Updates on an Epidemic: Efforts to Promote Safe Opioid Prescribing
According to the Centers for Disease Control and Prevention, more than 115 Americans die every day—one person every 12 minutes—from misuse of and addiction to opioids, heroin and synthetic opioids.
Through the Choosing Wisely campaign, ABIM Foundation has partnered with medical specialty societies that have created recommendations about appropriate opioid prescribing and benzodiazepine prescribing. Through adherence to the recommendations and promotion of patient-friendly materials, doctors and patients can better understand the risks of certain medications and dosages. The campaign is inspiring important conversations and efforts across the country to advance safe prescribing habits.
With a 25-year history and a presence across several states, QuadMed provides employers with medical, laboratory, pharmacy and coordinated care services through relationships with hospitals and doctors.
Chief Medical Officer Mary Ellen Benzik, MD, said that the organization used guidelines from the CDC and Choosing Wisely as a framework and tracked data around variation in opioid and benzodiazepine prescribing across its organizations throughout 2017.
All organizations received virtual education and regular reminders about safe prescribing habits and the controlled substance policy.
After identifying the top 10 highest prescribers, QuadMed created a virtual learning network to empower its clinicians to work together and explore solutions. Participation in the learning network was not mandatory but clinicians have turned it into a support group to work through challenging cases. Solutions—and even a physician champion—have emerged from the group.
“This was not a punitive approach,” Dr. Benzik said. “We realize that there can be differences in geographic areas and patient populations. Many participants found that they shared a high level of empathy for patients in pain, so the discussions have focused on weaning people off of high doses of opioids and avoiding co-prescribing opioids and benzodiazepines.”
QuadMed has also made other changes to help all clinicians follow guidelines:
- Incorporating guidelines and information into the EMR, including where patients can find the nearest location to safely dispose of unused medication
- Using muscular-skeletal assessments about pain rather than a pain score
- Introducing a “weaning calculator” to help clinicians reduce medication slowly and safely
These efforts led to a 34 percent increase in controlled prescribing by the end of 2017. Dr. Benzik said that even though this decrease surpassed the original goal of 25 percent, they will continue to look at reducing prescription lengths in the future.
“Having evidence-based guidelines and a clear policy was helpful to clinicians when having a conversation with their patients,” she said. “When the patient asks, ‘Why are you doing this now?’ the clinician can move quickly from what was done in the past to what we are doing now to prescribe medication safely.”
City of Philadelphia
Opioid abuse affects thousands of lives annually in Philadelphia annually. Last year, the ABIM Foundation (headquartered in the city) and local medical societies convened to provide guidance to the city around the issue of unnecessary prescribing.
At the time, Philadelphia Mayor Jim Kenney was also creating a task force, and as part of this team, the city’s Department of Public Health has focused on prevention efforts by educating prescribers about judicious prescribing and alternatives to opioids. Dr. Jeffrey Hom, a policy advisor in the Department of Public Health and co-manager of the department’s opioid program, described a multi-phase approach with outreach, education and support for area prescribers from fall 2017 to winter 2018:
- The health department mailed prescribing guidelines and information to 16,000 area prescribers.
- The next step was a public health detailing program. Department representatives visited 1,300 physicians for brief discussions to gauge their awareness of guidelines, understand their situations and re-enforce safe prescribing with a packet of resources.
- The health department paid 900 prescribers a second visit to troubleshoot issues and answer questions.
Dr. Hom said that the health department is still reviewing the data they collected, but so far can clearly see that between first and second visits, knowledge of key recommendations increased significantly. The health department heard during these visits that prescribers were challenged by, and wanted information on, how to best help patients who have been taking prescription opioids for an extended time. Their experiences informed the development of opioid tapering guidelines, which will soon be mailed to thousands of prescribers in the area.
“We are going to be in this for the long haul,” Dr. Hom said. “Already, so many prescribers have a story. They are on the front lines and are more and more aware of how tragic the epidemic is. We want to let them know that they are part of the solution.”
On May 23, Greater Detroit Area Health Council (GDAHC) held its third annual Opioid Abuse and Heroin Overdose Solutions Summit. Nicki Gabel of GDAHC said that the event keeps growing as more people become aware of the epidemic and want to join efforts to combat it. This year, 600 guests attended.
The goal of GDAHC’s first summit was to create a task force, which has since brought together members from the community every few months to advance education and training about opioid abuse. A Choosing Wisely grantee, GDAHC has disseminated campaign materials on opioid prescribing, but the summit went further in convening employers, clinicians, pharmacists, social workers and counselors, advocacy groups, law enforcement and educators to discuss the issue.
“Opioids were not an original focus for us for the Choosing Wisely campaign, but it is something that we were able to incorporate very easily as it makes perfect sense,” Gabel said. “We want to bring other community organizations together and look at the full person and all aspects of life that might be affected by opioids. Choosing Wisely is a great platform for educating people to ask more questions about tests and prescriptions.”
The 2018 summit included many topics:
- How youth, families and schools can address addiction
- Safe drug disposal, prescription drug monitoring and opioid-related legislation
- Research on how much medicine is being prescribed and how much is wasted
- What primary care physicians can do to make a difference
- The role of acute care prescribing
- An employer panel on changing the stigma of addiction