|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 http://escholarship.org/uc/uciem_westjem
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: firstname.lastname@example.org. 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.
1. Seth P, Scholl L, Rudd RA, et al. Overdose deaths involving opioids, cocaine, and psychostimulants – United States, 2015–2016. MMWR Morb Mortal Wkly Rep. 2018;67(12):349-58.
2. Rudd RA, Seth P, David F, et al. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65(50–51):1445-52.
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6. R3 Report Issue 11: Pain assessment and management standards for hospitals. Available at: www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf. Accessed November 21, 2018.
7. New National Quality Partners Action Team focuses on opioid prescribing. Available at: http://www.qualityforum.org/New_NQF_Initiative_Focuses_on_Opioid_Prescribing.aspx. Accessed November 21, 2018.
8. Thompson CA. HCAHPS survey to measure pain communication, not management. Am J Health Syst Pharm. 2017;74(23):1924-6.
9. FDA Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics. 2018. Available at: www.fda.gov/downloads/Drugs/DrugSafety/InformationbyDrugClass/UCM515636.pdf. Accessed November 21, 2018.
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|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
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
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.
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
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
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
Benchmarking current status
Implement harm reduction efforts
|Quality and information technology
Chair or co-chairs:
Chief medical information officer
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
Graduate medical education representative
Implement an awareness campaign
Implement a continuing education program
Collect feedback from constituencies