Confronting a Crisis 2017: HealthTrust Innovation Grant winner battles drug epidemic with perioperative opioid stewardship program
In 2014, providers wrote nearly a quarter of a billion opioid prescriptions. The intention may have been noble—to alleviate patient pain—but the fallout has been devastating. Since 1999, sales of opioid prescriptions have quadrupled, and so have overdose deaths involving prescription opioids.
As the government and other public health agencies sound the alarm on this nationwide crisis, healthcare providers around the country are looking at the role they can play in curbing the opioid epidemic. At San Diego-based Scripps Health, a multidisciplinary team of clinicians has developed an opioid stewardship program (OSP) that aims to fundamentally change the attitudes and expectations prescribers, nurses, patients and their at-home caregivers have about pain and how it should be managed.
As the winner of the 2017 HealthTrust Innovation Grant, the Scripps Health team—M. Jonathan Worsey, M.D., and David Dockweiler, M.D., co-chairs of the surgery care line; Valerie Norton, M.D., chair of the systemwide pharmacy and therapeutics council; Melissa Flaherty, PharmD, clinical pharmacy director and co-chair of the systemwide pharmacy and therapeutics council; and Emily Hernandez, RN, MSN, clinical resource specialist in supply chain—received a $25,000 cash award and $25,000 in HealthTrust service line expertise to help launch this important program and support sharing it across the HealthTrust membership.
The overarching goal of the OSP is “to decrease the amount and duration of opioid usage in an organized way across the spectrum of care, in response to the ongoing opioid epidemic,” Worsey says. And his health system is clearly on board: After a formal presentation by Flaherty and Norton, Chief Medical Officer Jim LaBelle and the rest of the Scripps Health leadership team quickly endorsed the opioid stewardship approach. Dockweiler took on the task of educating fellow physicians during grand rounds, and Norton, Worsey, Flaherty and the OSP’s Executive Sponsor Lisa Thakur (corporate vice president of OR, pharmacy and supply chain) worked to achieve buy-in for the program across the enterprise.
“Our medical staff has been overwhelmingly supportive and passionate about this initiative, raising the awareness and our call to action among their peers,” Flaherty says.
The Catalyst for Change
The idea for the initiative emerged last spring after the team participated in the HealthTrust Perioperative Pain Management Collaboration Summit, which brought clinical leaders from five health systems together to create provider-specific action plans for building programs to manage surgical pain using fewer opioids. (See story on page 70 for an update on what other participating health systems have accomplished since the summit.) During the two-day event, the role of healthcare professionals in the opioid crisis was a key component of the discussion.
“Before the summit, we knew there was an opioid epidemic, but saw it more as something that affected chronic pain patients,” Norton says. “We hadn’t wrapped our heads around the fact that providers might actually be creating some of these dependency situations in opioid-naive populations. The summit really opened our eyes to this and let us see that we can play a pivotal role in prevention.”
Scripps Health leaders developed the OSP with five key factors in mind:
1. Opioid overuse and misuse is often a healthcare-acquired condition, one that Scripps Health has no formal program to address.
2. Six percent of opioid-naive patients become chronic opioid users after routine surgery.
3. Orthopedic spinal surgeons are challenged with patients who have chronic pain syndrome prior to spinal surgery; these patients are among the most complex in terms of perioperative pain management, and remain difficult to manage after surgery. Scripps does not have the specialty resources to support these patients perioperatively and thereafter.
4. Lawmakers and payers are setting refill limits on opioids and requiring prior authorization to renew prescriptions for ongoing pain.
5. The Joint Commission recently announced new and revised pain assessment and management standards, including requirements for safe opioid prescribing, effective Jan. 1, 2018.
Changing Patient Expectations
The first wave of OSP implementation is focused on preventing surgery patients from becoming chronic opioid users. At the heart of the initiative is a series of education-oriented interventions delivered across episodes of care—starting with a patient’s initial visit to the hospital or physician’s office—and continuing for three months after surgery.
These interventions will help set realistic expectations of postoperative pain and ensure a clear understanding of the side effects of opioids, including the potential for addiction, abuse and diversion. Patients will be contacted at 30, 60 and 90 days; asked about continued opioid use and potential side effects; and counseled on the safe disposal of unused opioids.
“Many patients think they should have no pain after surgery, and that if they do, we’re not doing our jobs,” Norton says. “Through these educational materials, we want to show them that some pain after surgery is normal, the risks associated with opioid use are real, and there are other ways to manage pain that don’t involve opioids.”
The team plans to use the grant funding from HealthTrust to partially offset the cost of producing the patient education materials, which will include print brochures and videos tailored to different types of patients. A former newscaster working in the Scripps Health education department is even preparing a short informational video for posting on YouTube.
Initially, the focus will be on general and gynecological surgeries that are part of the enhanced recovery after surgery (ERAS) pathway. “ERAS is a good starting point because rapid recovery protocols already promote the use of multimodal pain management over opioids,” Worsey says. “Research shows that opioid overuse or prolonged use slows recovery time, lengthens hospital stays and increases the risk of complications.”
Reforming Prescriber Habits
In addition to developing educational materials targeted to patients, the team will also work to change the mindsets and prescribing habits of clinicians.
“This is as much about changing patients’ expectations of pain as it is about changing prescribing habits that are decades in the making,” Worsey adds. Some of the overprescribing of opioids can be traced to 1996, when the American Pain Society declared that pain was the fifth vital sign—and that it was being undertreated. As a result, in 2001 The Joint Commission established its first standards for pain assessment and treatment.
“After the standards were published, physicians responded appropriately by prescribing more pain medication, predominantly opioids,” Worsey says. “This has clearly contributed to the problem we have now. It’s time to change the way physicians think about pain.”
Nurses need a fresh perspective, too, Hernandez says, since they are often the ones assessing pain and dispensing medications.
“As nurses, we’ve always been grateful to receive an opioid prescription for our patients in pain,” Hernandez says. “Now, we’re asking patients to tolerate a bit more pain and be open to other treatment options. That’s a huge shift; the challenge will definitely be in how best to communicate this for understanding and acceptance.”
Scripps Health is assembling an opioid stewardship committee, composed of physician champions like Norton, Worsey and Dockweiler; pharmacists and nurses; and other clinicians from across the enterprise, including those in primary care, emergency medicine, anesthesiology, surgery and hospice care. The committee will be tasked with developing and disseminating patient and clinician education, as well as creating enterprisewide policies to identify patients at high risk of opioid abuse. It will also be responsible for tracking outcomes related to the initiative. Pharmacists will drive appropriate tapering schedules for postoperative opioid use and encourage the use of non-opioid pain relief options, among other interventions for acute, post-acute and ambulatory patients.
Norton has developed a newsletter for physicians and nurses that talks about goals of the opioid stewardship program, the role of clinicians in preventing addiction and effective non-opioid pharmaceutical cocktails. The newsletter includes program mantras such as “Opioids are not benign,” and “Complete pain relief is not a reasonable or healthy goal: We need to reset patient expectations.”
Moving forward, post-discharge phone calls with surgical patients will track if and when prescribed opioids were discontinued, Worsey says. Opioid use and adverse events related to opioid consumption in the hospital will be tracked and compared to historical data on matched patient populations. Readmissions or ED visits for opioid-related issues in these patients will also be measured. And, to provide feedback from the perspective of patients, a survey will be developed to evaluate satisfaction with post-operative pain management and perceptions of multimodal pain management.
Scripps Health will also provide instructions on how patients should dispose of excess pills to eliminate the risk of their diversion to someone else, including teenagers or anyone with access to leftover medicines. Meanwhile, prescribing physicians will monitor California’s Controlled Substance Utilization Review and Evaluation System (CURES) for one of the early telltale signs of addiction—doctor-shopping for more opioids.
While Norton acknowledges that opioid stewardship will require a shift in patient expectations, she doesn’t expect it to have a negative impact on patient satisfaction.
“Studies have shown that when we take the time to explain our decisions, patients get the message that we are concerned about them,” she says. “This is not us being punitive. We care, which is why we want to limit their exposure to opioids.”
The challenge will be getting this message across clearly and consistently, which Worsey says is aided by more and more patients realizing the gravity of the opioid epidemic.
“The response of our colleagues has been amazing,” he says. “Without exception, they want to know how they can help.”
By next summer, Norton expects all ERAS patients to have access to the patient education materials. Eventually, the program will expand to spine surgery and orthopedics. The team wants to develop similar prevention content for nonsurgical patients, including those in inpatient, ambulatory and emergency settings, as well as a standardized approach to managing patients who are already opioid-dependent.
“We’ll look to create better connections with pain specialists and addiction medicine specialists around the county,” Worsey says, “and educate our colleagues about resources to help patients experiencing withdrawal symptoms.”