, Walsh adds. “If there are, the facilities can be proactive in providing training and information to those physicians to help them better control the opioids for which they are responsible.”

Recently, York Hospital created a multimodal order set in conjunction with its electronic prescribing system. “When a physician orders opioids, they are presented with an option for a non-opioid treatment to consider,” Patti says. “Our order set also limits how long the order for an opioid will be active in the system; the order is available for 72 hours and doctors get a reminder notice 24 hours before it expires so they can decide if the patient still needs it.”

Also, York is utilizing surveillance software combined with protocol changes to minimize opioid orders on patients’ charts and converting intravenous orders to oral therapy as soon as possible. As Patti explains, if a patient has an active order for patient-controlled analgesia, separate orders for intermittent doses of injectable opioids will be discontinued. Additionally, if a patient is tolerating other scheduled oral medications, intravenous opioid orders will be discontinued and replaced with oral options.

4. State databases for monitoring controlled substances. Many states employ a prescription drug monitoring program, a database that helps them track and address their residents’ prescription drug abuse, addiction and diversion. These databases contain controlled substance prescription information, often provided by retail pharmacies, which can include patient, medication and provider level details.

“States can use this information to try to track patients who might be doctor shopping or identify prescribers who may be outliers in comparison to their peers,” Walsh explains. “Some states encourage physicians to check these controlled substance databases to evaluate patients’ recent controlled substance prescriptions and use this information to augment their exam and patient interview.”

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