No hospital is safe from the effects of an opioid epidemic that’s raging across America, and neither is any patient. An estimated 44 people die every day in the United States from overuse of powerful prescription painkillers, from teens to senior citizens, in isolated rural towns and large cities alike.
The year 2014 set a high-water mark for the number of overdose deaths from opioids — including commonly prescribed oxycodone and hydrocodone, alongside illegal drugs like heroin — at 28,647, according to the Centers for Disease Control and Prevention.
The epidemic is clearly worsening, the agency believes, with the number of opioid deaths quadrupling since 2000. As a result, President Barack Obama last month proposed adding $1.1 billion in federal funding to address the problem, with $1 billion going toward expanded access to treatment and $90 million toward supporting drug overdose prevention strategies.
On the ground, the health care field is working to reverse the trend and raise awareness of the problem. “I don’t think it’s getting the attention that it needs to get on a national stage, and I’m worried about a generation here that is at risk,” says Peter Holden, president and CEO of Beth Israel Deaconess Hospital in Plymouth, Mass., one of the states where the growth in opioid-linked deaths is particularly acute. "We have had [patient] overdoses in our emergency room from the ages of 13 to 69, in three-piece suits or cutoff blue jeans. This knows no age barriers, no class barriers, no racial barriers. It’s just hideous," Holden says.
The commonwealth has been ravaged by opioid use, with nearly 1,300 drug overdose deaths in 2014, an uptick of 19 percent compared with those of the previous year, making it one of 14 states where the problem is growing fastest, according to the CDC.
To combat the problem, the Massachusetts Hospital Association helped form a field task force that has found some early success with nine recommended best practices for managing opioids in the emergency department. The guidelines include everything from refusing to replace lost or stolen controlled substances, to counseling ED visitors on how to store and dispose of medications properly. All 51 MHA member EDs have put the nine recommendations in place, and some, such as Beth Israel Plymouth, believe they’re starting to move the needle on opioid use. In the five months after implementation, the number of such painkillers prescribed has dropped by 25 percent. They’re now moving on to Phase 2, developing the same best practices for every other area of the institution where prescriptions are written — surgery, inpatient, etc.
“I absolutely believe that we are reducing the amount of unnecessary pills that find their way into the streets,” Holden says.
That type of collaboration among hospitals is taking place across the country, says Evelyn Knolle, senior associate director of policy at the American Hospital Association.
Provider organizations are desperately seeking guidance on the safe prescribing of opioids for pain, and the association in January urged the CDC to move swiftly to finalize guidelines the agency released in draft form in December. “As your data so clearly show, the dangers are substantial and the need for sound guidance to steer clinical activities is urgent,” the AHA wrote.
In the meantime, the association is gathering best practices from the field on how to address the epidemic and properly manage pain without causing harm. It planned a March 8 webinar with Holden and other Massachusetts trailblazers to discuss their “groundbreaking efforts," which is available now at www.hpoe.org.
Hospitals must find a way to strike a balance between undertreating chronic pain and overprescribing opioids, and the AHA is compiling tools and education to help hospitals and doctors do so, Knolle says. “It’s a big problem,” she says. “Our members are seeing it every day on the front lines, and they are engaged in many different ways to help fight it.”
Among the health systems taking a concentrated approach to ensuring opioids are prescribed properly and that patients addicted to opioids get appropriate treatment is Gundersen Health System, La Crosse, Wis.; Boston Medical Center; and Spectrum Health, Grand Rapids, Mich.
Taking steps before the prescription is written
While some hospitals are just getting started stemming the opioid tide, Gundersen Health System has been at it for years. Back in 2008, a pain med specialist with the system set about ensuring that primary care doctors better understood patients' battling chronic pain and had systematic guidelines in place to treat them, says Holly Boisen, R.N., a project manager and Lean specialist with Gundersen.
What bubbled up was a committee of like-minded folks aiming to address the epidemic, including everyone from the legal department to primary care, pain management and information technology. The committee members devised a standard list of operating procedures to assist every clinician in caring for patients who were coping with chronic pain, outlining responsibilities of each member on the care team, and stricter guidelines for long-term opioid use.
Today, Gundersen patients must sign a three-page “opioid agreement” before obtaining their pills. Those who break the agreement — whether because they are facing criminal charges, failed a urine screening or missed an appointment — will lose their prescriptions. The 325-bed health system also established a “chronic pain registry” for patients using Schedule II opioids, with a high potential for abuse, for six consecutive months. The roster of patients on the list has swelled by almost 10 percent in the past year, up to 2,300 users, Boisen says.
One of the key lessons learned by Gundersen early on was the importance of involving all stakeholders in its chronic pain committee, including patients, Boisen says. And, once a hospital’s efforts start to gain momentum in dropping opioid use, the committee must continue to convene, even after hitting its goals. Several years after the initiative launched, the Wisconsin hospital’s pain experts continue meeting regularly because medication standards and patient populations can always change.
Provider resistance was a hurdle as Gundersen worked to standardize prescribing practices. Some doctors didn’t want to believe a urine screening was necessary, and were shocked when trusted patients tested positive for meth or cocaine. That’s why the hospital continues to stress the importance of education and is exploring making opioid training mandatory for all who write prescriptions. Doctors’ first inclination is often to ease patients’ pain and improve their experience, but opioids don’t always perform that task, Boisen says.
While prescriptions for opioids have skyrocketed — quadrupling since 1999, according to the CDC — there hasn’t been a corresponding drop in pain, she believes. One study by Danish researchers, she notes, even found that chronic pain patients who were liberally prescribed opioids reported worse pain, higher health care utilization and lower activity levels compared with those who did not.
“The evidence is out there to say that more opioids are not always a good thing,” Boisen says. “It’s not helping. It’s not doing anything for the patient. We’re giving more people more problems by just giving them more medication.”
A lack of training and standards for doctors was one reason the CDC started developing guidelines, says Deb Houry, M.D., director of its injury center. She says the emphasis in med school when learning about pain often centered around aggressive use of pharmaceuticals and improving patient satisfaction.
Health care’s drive toward value, population health and prevention of disease also helped to propel the CDC toward creating recommendations on curbing opioid use. One of the most important takeaways for hospitals in the new guidelines, Houry says, is to not start with opioids as the first line of defense against chronic pain. The CDC’s strategies, which she hopes will be finalized sometime in the spring, include several steps to take before a doctor even issues a prescription — weighing non-medication alternatives, considering how therapy will be discontinued if a drug fails and discussing the real risks of using opioids.
Houry hopes the CDC can move quickly with its recommendations, because dozens of lives are lost every day it waits. “During the 30-day comment period, there were about 1,500 overdose deaths, so we understand the urgency,” she says.
Patient presents with an addiction: What then?
Of course, taking steps to properly prescribe opioids isn’t enough to stop the epidemic, especially when patients are obtaining them illicitly, whether through a drug dealer or acquaintance. About 55 percent of those who use prescription painkillers for nonmedical reasons procured them for free from a friend or relative, according to a 2010 study by the Substance Abuse and Mental Health Services Administration.