If he had remained on prescription painkillers for much longer, Anthony Newberry was fairly certain he would have taken his life.
It had been about 15 months since a giant metal bar fell at the construction site where he was working and crushed his foot, nearly severing his toes. Newberry, 38, of Millington, Ill., had been taking opioids for months to relieve the pain, with improperly healed nerves making it feel as if his foot and leg were “a pack of firecrackers, all day everyday. Just like someone lighting one every day, every second.”
Opioids helped to mask the pain, but he didn’t feel like himself on the drugs and couldn’t regain his commercial driver’s license while medicated. One night, in a moment of desperation, he dumped the pills in the toilet and promised he’d find another way to return to his normal life.
Heroin and prescription painkiller abuse kills tens of thousands of Americans each year and ensnares many more in crippling addiction. The tragic phenomenon corresponds with — and to an alarming degree, arises from — an epidemic of pain that afflicts millions, driving them to seek relief at hospital emergency departments and primary care clinics.
Now, health care providers are confronting the intertwined epidemics by working to break their own long-entrenched proclivity toward prescribing opioids to treat their patients’ pain.
About 60 percent of ED patients suffer from acute painful conditions, and 74 percent are discharged from there in moderate to severe pain, according to the Institute of Medicine. Primary care providers prescribed half of all narcotic painkillers dispensed from 1999 to 2014. Many received little to no training on opioid safety and pain management in medical school, according to the Centers for Disease Control and Prevention.
Breaking the opioid paradigm is a daunting undertaking. But health care organizations across the nation — from the largest American health system to a tiny critical access hospital in Illinois — are stepping up to the challenge.
The massive Veterans Health Administration — with more than 1,700 care sites treating nearly 9 million patients annually — recently rolled out a systemwide effort to better address the complex pain from which returning vets often suffer. Dubbed the Opioid Safety Initiative, it targets individuals on high-dose prescriptions, and helps them to treat their pain through education, a mobile app called Pain Coach, and such alternative treatments as acupuncture. At the initial implementation sites, the VA reduced high-dose opioid use by more than 50 percent, with no rise in pain scores. Rollin Gallagher, M.D., the deputy national program director for pain management at the VA, believes these results can be duplicated easily at any hospital. It just requires an interdisciplinary team working together to flesh out a plan, develop metrics and rigorously adhere to it.
“There has to be a culture change from the top on down,” Gallagher says. “Everybody has to be informed about the importance of an intervention like this, and that it’s something the entire hospital system wants to change. If you have a few clinicians trying to do it on the front lines, but the CEO or chief medical officer of the hospital aren’t behind it, that’s going to be a problem. You have to have everybody on the same team.”
In March, the Department of Health & Human Services released the “National Pain Strategy,” an 84-page document outlining a population health approach to pain management, following years of work by experts across the field. The report lays out several steps the hospital field might take, among them: eliminate barriers to appropriate pain care, particularly for the vulnerable and underserved, such as those who perform manual labor but have limited health care coverage; develop a system of caring for these patients that is much more coordinated and centered around the patient’s needs; and bolster education on the topic for providers.
Of course, part of a more systematic approach to pain treatment is the safer, more balanced use of opioids. The National Pain Strategy recommends that providers better evaluate the risk-reward equation for these drugs, educate patients about the dangers and offer them strategies to self-manage their pain.
The slew of experts involved in the HHS effort — including scientists, insurers, patient advocates, accreditation agencies, professional societies and hospital and health system professionals, among others — are now hammering out a plan to implement the National Pain Strategy. Pain is a “huge public health problem” for the country and it’ll require an equally massive effort to fine-tune the system, says Linda Porter, director of the National Institutes of Health Office of Pain Policy and co-chair of the committee that developed the report.
For years, pain went woefully undertreated. But fueled by aggressive pharmaceutical companies, including the marketing of prescription drugs like Vicodin and Oxycontin, inaccurate science about the safety of opioids, and mandatory patient satisfaction surveys that inadvertently encouraged some physicians to prescribe painkillers, the pendulum swung dramatically in the other direction. Groups like the American Hospital Association urged the Centers for Medicare & Medicaid Services to remove pain-related questions from patient satisfaction surveys and, in July, CMS agreed to do so.
John Combes, M.D., the retiring chief medical officer of the AHA, encourages hospital leaders to work closely with their medical staffs to develop a more standardized and stepwise approach to pain treatment. The emphasis should be on management, he says; eliminating chronic pain completely is not realistic in most cases.
“I don’t think it is the right goal to be striving for zero,” Combes says. “Pain is a very, very subjective thing and there are all sorts of factors that influence it. What you want to do is get people comfortable. You don’t have to take away every ounce of pain.”
Newberry, the pain patient from Illinois, dug his way out with the help of Asokumar Buvanendran, M.D., a professor and director of orthopedic anesthesia at Rush University Medical Center in Chicago. The doctor installed a surgically implanted device that stimulates Newberry’s spine and helps to block the pain signals shooting up from his leg.
Almost two months later, Newberry feels as though he’s slowly starting to get back to his old self, and is mowing the lawn and driving again. The pain is still there at times, but it’s tolerable.
“This is my life. My life is going to have pain in it from now on,” Newberry says. “Yeah, we’ve got some pretty cool medical stuff out there, but the fact is that I was still in an accident and I’m never going to be right again. You have to be able to swallow that pill first.”
Now, he says, “I am liking myself better. I got to the point where I wanted my life back, and if I’m on meds, I’m never going to get my life back.”
Buvanendran, who also served on the committee that reviewed the CDC’s safe-prescribing guidelines for opioids, believes Newberry’s story illustrates the importance of making pain care a two-way street. Those guidelines specifically urge providers to set treatment goals with patients, discuss risks and avoid opioids as the first option.
“It’s patients like this that we need to encourage to use different treatment modalities, so that they can get better instead of just putting them on opioids,” Buvanendran says. “It is the wrong thing to do, and it’s not in the best interest of the patient.”
The three stories that follow will explore what some other hospitals are doing to shift their cultures away from opioids, as well as some alternative methods of pain management and next steps that can be gleaned from the National Pain Strategy.
St. Joseph’s Regional Medical Center: Transforming the ED’s culture with a shift away from opioids
Can leadership run a busy, urban hospital emergency department without using opioids to relieve pain? It’s a question that St. Joseph’s Regional Medical Center set out to answer.
About 75 percent of the time, pain is what brings patients to the ED. And too often, doctors at the busy Paterson, N.J., ED — with about 170,000 visits expected this year — were reaching into a toolbox of resources that primarily included opioids. Often, the approach to pain management was haphazard, with some patients receiving overtreatment, while others’ pain went neglected, says Mark Rosenberg, D.O., chairman of emergency medicine at St. Joe’s.
When leaders set out to create a more uniform approach to emergency pain treatment, the original goal was to run an “opioid-free ED.” However, Rosenberg says they soon realized that this was unrealistic and, instead, have fostered a culture in which physicians have a broader range of resources. Opioids are now the last line of defense.The medical center's Alternatives to Opioids program was launched in January for patients who present with one of five acute pain diagnoses — headache, long bone fractures, kidney stones, back pain and other musculoskeletal pain.
Clinicians apply such non-opioid approaches as trigger-point injections, nitrous oxide and ultrasound-guided nerve blocks. All are evidence-based, multimodal pain treatments, which aren’t experimental. ED clinicians also work closely with primary care providers and patients to recalibrate pain expectations so everyone understands that the goal is not to get scores down to zero. Since January, St. Joe’s already has cut the number of opioids prescribed in its ED by 38 percent.
“We needed to change the perception so that physicians now had a larger toolbox; they had more medications that they could go to,” Rosenberg says. “For physicians, these have been a panacea, an opportunity to really aggressively manage pain without going to the opioids first. The goal of the program was to go to opioids last.”
Alexis LaPietra, D.O., medical director of pain management in the ED, developed the new “opioids last” protocols during a residency fellowship a few years ago. Gaining program buy-in from physicians wasn’t difficult; most were confronting addiction issues in their daily practices, and were receptive to effective ways to respond. “Every doc has to deal with this and no doc wants to find out that their Percocet prescription was the thing that led Mrs. Smith to become a heroin addict,” LaPietra says. Navigating the “turf battles” in the ED can be difficult, however, says Rosenberg, and that is one area in which clinicians can use an assist from hospital leadership.
But Rosenberg was surprised how quickly even the most skeptical doctors started to believe, and the organization’s mindset shifted. “Once we had a couple of physicians trying it, and residents started using it more and more, we did something that surprised me — we changed the culture in the department. Nobody is just reaching in the toolbox for Percocet. They’re reaching for an alternative first,” says Rosenberg, who is also medical director for population health at St. Joe’s parent health system. “The culture has changed, but it changed much more quickly than I ever thought. We reached the tipping point as soon as docs saw this working.”
Of the hundreds of patients treated with the new protocols in St. Joe’s ED, about 25 percent still require an opioid prescription. Typically, those patients suffer from such ailments as sciatica pain in their legs, kidney stones or severe headaches. St. Joe’s doctors warn them of the risk of taking such narcotics, along with the availability of physical therapists, psychiatrists and other clinicians to treat the root of the pain and honor the Alternative to Opioids goals.
As the next step, LaPietra is having conversations with everyone from the head of family medicine to physical therapists, trying to use similar ways of treating pain throughout St. Joseph’s Healthcare System. She hopes the opioids-as-a-last-resort approach will become standard throughout the organization within the next five years.
“There is a lot of talk and a lot of excitement, and because we have the high-level administrative support, that allows the enthusiasm to trickle down into the different departments,” she says.
Duke University Health System: Education and simplified documentation are critical to shifting the culture
With an uptick in the use of opioids to treat pain at Duke University Health System came a corresponding hike in the number of individuals suffering from addiction and death.
Often, primary care physicians and others with minimal training in pain management were prescribing these potentially dangerous drugs. With that in mind, Duke formed the Opioid Safety Task Force a few years ago — comprising experts from across the Durham, N.C., health system — to look at best practices set forth by the state medical board and figure out how it could better adhere to them, says Lawrence Greenblatt, M.D., an associate professor of community and family medicine and co-leader of the effort.
Among the responses they developed: creating one uniform pain agreement for all doctors to use, incorporating drug testing and launching a simplified template in Duke’s electronic health records to make it easier for doctors to stick to opioid prescribing guidelines. Physicians rebelled against these ideas at first, Greenblatt says, but have come around. It’s helped, he says, that the state medical board has “been very clear that this is no longer an option.”
“In the oncology group, they practically threw tomatoes at me a year and a half ago when I talked to them,” Greenblatt says. They were “completely uninterested in this, but they didn’t know how many of their patients had a drug problem or were sharing pills because they didn’t look, they didn’t ask and they didn’t get urine drug screens. I think once they started doing those things, they realized that just because you have cancer doesn’t mean you’re exempt from having a drug problem.”
Provider education — another key piece of the National Pain Strategy — also has been critical. Duke created continuing medical education for doctors on the nuts and bolts of pain management and opioid safety. The topics also have been incorporated into residency programs.
The task force encourages doctors to learn more about pain and own the problem, rather than punting patients to pain specialists. A shortage of experts in North Carolina means that some such clinics have months-long wait times for appointments. “Standard pain management should not be a specialty,” Greenblatt says. “It has to be something where we all do our part.”
Cindy Haynes, Duke’s chronic pain initiative coordinator, facilitates monthly consultation calls during which a pain specialist presents three actual patient cases. Doctors can call in to chew over each case and come up with responses.
On the flip side, Haynes hosts six-week workshops for patients to learn to self-manage their pain. They're taught a variety of methods to minimize discomfort, including better breathing, informed treatment decisions, positive thinking, healthy food choices and weight management. For Haynes, it’s all about “educating and empowering the patient and letting them know that they are a critical part of their care management outside of the doctor’s office.”
One key takeaway for hospital leaders, according to Greenblatt: You must invest time and resources to change pain management culture. Executives can’t demand that already overloaded doctors start educating patients, counting pills and performing drug screens without any support. Such investments may not produce a tangible financial return in today’s health care world, but he believes they’re still worthwhile.
“You’re not going to get a payback on that, other than improved safety in your community, but it’s not going to be financial,” he says. “Maybe under a population health model, but in the fee-for-service world — and we’re in the fee-for-service world here — you do it because it’s the right thing and it’s the safe thing.”
Salem Township Hospital: Addressing pain on a shoestring budget
In isolated, rural areas, patients suffering from pain often have few options to turn to for relief.
That was the case for those served by small critical access Salem (Ill.) Township Hospital, about 90 minutes east of St. Louis. President and CEO John Kessler heard continually from his medical staff that they were ill-equipped to deal with the issues of complex pain and trying to keep track of who is and isn’t seeking pills.
Earlier this year, the 25-bed hospital signed a pain specialist to travel an hour up from Marion, Ill., twice a month to treat patients. Paul Juergens, M.D., works out of Salem’s anesthesiology practice, providing trigger-point injections for long-term pain and promoting physical therapy and other avenues of treatment.
Those who want to continue with opioids must sign an agreement stipulating that they will take regular drug tests and not ask for early refills. Since April, only three out of 56 patients have chosen to stick with opioids, which Kessler believes signals increasing patient demand for alternative methods of pain treatment.
“What we’re finding is that those patients who are truly struggling are willing to do anything to become pain-free,” Kessler says. “We’re just providing those who want a pain-free existence with alternatives to narcotics.”
Hospital leaders are considering asking Juergens to increase his visits to Salem from two to three or four a month. He sees patients in increments of 60 minutes or so to allow time for careful, personalized treatment. Previously, Salem patients would have had to travel an hour or more to see a pain specialist.
Investment was minimal, at about $25,000 for capital equipment. Kessler believes the program can be replicated easily elsewhere, with sufficient attention from leadership. “From everything that I’ve heard and can tell, the program has gone very well and the patients have taken to it. So I’m encouraged that we’ve not only made the right decision, but we’re heading in the right direction,” he says.
Executive Corner: 3 Hospital Objectives for Improving Pain Care
The National Pain Strategy, released by the Department of Health & Human Services in March, outlines three objectives the health care delivery and payment system must tackle to improve pain care in America. It includes specific strategies for hospitals to undertake in the short term (one year), medium term (two to four years), and long term (within five years). Here are the objectives and short-term strategies. For the full list, go to hhnmag.com.
Objective 1: Define and evaluate integrated, multimodal and interdisciplinary care for people with acute, chronic and end-of-life pain, which begins with a comprehensive assessment; creates an integrated, coordinated, evidence-based care plan in accord with individual needs, preferences and patient-centered outcomes; and is supported by appropriate payment incentives. Short-term strategies include:
- Performing an environmental scan to access quality of care and cost of current treatment approaches, and identifying the existence of more effective models.
- Convening expert stakeholders to develop strategies to address the shortcomings in quality of care and the high costs of current pain treatment approaches, the existence of more effective models, and the steps that can be taken toward achieving high-quality care and outcomes.
Objective 2: Enhance the evidence base for pain care and integrate it into clinical practice through defined incentives and payment strategies to ensure that the delivery of treatment is based on the highest level of evidence, is population based and represents real-world experience.
- Perform an environmental scan to assess barriers to quality care (i.e., identify outcomes of current insurers’ practices of prior authorization, fail-first protocols and caps on treatments and pharmacy benefit managers).
Objective 3: Tailor payment to promote and incentivize high-quality, coordinated pain care through an integrated biopsychosocial approach that is cost-effective, value-based, patient-centered, comprehensive and improves outcomes for people with pain.
- Identify and invest in the development and implementation of models of care that deliver high-value pain treatment that both maximize patient benefit and minimize risk and costs, and account for the potential need for long-term and enduring care.
- Identify alternative strategies to serve those most likely to lack access to these innovative models and those with unique needs such as patients with or at risk for addiction, those who have suffered psychological trauma, pediatric populations and older adults.
- Identify, measure and recommend means to control variation in pain care and access to pain care that lead to low-quality or high-cost care.
- Develop new tools to facilitate payment for higher-quality pain care.
- Define, identify and engage eligible pain care clinicians, long-term services and supports, and social service providers willing to participate in quality and utilization reporting pain measures, including those participating in existing programs, such as the Medicare Physician Quality Reporting System, the Advancing Excellence campaign and all of the other quality reporting systems that CMS hosts.