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

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.

Footnotes

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: sweiner@bwh.harvard.edu. 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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