The challenge

In 2008, long before excessive use of opioids became a national concern, clinicians at Gundersen Health System, based in La Crosse, Wis., already were seeing early signs of the impending epidemic. Even then, Gundersen’s pain medicine specialist noted an exponential rise in the number of pain patients referred by family physicians in Gundersen’s outpatient clinics.

“Part of the issue was that the pain medicine specialist didn’t have the capacity to see all the patients coming in through referrals from primary care,” says Holly Boisen, R.N., a project manager and Lean specialist with Gundersen. What’s more, the pain medicine specialist noted that opiate prescribing practices were inconsistent throughout the system.

Gundersen rallied immediately, first by forming an interdisciplinary chronic pain committee and, ultimately, by developing the program that exists today, a systemwide, standardized approach to prescribing, educating clinicians and patients and tracking patient activity.

For more resources to help deal with the opioid crisis, see the American Hospital Association's toolkit.

Committees and registries

Concerned about its burgeoning caseload of chronic pain patients and inconsistencies in opioid prescribing practices — particularly by primary care physicians in its outpatient clinics — Gundersen established a chronic pain committee to try to understand and tackle the problem. The committee is composed of experts from across the system and includes pain medicine specialists, addiction medicine specialists, psychiatrists, primary care physicians and other physician leaders, nurses and pharmacists, as well as experts in legal affairs, patient education and nursing education, all working together to craft and implement a program.

As a first step, the team determined it needed to identify chronic pain patients, since they are most likely to be prescribed opiates. By 2009, the system had created a chronic pain registry via its electronic health record system. Patients receiving a Schedule II opioid for six or more consecutive months who were not in hospice care were placed in the registry. Some examples of Schedule II opioids include morphine, oxycodone, hydrocodone and fentanyl. A patient’s chronic pain registry status appears on the front of a patient’s chart so that any physician within the Gundersen system knows that the patient is taking opioid pain medication.

The patient registry enables the team to track which medications are prescribed for each patient and which prescriptions are being filled and how often. Gundersen’s internal efforts have been aided by Wisconsin’s statewide database of controlled substances, ePDMP (enhanced Prescription Drug Monitoring Program). It is now law in Wisconsin that before writing a prescription for controlled substances — which include opiates — a clinician must consult the state website to determine where and when a patient already has obtained controlled substances. This allows Gundersen clinicians to quickly identify patients who may be obtaining drugs from multiple sources, possibly signaling a substance use disorder or diversion.

Guidelines

After establishing the registry, the chronic pain committee next drafted a set of prescription guidelines that were disseminated to all clinicians who prescribe Schedule II opioids. The current guidelines are based on state and national guidelines (Wisconsin Medical Examining Board Opioid Prescribing Guidelines and guides from the Centers for Disease Control and Prevention) as well as evidenced-based practices published in peer-reviewed medical literature.

Gundersen’s guidelines include the following:

  1. Prescriptions are written for 28, and not 30, days, so patients never run out on a weekend.
  2.  A clinician must approve a refill each month.
  3. Patients must come in for face-to-face evaluation every three months and have telephone or electronic communication with the nurse and clinician to receive a new prescription each month. The same data are collected for each patient whether contact is made in person or electronically:
    1. Date of last refill.
    2. Date of last appointment with prescriber.
    3. Pain location and duration.
    4. Medication dose, directions and quantity prescribed.
    5. Assessment of medication side effects.
  4. Patients undergo urine toxicology screening when they’re first prescribed opioids and are tested at least once a year after that to determine whether they’re adhering to their prescribed medications and to determine whether the patient is taking medications or illegal substances not prescribed to them. Urine toxicology screening may be performed more frequently if a patient exhibits signs of substance use disorder or diversion. 
  5. Clinicians try to avoid concurrently prescribing opioids and benzodiazepines, a potentially lethal combination.
  6. A Diagnosis, Intractibility, Personality and Efficacy (DIRE) score is used to determine whether a patient is a candidate for long-term opioids. This is completed once.

Contract

Patients placed on the registry enter into a chronic pain agreement, which outlines expectations for both the patient as well as for Gundersen clinicians.

For its part, Gundersen pledges not to curtail care, even if the patient violates the terms of the agreement. Gundersen will continue to treat the patient, will taper the patient off opioids or will refer the patient to an addiction specialist.

Gundersen also expects patients to agree to the following:

  1. Not to call for early refills.
  2. Not to operate heavy machinery.
  3. To keep drugs in a safe, locked place.
  4. To be willing to undergo drug screening.
  5. To be willing to try other pain treatment modalities — physical therapy and chiropractic care, for example.
  6. Proper disposal of medication.
  7. Respectful communication with support staff and clinicians.

Education

To ensure that opioids are appropriately administered, it was crucially important for Gundersen to create an educational program to teach clinicians the guidelines for prescribing Schedule II opioids and for recognizing signs of potential substance use disorder. Especially in the early years of the epidemic, the stereotypical view of a person with a substance use disorder was someone who existed on the fringes of society.

So, clinicians initially were reluctant to recognize that people in the mainstream could have substance use disorders. Clinicians had to learn to overlook social cues and rely on objective evidence to identify signs of potential substance use disorders, notes Boisen. Equally important to the program’s success was to embed the guidelines into routine practice.

Educational information takes multiple forms: in-person training, written material and emails. But all clinicians who prescribe Schedule II opioids are required to go through the educational program. Some clinicians bristled at the idea that they needed guidelines for prescribing, which seemed a challenge to their expertise and skill.

The most effective strategy , says Boisen, is peer-to-peer training and the assurance that guidelines reflect evidence-based practice. In a train-the-trainer approach, a pain medicine clinician provides education on the guidelines as well as signs that a patient may have a substance use disorder to many of the primary care clinicians in Gundersen’s outpatient family and internal medicine clinics. The department of nursing provides education to support staff, nurses and medical assistants on the guidelines and standard operating procedures. 

Education is not just for clinicians. Patients also receive education. All patients with chronic pain are given a booklet and a tutorial, conducted by a nurse, when they are first prescribed their medication. Patients are instructed about chronic pain, their individual treatment plans, potential side effects and the potential for developing a substance use disorder. Patients also are told to avoid taking alcohol or benzodiazepines while on opioids. The nurse reads the booklet to all patients who are prescribed opioids and in the chronic pain registry, and asks the patients to teach back; that is, patients explain what they just heard to make sure the meaning is clear.

Crucial to patient education, notes Boisen, is making patients understand the necessity for screening and monitoring their drug intake. “Patients feel like they’re being punished,” she says. So it’s important that they recognize monitoring as a means to ensure their safety.

Red flags

All clinicians, but especially nurses, are taught the warning signs that a patient is potentially developing or has a substance use disorder. Nurses are the ones who interact most with patients, explains Boisen. They speak with patients each month about their refills, and nurses act as “the eyes and ears for the doctors.” In particular, nurses are taught to evaluate a patient’s behavior in objective terms and are armed with a checklist of behaviors that signal that  patient is potentially developing or has a substance use disorder.

Nurses are taught to look for the following warning signs:

  1. The patient fails to show up for scheduled appointments.
  2. The patient frequently requests early refills.
  3. The patient frequently reports lost or stolen drugs or prescriptions.
  4. The patient refuses to give a urine sample or leaves the clinic before producing one.
  5. The patient requests escalating doses of medication.
  6. The patient frequently requests extra medication.
  7. The patient uses abusive or threatening language.

Outcomes

Since implementing the program, Gundersen has seen an increased use of other therapies — chiropractic care, physical therapy, acupuncture and additional treatment options provided by the Integrated Medicine Center. Gundersen also has a robust physical medicine and rehab department that offers a host of complementary nonopioid treatments.

Staying current

The opioid epidemic is evolving quickly, says Boisen, and it can be hard to keep up. New drugs are available on the street that complicate pain treatment and screening, and new ideas are emerging about how to treat pain and help patients to avoid developing a substance use disorder.

That’s why Gundersen developed a mandatory continuing medical education program on controlled substances and chronic pain management. Every Gundersen clinician who prescribes controlled substances is required to take a two-hour class to hone their skills and learn about changes in Gundersen’s guidelines or new methods for controlling pain and preventing the development of substance use disorders. The course has been offered face to face and is also available online for convenience. 

Boisen also stresses that success depends on taking a “layered approach” to communication: Information is shared in person, on paper and electronically. The essential thing, she says, is to have someone available to answer clinicians’ questions quickly and to be approachable.

For more resources to help deal with the opioid crisis, see the American Hospital Association's toolkit .

Acknowledgments

Our thanks to Stephanie Neuman, M.D., pain medicine specialist and chair of Gundersen Health System’s Chronic Pain Committee, and Holly Boisen, R.N.-B.S.N, project manager of quality and efficiency at Gundersen, who helped prepare this case study.