Hospitals have become adept at using big-picture, strategic thinking to try and rearrange how health care is delivered and solve the most vexing of problems. Why not use those same system-thinking approaches to address the opioid epidemic that’s killing dozens of Americans every day?
That’s what innovation experts at the Institute for Healthcare Improvement, and Kaiser Permanente in Oakland, Calif., have done in recent years while trying to find a way to curb the plague of pain pills and heroin hitting the streets.
During a web chat Thursday afternoon, two IHI experts discussed how they’ve spoken with a wide array of folks linked to the epidemic, be it police commissioners, EMTs, public health officials, etc., while seeking out answers. They found that there are many gaps along the health care pathway for opioids addicts that could be addressed through sometimes simple means.
“There’s a pervasive lack of design in intervention efforts,” says Mara Laderman, a senior research associate with IHI and member of its innovation team. “We think that a system approach has the potential to address some of the barriers to success that are being faced by efforts around the country, and can help with coordination and collaboration and help spread promising practices around communities.”
Carefully mapping out the pathway that patients traverse, from the onset of pain, all the way to an overdose death, IHI determined that there are four specific types of populations with respect to opioid use, and how to address them:
- The naïve patient: Avoid starting, thus preventing opportunities for opioid use and abuse
- High-dose chronic use: Compassionately taper opioids and move to alternative pain management
- Opioid dependent, seeking within health care: Address opioid-seeking behavior without moving patients to illegal means of obtaining opioids
- Opioid dependent, seeking outside of health care: Address addiction behaviors and outcomes of opioid-seeking individuals
Health systems must pinpoint those four groups specifically to find the biggest success, says Lindsay Martin, executive director and improvement advisor at IHI.
“While these categories are fluid, it’s important that we think about turning off the faucet while also emptying the bathtub and really targeting specific interventions,” Martin says.
Working backwards from the skyrocketing measures of overdose deaths and opioids prescriptions written this past decade, IHI’s team came up with the four primary drivers of the epidemic, and how to address them:
- Limiting the supply of opioids: “By changing prescribing patterns, by changing dispensing patters, by looking at diversion, thinking about the actual pharmaceutical production and thinking about the availability of alternative pain management,” Martin says. “Sometimes opioids are prescribed because we have limited awareness or providers may have limited options of alternative pain management treatment.”
- Raising awareness of the risk of opioid reaction: “Mara and I have been constantly surprised by the number of individuals who are not aware that prescription opioids can be just as dangerous as heroin,” Martin says. “It seems that there’s a real lack of that knowledge. Individuals, when they’re prescribed by their providers, assume safety. They do not recognize that they could become addicted and then wind up with a heroin, fentanyl or prescription opioid problem. We know that adolescent education is extremely important. We heard story after story of high school athletes who became injured and then addicted to opioids because of that injury, and there needs to be a real reduction around stigma related to substance abuse.”
- Identifying and managing opioid-dependent populations: “These are individuals who are dependent on opioids,” Martin says. “They are within the health care system and they really need compassionate, consistent care that enables them to be tapered off this medication. They need education on pain management and there needs to be an availability of alternatives to pain management. Providers need to be re-educated on what opioids can and cannot help, as do patients. We know that patients are afraid of coming off their pain medication. Pain is very important, but at the same time, the opioids may not be helping at all, and yet we assume that they are.”
- Treating opioid-addicted individuals: “These are are individuals who are now addicted that may be seeking within health care or likely outside,” Martin says. “We need to be able to think about detox, how that has to happen and if that has to happen in an inpatient or outpatient setting. We need to know if long-term, ongoing care is available for those who are addicted. We know it can take several years for an individual to really move past the acute phase and recovery and get to an ongoing treatment plan.”
In the West, Kaiser Permanente’s Southern California Medical Group has been thinking in this fashion for years, after first discovering the deep problems that opioids were causing its organization around 2009. Kaiser found, in its regular drug utilization work, that prescriptions were rampant for opioids. OxyContin — not a hypertension or cholesterol drugs — was its No. 1 non-formulary prescribed medicine and hydrocodone was No. 2, says Joel Hyatt, M.D., emeritus assistant regional director for community health initiatives at the doc group. “This really raised some eyebrows.”
After a call to action, the group came up with a systematic framework to try to address overprescribing. They organized a regional steering committee, devised a strategy and a plan, and involved everyone from primary care, to pain management, addiction medicine, psychiatry, IT and legal in the process. The effort has borne fruit six years later, as the Kaiser group has been able to drop the number of OxyContin prescriptions by 85 percent, among other gains.
Hyatt believes that, with the right mindset and people at the table, others can produce similar results, regardless of their size and resources.
“Everything we have done can be done in any setting,” Hyatt says. “We’re often accused at Kaiser Permanente of being unique. We face, believe me, all of the same resistance and pushback and barriers that anyone would face.”