By Ellen Decareau
Cities across the United States are struggling to keep up with the wake of tragedy left behind by the opioid epidemic. The regions hardest hit are the Northeast and Midwest, where overdose deaths from prescription pain killers and their synthetic look-a-likes have skyrocketed over the last decade.
The unrelenting opioid crisis has put major pressure on states to stem a rising tide of fatal overdoses and the wake of destruction — from suicide to unemployment to crime — it leaves behind.
While Texas is not the hardest-hit state, its hospitals have felt the impact and are taking aim at reducing opioids’ grip — from tightening controls on prescription opioids in the emergency department to establishing a new culture of pain therapy in the inpatient unit to changing the curriculum for the newest crop of physicians.
Starting at the Entry Point: The Emergency Department
Opioid abuse has quickly become one of the nation’s most pressing population health issues, not only because of its toll on patients, but also because of the financial impact on hospitals and the rest of the health care system.
Recognizing a pending tidal wave, last spring, the Behavioral Health Council of the Texas Hospital Association took steps to create a working group to help hospitals tackle the opioid epidemic. The initial target — emergency departments.
The reason for targeting EDs is two-fold, said Sara Gonzalez, THA vice president of advocacy and public policy, who handles issues related to behavioral health policy.
- A recent study in Massachusetts and Connecticut amassed ample research on how providers in the ED are best positioned to curb opioid use.
- The ED is often a hospital “entry point” for addicts.
“The opioid epidemic affects hospital emergency rooms in different ways,” said Cyndy Dunlap, DNP, RN, THA vice president of clinical initiatives and
quality. Often, addicted patients present in the ED asking for prescription opioids to manage pain. Other times, patients overdosing on heroin and other opioids arrive for treatment or are experiencing related crises.
“These patients are complex and often take up resources in the ED — it slows productivity and efficiency, impacting hospitals from a cost and quality standpoint,” said Dunlap.
Hospital leaders are still looking for ways to identify best practices to treat this population as the opioid epidemic continues to grow. Tracking successes in other states while determining how best to develop programs, THA commissioned a survey asking its membership whether they have existing guidelines for prescribing opioids in the ED and whether they would be willing to participate in a THA workgroup aimed at developing best practices.
“The results showed that there is a real interest and a real need,” Gonzalez said. Three-quarters of respondents indicated that they do not currently have existing guidelines in place in their hospital EDs, and nearly half of the respondents volunteered to participate to help finalize recommendations.
In the coming months, Gonzalez said, THA plans to organize a meeting for the Opioid Prescribing Guidelines Workgroup and publish its feedback in a set of best practices that ultimately will be shared to its 450 hospital-member body ideally by early 2018.
There are many other aspects of the opioid epidemic for hospitals to tackle from in-patient care to maternity care to mental health access, said Dunlap. “Establishing guidelines to care for patients with opioid addiction who present in the ED is a good first step for hospitals and their communities.”
Pain Therapy Culture Shift
In the wake of the opioid crisis, many physicians in the inpatient setting are more reluctant to prescribe narcotic pain medicines, says Craig Rhyne, M.D., chief medical officer at Covenant Health System in Lubbock. The result may be that patients’ pain is not well managed.
Rhyne says there is a happy medium when it comes to prescribing opioids between “too cavalier” and “overly conservative”. He suggests a multi-modal
pain management approach, which his hospital initiated about one year ago.
Many drugs other than opioids are available for treating pain, and each has a different mechanism of action. The multi-modal approach relies on combining pain therapies, often non-narcotic, to treat the course of a patient’s pain, explained Rhyne.
The approach seems ideal for preventing addiction associated with narcotic usage. He says, however, its application is complicated.
“Physicians of my generation were taught that opioid analgesics are the best way to manage post-injury pain. They have been the ‘gold standard’,” said Rhyne, a general surgeon by training.
Single prescription pain treatment (monotherapy) has been considered easier to administer and manage as well as transitioning the patient from the hospital. But, he says that the theory is misguided.
“Narcotics’ side effects are costly to the hospital and patient, in terms of complications and longer hospital stays,” said Rhyne.
When a sister hospital of Covenant Health reported impressive results from the application of a multi-modal pain therapy program, reducing opioid usage by 15 percent, Rhyne decided to take steps, too.
The tactic: embed a multi-modal pain therapy order into the electronic medical record. This way, prescribing physicians have at their fingertips a comprehensivepain plan for each patient.
Rhyne and his colleagues have been talking about applying multi-modal pain approaches for several years. “But it was complex. You had to write two or three or four prescriptions and know the proper dosage and timing for each patient,” he said.
Embedding an order set made it simpler and more accessible to all physicians.
Rhyne says the culture shift away from monotherapy reliant on narcotics has been slow. He estimates only 20 percent of Covenant Health physicians are using the order set in the EMR today. But, the ones who do use it already have seen improvements.
“It’s good medicine,” Rhyne explained. “The doctors on board are seeing that their patients are happier, more alert, that they can get up quicker, eat sooner and often have a reduced length of stay.”
Ultimately, he believes this approach will improve outcomes and quality scores while reducing the risks of opioid-related adverse events or addiction.
“I had to go back to school to learn this,” said Rhyne, explaining how a pain therapy culture shift will take time. “But, as we get more physicians on board, as doctors get more familiar with this approach through their medical training, we’ll see less and less use of narcotics.”
Mental Health and Medical Education
Changing opioid prescribing patterns is just one part of the solution, says Stephen Strakowski, M.D., department chair of psychiatry at the Dell Medical School at The University of Texas at Austin.
Strakowski has seen and experienced firsthand the pervasive impact of opioids. Prior to arriving in Austin, he was an administrator and psychiatry chair at UC Health in Cincinnati, Ohio.
The rust belt state is particularly hard hit by the opioid epidemic.
“It [the opioid crisis] was infiltrating virtually everything. We had deaths occurring almost daily in the region. It was linked to huge increases in crime. It was even impacting rural places where it was not common before,” described Strakowski of Ohio’s narcotics crisis.
Today, he is helping to build a new type of medical education program at Dell Medical School, which aims to “rethink the role of academic medicine in improving health.”
One aspect of that change is to embed more mental health and substance abuse education into the curriculum.
“Historically, there was very little attention to mental health. What we’re trying to do is bring more awareness to our medical students — how do you recognize it, how do you manage it and how do you help get people care,” explained Strakowski.
“Getting addicted people care” is another hurdle to overcome. Most addiction programs are psychiatric-based, yet Texas has a history of limited mental health care access, he explained. Greater public access to mental care options is among several ongoing initiatives.
“I commend Texas for trying to get ahead of the opioid crisis,” said Strakowski. “It’s hard to overstate what an enormous problem is has become in places like Ohio. If we can get ahead and work with people to intervene, we can prevent deaths and other social problems like crime that come with it.”