Others, cut off from prescription painkillers, are turning to heroin on the street, which is high in purity and cheaper than pills, according to the CDC. Heroin-related deaths skyrocketed by 26 percent year over year in 2014, up to 10,574 deaths, and the strongest risk factor for heroin initiation, the CDC says, is past abuse of opioids.
One would assume that an opioid overdose might be a moment to retool a patient’s care plan and move him or her toward other treatments. However, of those who overdosed on prescription opioids for chronic pain, 91 percent continued to receive a supply of pills, according to a December study by the Boston Medical Center. About 70 percent received that next prescription from the same doctor who wrote the original order. Plus, at two years of follow-up, patients who kept taking a high dose of opioids following that initial overdose were twice as likely to experience another overdose compared with those who discontinued the drug, the study found.
It’s possible that the original prescribing physician wasn’t even aware of the overdose if it took place at a different hospital, notes Marc LaRochelle, M.D., a physician in internal medicine with Boston Medical Center and leader of the study. That’s why it’s essential hospitals facilitate easy communication between ED physicians, primary care doctors and clinicians at other outpatient facilities. There are prescription-monitoring programs in 49 states, the study notes, which could be leveraged to help bolster such communication. Or, why not use the public health reporting system for infectious diseases to track addiction waves? LaRochelle asks. Researchers also suggest — since health plans keep track of hospitalizations and prescriptions — that providers require prior authorization before a patient can pick up his or her next bottle of opioid pills following an overdose.
“It’s very plausible that a large number of people aren’t made aware of the fact that the overdose occurred, and that’s a real potential problem,” LaRochelle says. “So, if you are seeing a patient back in your office, and you didn’t know that this drug that you’re prescribing almost killed them, there’s little reason for you to change what you’re doing." That might explain, he says, why, for a large number of these patients, the prescribing patterns didn’t change. "We really need to make sure we’re communicating this information, and if you work in health care, it’s not shocking that that communication isn’t happening seamlessly.”
Beyond interoperability, BMC also has its own more traditional means of treating addiction, some of which have been around for decades. Its project ASSERT (Alcohol & Substance Abuse Services, Education and Referral to Treatment), started in 1994, connects emergency department visitors with a variety of services — linking them with primary care, finding a detox program, or even assisting an individual who needs shelter or a ride to a follow-up appointment. More recently, the hospital started an addiction consult service so that anytime someone arrives at the hospital for an overdose, it triggers a mandatory consultation to engage patients with treatment, or notify providers if any concerns pop up in the hospital’s prescription monitoring program. The ED is the engine driving BMC’s opioid strategy, but it’s important that every piece of the hospital plays a role in such efforts.
“It’s tough to throw the entire burden onto a busy emergency room provider, but there are ways you can build systems within your hospital to try to respond effectively,” LaRochelle says.
Spectrum Health is also pursuing ways to reach upstream and treat addiction before patients show up in the emergency department with an overdose. The 12-hospital system, in Grand Rapids, Mich., recently began requiring its hundreds of employed primary care physicians to screen patients for addiction by asking a couple of simple questions, and testing the urine of those who are pregnant or who reveal signs of drug abuse in their answers. Doctors then use results to decide whether to refer patients to behavioral therapy and other care, rather than to filter them away from a primary care practice. The goal is to have all 350 employed primary care doctors performing the screenings by the end of 2016, says R. Corey Waller, M.D., an addiction, pain and emergency medicine specialist and medical director of the Spectrum Health Medical Group Center for Integrative Medicine.
Early on, physicians feared that the organization wouldn’t have the resources to treat all the problems that manifested; in the early stages, Waller was the only board-certified addiction doctor in a $5 billion system. But it has since hired other physicians and specialists to the treatment team, doubling the clinic's in capacity to provide for patient needs as they were revealed. Worries or stigmas about addiction started to dissipate. One of the biggest mistakes hospitals can make is simply quitting a patient because of opioid abuse, or letting emotions dictate a treatment plan, Waller believes.
“We’ve seen a lot of resistance go away and now, interestingly enough, a lot of primary care physicians who were worried about having to deal with 'those patients' are now feeling empowered to learn more about it and actually treat this no differently than hypertension or high cholesterol,” Waller says.
“It definitely makes it more palatable, especially once they start to understand that this is a chronic disease that these patients didn’t choose,” Waller adds. “Nobody woke up in the morning and said, ‘I want to be a heroin addict because it sounds super awesome.’ There’s a series of events that take place, a lot of which we had a hand in, and empowering physicians with the knowledge and capability to fix it has really been motivating.”
The first phase was seeking out those who had already developed an addiction; next Spectrum wants to determine how to prevent future opioid abuse. Leaders plan to build dashboards into the electronic health record so that physicians can compare their own prescribing habits with others, both in the system and across the nation, and educate them on how to wean patients off of opioids, along with other pain treatment methods. Waller hopes that training and testing of that next phase begins in August. He says they placed priority on treating those already addicted because of the significant mortality rate tied to that patient population.
Waller — who wears many hats, including head of the advocacy committee at the American Society of Addiction Medicine and member of the Michigan Prescription Drug and Opioid Abuse Task Force — is also working with the Robert Wood Johnson Foundation and Camden Coalition of Healthcare Providers to release a series of videos at www.complex.care, which is scheduled to go live in June, with more than 50 hours of free training on pain addiction and behavioral health.
Unlike Gundersen, Spectrum didn’t determine its opioid strategy with a formalized committee. Rather, it started with a few nurses, doctors and, eventually, patients, "angry," Waller says, over the fact that opioid misuse was harming some patients. They began to meet on a regular basis and, over time, nailed down a vision and mission. Spectrum leaders recognized the recommendations as "the right thing" but had to figure out how to fund it all in a climate of shrinking margins, in which payers don’t always cover addiction abatement and treatment.
“Because of the ways in which reimbursement works or doesn’t work, and figuring out how to shift a whole culture within a massive health system, it’s a daunting task,” Waller acknowledges. Everybody must be on the same page and focus on what is the right thing to do for the patient.
"At the end of the day, once the system coalesced on that focus, then these things just started to drop like dominoes and it was really pretty fun," he says. "When the CFO and the CEO and the strategic development people all understood that this was, in the end, just doing the right thing for every patient who walked in our door, that seemed to be the moment that everybody stopped pushing back and started helping in every way they could.”