Stewarding Recovery from the Opioid Crisis Through Health System Initiatives

Author Affiliation
Jeanmarie Perrone, MD Perelman School of Medicine at the University of Pennsylvania, Department of Emergency Medicine, Philadelphia, Pennsylvania
Scott G. Weiner, MD, MPH Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts
Lewis S. Nelson, MD Rutgers New Jersey Medical School, Department of Emergency Medicine, Newark, New Jersey

Limiting opioid initiation: keep opioid-naïve patients opioid naïve when possible
Using opioids when, and only when, an opioid is indicated
Treating patients with opioid use disorder



As the consequences of liberal opioid prescribing have become apparent, efforts to address the role of the health care system in supporting more balanced opioid use and the prevention and treatment of opioid use disorder have increased. Developing a unified and multidisciplinary approach can lead to an integrated care model that emphasizes primary prevention, harm reduction, and transition to life-sustaining treatment while also maintaining attentiveness to effective pain management. A model for this, which follows the nomenclature in proscribing antimicrobial use, is the development of an opioid stewardship program. Such programs allow for the integration of diverse perspectives and new mandates and uses a patient-centered approach with an iterative evaluation process. We describe a group of adoptable efforts that have been utilized successfully at our institutions and may be adapted and optimized to the needs and resources of other hospitals and health care systems.

Limiting Opioid Initiation: Keep Opioid-naïve Patients Opioid Naïve When Possible

We individually developed pain management pathways and order sets that deemphasize opioid use using an iterative consensus process by engaged providers starting with specialties with high utilization (e.g., primary care, emergency medicine). For procedure-focused specialties such as orthopedics and general surgery, direct, procedure-specific modifications in pre- and post-procedure prescribing were similarly created. Patient feedback, both obtained during deliberate rounding and through direct post-procedure assessments at three to seven days suggested opportunities to “right size” the number of pills prescribed while still assuring the provision of adequate pain management. Certain states (e.g., Massachusetts. New York, New Jersey) have placed regulatory controls on initial opioid prescribing that dovetailed with the implementation of the OSP guidelines.

The recently modified pain questions in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) are an attempt to shift the focus from pain management outcomes, which are often medication-centered, toward adequacy of pain assessment.8 To support this, institution-specific multidisciplinary education modules emphasizing the role of opioid alternatives can be created, aligning with the U.S. Food and Drug Administration’s 2017 blueprint for the treatment of patients with pain.9 Programs should highlight the significant risk for developing long-term opioid use and the recognition that our ability to predict who may develop an OUD following even minimal (one-day) opioid exposure is limited.10 Electronic health record (EHR) decision support can prioritize non-opioid and non-pharmacologic pain management options and redirect providers who have been trained to practice using opioids as a first-line pain relief option.

Using Opioids When, and Only When, an Opioid is Indicated

OSPs identified resources from local, state, and federal governmental agencies and professional organizations to guide appropriate and safe opioid use when indicated. Such guidance addressed various aspects of pain, such as in the post-operative setting or managing acute severe pain in the ED and were adopted or modified to be institution or procedure specific.11 Guidelines were implemented with corresponding outcome measurements to allow incremental standardization of opioid prescribing practices. Monitoring outcomes highlights success, such as a recent pilot in Colorado designed to reduce ED opioid prescribing by 15% through implementation of standardized alternative pain-management strategies that exceeded expectation (36% reduction).12 They similarly allow for assessment of adverse outcomes, as noted by an effort to use evidence-based, postoperative prescribing guidelines led to a 63% reduction in opioid prescribing,13 and lowering the EHR default reduced opioid prescribing by about one-third,14 both without an increase in requests for medication refills.

Attention to the frequent use of opioids for the treatment of chronic pain is of paramount importance given the increasingly recognized role of hyperalgesia in perpetuating continued use. In accordance with Centers for Disease Control and Prevention guidelines, health systems can facilitate compliance with opioid use agreements, urine drug monitoring for both compliance (e.g., diversion) and prohibited drug use, prevent benzodiazepine co-prescribing, and performance of functional outcome assessments. Safe-use education should become part of opioid-specific discharge instructions including emphasis on appropriate storage and disposal of remaining medication. For those patients already managed on high-dose opioids for their chronic pain, we encouraged the creation of pathways for dose reduction to the recommended dose of 90 morphine milligram equivalents (MME).11 For patients unable or unwilling to undergo gradual dose tapering, they were cautiously maintained on their dose and the recommendations of existing pain-management guidelines for monitoring were followed.

OSPs can leverage EHRs to develop dashboards of opioid-use patterns by department or prescriber with the goal of reducing variability as a marker of quality care. OSPs can provide oversight of regulatory changes and evolving state laws affecting prescribing, such as mandatory prescription drug monitoring program (PDMP) queries, consent for minors for opioid prescriptions, and prompts for the initiation of controlled medication agreements. Providing decision support, order sets, prescribing defaults, maximum MMEs, and using nudges, reminders, and best practice alerts are efforts that helped reduce the initiation of opioids or limit the dose and duration provided.15

Treating Patients with Opioid Use Disorder

OSPs must expand recognition and timely management of patients with OUD. Compassionate care of hospitalized patients suffering from complications of illicit opioid use (e.g., endocarditis, abscess) emphasizing opioid agonist therapy to mitigate opioid withdrawal, reduce premature self-discharge and readmission, enhance opportunities to transition to methadone or buprenorphine, and improve other medication adherence such as antibiotic therapy is essential.

Additionally, resources should be allocated for “warm handoffs” to addiction treatment programs using hospital-based substance use disorder clinics and peer recovery coaches to engage patients into treatment. A comprehensive approach to mitigating opioid harm includes naloxone prescribing and distribution programs for at-risk individuals. Primary care providers should be supported to integrate buprenorphine prescribing into their practices to expand capacity for referrals and allow patients to find evidence-based treatment within the health system home.16

These concepts broaden existing new mandates to address multiple, intertwined morbidities associated with opioid use. They implement best practices and necessary resources to guide health systems tasked with this challenging work. The severity of the crisis and the rapidly changing regulatory and public health landscape dictate that sensible change must start immediately. Although the mandate for action is national, a substantial component of the solution is local. Hospitals and health systems are uniquely poised to create an integrated care model that emphasizes primary prevention, harm reduction, and transition to life-sustaining treatment. OSPs provide a specific mechanism to integrate many perspectives and requirements into a process to reduce consequences of excessive and inappropriate opioid use, and assure that those in pain receive safe and effective care.


Section Editor: Mark I. Langdorf, MD, MHPE

Full text available through open access at

Address for Correspondence: Scott G. Weiner, MD, MPH,, Brigham and Women’s Hospital, Department of Emergency Medicine, Boston, Massachusetts, 75 Francis Street, NH-226, Boston, MA 02115. Email: 3 / 2019; 20:198 – 202

Submission history: Revision received May 14, 2018; Submitted November 6, 2018; Accepted November 21, 2018

Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.


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Table 1Roadmap to the implementation of an opioid stewardship program (OSP).

The leadership team:Multidisciplinary stakeholder input: representatives from primary care, anesthesiology, emergency medicine, psychiatry, surgery, and pharmacy with executive support from the chief medical officer, chief quality officer, and chief nursing officer.Potential task forces/subcommittees:
Guidelines and pathways


Education and outreach


Legal and compliance


Information technology

The missions:

Limit opioid initiation


Rationalize expectations among patients for pain and pain relief


Create prescribing guidelines


Standardize order sets emphasizing non-opioid approaches as first and second line


Education and best practice alerts about non-opioid and non-pharmacologic (multimodal) therapies


Community intervention/education programs to discourage diversion and non-medical use


Improve the safety of opioid use


Leverage the electronic health record


Best practice alerts for compliance with safe opioid treatment guidelines and state/federal regulations.


Integrate prescription drug monitoring program access


Track and nudge providers and departments using dashboards and e-alerts following compliance trends.


Default formulations (immediate release), doses, and schedules for opioid orders and prescriptions


Prompt at discharge to educate patients about safe storage, appropriate disposal and naloxone


Create pain management strategies


Standardize short-term dosing based on common diagnoses and procedures


Compliance with state regulations and documentation requirements


Create monitoring parameters for patients receiving high-dose opioids


Develop systems or registries to check for presence of opioid use agreements, urine drug-screen results, maximum morphine equivalent dosing, and rates of co-prescribed benzodiazepines


Create endpoints for acceptable opioid use (e.g., maximum of 90 morphine milligram equivalents/day) and exit strategies such as weaning


Other activities


Disseminate educational modules on pain assessment and opioid stewardship to meet Joint Commission recommendations


Integrate clinical pharmacists into medication management


Treating patients with opioid use disorder


Operationalize addiction management


Increase screening for opioid use disorder at admission and in primary care practices


Reduce barriers for the use of buprenorphine or methadone to mitigate opioid withdrawal in hospitalized patients


Organize resources to improve hand-offs to settings that provide opioid agonist therapy


Implement harm reduction strategies


Naloxone distribution or prescribing


Certified recovery specialists/peer navigators and other social services


Family and community engagement processes


Safe practices (clean syringes, counsel about risk of infection)


Table 2An example organizational structure for an academic health center opioid stewardship program.

Steering committee
Chair or co-chairs


Chair of anesthesiology (or designee)


Chair of emergency medicine (or designee)


Chair of internal medicine (or designee)


Chair of psychiatry (or designee)


Chair of surgery (or designee)


Chief medical officer


Chief nursing officer


Chief information office


Graduate medical education director/designated institutional official


Pharmacy director


Project manager






Prioritize efforts


Populate task forces


Develop initial expectations and metrics


Guide committee efforts with periodic meetings and oversight


Evaluate metrics and suggest improvements


Guidelines and pathways/pain management
Chair or co-chairs


One representative from each:


Ambulatory care/primary care


Emergency medicine


Hospice/palliative care


Internal medicine/hospitalist






Orthopedic surgery


Pain medicine/anesthesia












Assessment of current state


Benchmarking of progress


Guideline development for pain management




Addiction and harm reduction committee
Chair or co-chairs


One representative from each:


Addiction psychiatry/addiction medicine


Ambulatory care/primary care


Emergency medicine


Internal medicine/hospitalist




Pain medicine/anesthesia




Social work






Benchmarking current status


Capacity development


Process improvement


Implement harm reduction efforts


Quality and information technology
Chair or co-chairs:


Chief medical information officer


Quality/safety leader


Information technology


Physician leader


Nurse leader


Pharmacy leader


Other committee chairs




Define the scope of the problem


Develop and implement recommendation with other committees


Analyze capacity for addiction treatment


Process improvement for addiction management


Assess rates of hospitalized patients with opioid use disorder who leave against medical advice as these are missed opportunities to improve withdrawal care

Provide strategies for opioid withdrawal management with buprenorphine and methadone


Education and outreach
Chair or co-chairs


Physician leader


Nursing leader


Pharmacy leader


Graduate medical education representative




Implement an awareness campaign


Implement a continuing education program

Collect feedback from constituencies