'Out in front' — how healthcare leaders can help solve the opioid crisis


The number of Americans dying from opioid overdoses is staggering. In 2015, a record 52,404 people in the U.S. died from drug overdoses. The rise in deaths was largely driven the 33,000 deaths attributable to opioids — a record number, according to the CDC. Heroin contributed to more deaths than handguns in America in 2015.

                     This content is sponsored by Pacira Pharmaceuticals

A projection published by The New York Times in June suggests the number of overdose deaths in 2016 is not only going to surpass the year prior, but the rate of increase will be the most pronounced uptick yet. The Times estimates that when the CDC finishes compiling overdose deaths for 2016, the total will hover around 62,500. This figure represents a 19 percent rise in overdose deaths in a single year, the sharpest rise on record. A worst-case scenario projection from STAT suggests 650,000 people could die from opioid overdoses within the next decade if significant efforts to truncate the epidemic's reach aren't successful.

The national opioid overdose crisis is one of the most lethal and troubling public health issues in modern American history. But, unlike most other public health crises, the opioid overdose epidemic can be linked to the healthcare system. 

In an interview with Becker's Hospital Review in July, Michael Botticelli, former director of the White House Office of National Drug Control Policy under the Obama administration and the current director of the Grayken Center for Addiction Medicine at Boston Medical Center, said healthcare leaders need to understand "however well-intended, it was our healthcare system that really drove this epidemic."

"This was not an epidemic enacted by drug cartels," said Mr. Botticelli. "This started with overprescribing and has exacerbated some very long-standing issues regarding the underdiagnoses of addiction. Our healthcare leaders have a moral and ethical responsibility to do everything they can to put an end to this epidemic."

Although the overdose epidemic may have begun with overprescribing, hospitals and health systems remain uniquely positioned to be a driving force in the resolution of this crisis. Steven Berkowitz, MD, president and founder of SMB Health Consulting, and Eric Bour, MD, a bariatric surgeon with Greenville (S.C.) Health System and associate professor at the University of South Carolina School of Medicine-Greenville, spoke with Becker's about three key strategies organizations can use in the fight against addiction.

Emphasize multimodal pain management

The Joint Commission introduced standards regarding the treatment and assessment of pain in 2000. In 2001, the Commission declared pain the fifth vital sign, marking a pivot point in the way narcotic painkillers are prescribed. In subsequent years, pockets of the country experienced a significant surge in opioid prescription rates.

Consider West Virginia. From 2007 to 2012, the number of hydrocodone and oxycodone prescriptions rose sharply, amounting to 433 pain pills per resident, according to a report from the Charleston Gazette-Mail. This is a substantial amount of medication, especially considering many patients do not use their entire prescription for post-operative pain. A 2016 study published in PLOS found 83 percent cesarean section patients and 71 percent of thoracic surgery patients took no more than half of the pain pills they were prescribed after surgery.

Leftover opioid pain prescriptions, sitting in medicine cabinets, can be diverted by friends and family members and may contribute to the development of opioid addiction. During the same time period, more than 1,700 West Virginians fatally overdosed on hydrocodone and oxycodone alone.

Multimodal pain management methods are being increasingly embraced by clinicians as an effective way to control patient pain while simultaneously limiting the overprescribing of opioids. Multimodal pain management can target specific pain pathways and potentially involve the use of preoperative intravenous acetaminophen, local anesthetics like lidocaine and the limited use of post-operative opioids for breakthrough pain only, among other potential strategies.

When implementing multimodal pain management protocols, providers must examine case-specific treatment considerations. A collaborative team of anesthesiologists and surgeons must work together determine the drug regime based on the procedure. The team should also discuss potential side effects and post-operative patient pain.

"We've been able to really implement [multimodal protocols] by really collaborating with anesthesia," Dr. Bour says. "[The effort] is not just surgeon-driven … it's a team of individuals from across specialties. We've all sat down together and said, 'We need to do something about this.'"

Dr. Bour says multimodal strategies can consist of preoperative, intraoperative and post-operative medication regimens. Preoperative medications can include pregabalin and Celebrex; intraoperative medications can include ketamine and liposome bupivacaine — known by the brand name EXPAREL — and post-operative regimens can include the use of oral acetaminophen.

For these multidisciplinary teams to be effective, it's crucial for C-suite leaders of hospitals and health systems to fully endorse the protocols and work to identify and tap enthusiastic clinician champions to facilitate cultural change in pain management at the care level.

Dr. Berkowitz says his mantra to CEOs is that "surgeries cause pain" and this pain requires treatment, but treatment doesn't necessarily require lengthy opioid prescriptions that could be potentially diverted or misused by the patient.

"What I tell the CEO is [surgery] happens thousands of time in your hospital, [then I ask] 'Are you state of the art in managing perioperative pain?'" says Dr. Berkowitz, who previously served as CMO of St. David's Healthcare in Austin for 13 years.

Engage patients to alter cultural pain expectations

Another key strategy in reducing the amount of opioids prescribed in a hospital is to address patient expectations of pain prior to surgery. Patients in America consume 99 percent of the world's hydrocodone, according to a report from the United Nations cited in an analysis written by Keith Humphreys, PhD, a professor of psychology at Stanford (Calif.) University, published in The Washington Post. America's disproportionate consumption of opioids is likely the result of a myriad of factors including economics, marketing and politics. However, in his analysis, Dr. Humphreys argued another factor at play may be Americans' faith that "life is perfectible."

"Consider, for example, a 55-year-old who feels acute back and leg pain after doing the workout that was easy when he was 25. A European in this situation might reflect sadly that aging and physical decay must be accepted as part of life, but an achy American might demand that his doctor fix what he sees as an avoidable problem by prescribing him opioids," wrote Dr. Humphreys.

On a 10-point pain scale, a patient's expectation for post-surgical pain should never be zero. It's important for providers to engage patients before surgery on their current state of pain and coach them in their expectations of post-operative pain.

"It's very important that a patient receives appropriate [coaching] and acknowledges that they will have pain," says Dr. Berkowitz. "The goal is not to be pain free. The goal is to manage pain … Our goal is not to eliminate narcotics, but to exercise all other alternatives prior to resorting to them."

Eliminate side effects

In addition to the risk of addiction associated with narcotic painkillers, the drugs can also produce a litany of other side effects including nausea, vomiting, dizziness and constipation. These side effects can potentially contribute to extended hospital stays and potential post-surgical complications, especially among patients using the medications prior to surgery.

In a study published in the Annals of Surgery in April, researchers found surgical patients who used opioids preoperatively were more likely to be discharged to a rehabilitation facility, readmitted to the hospital within 30 days and experience higher costs of care.

"Narcotics' side effects are clinically and economically significant to our hospitals," says Dr. Berkowitz. "Even trivial side effects like post-op constipation and post-op nausea can prolong length of stay."

While CMS announced it would no longer incorporate pain management questions on HCAHPS surveys into hospital payment calculations beginning in 2018, some stakeholders have expressed concern that limiting opioid prescriptions may hinder a hospital's chances of earning high marks on HCAHPS' pain management assessment, which factors into patient satisfaction scores. However, in a study published in JAMA in May, researchers found post-operative opioid prescribing had little correlation with pain management or pain dimension HCAHPS scores. The study involved more than 30,000 surgical patients treated at nearly 50 hospitals across Michigan.

Dr. Berkowitz suggests limiting post-operative opioid prescriptions and implementing a patient-specific multimodal pain management strategy could positively affect patient experience and patient satisfaction due to the elimination of opioid-induced side effects, which could possibly result in improvements to HCAHPS scores.

According to Dr. Berkowitz, if hospitals or health systems implement such protocols they "will improve pain management HCAHPS [scores] and decrease narcotic side effects with a tangible clinical and economic effect."

Get out in front

With the launch of state databases to track opioid prescriptions across the nation, the implementation of new opioid prescribing guidelines and the ratifying of legislation meant to curb opioid overprescribing and target pill mills, many hospitals and health system leaders are already changing the way their organizations prescribe opioids and manage patient pain. As the opioid crisis continues to evolve, more changes are poised to roll in. Healthcare leaders pushing their organizations to meet the challenges created by the opioid crisis head-on are putting their organizations in a position to succeed.

"Being ahead of the curve is going to be a better place to be," says Dr. Bour. "I think there's going to be … a competitive advantage based on the ability of [an] organization to get out in front of this [crisis]."

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