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August 20, 2019

New council addresses issues of opioid safety

Christy Norman, Noreen Peyatt, and Penny Castellano

In 2017, more than 47,000 people in the U.S. died from drug overdoses involving prescriptive opioids, according to the CDC. Of those deaths, 568 occurred in Georgia.

Such statistics weigh on the minds of Emory Healthcare (EHC) providers like Christy Norman, VP for pharmacy services. Last year, Norman co-led formation of the EHC Opioid Stewardship Council to address an epidemic that claims 130 lives in the U.S. every day.

The council spans care settings, service lines, and clinical and nonclinical roles throughout EHC. It coalesces grassroots efforts begun by emergency departments and ambulatory surgery sites to prescribe opioids more responsibly to prevent harm to patients.

"There was a lot of duplication of efforts, and we weren't collaborating and sharing expertise across the system to come up with solutions to use opioids more wisely to safely manage pain," says Norman. "The council helps ensure that providers across the system use the same protocols, resources, and tools based on national guidelines and best practices."

In March 2018, EHC adopted the National Quality Partners Playbook: Opioid Stewardship as the framework for establishing the new council. Norman and Noreen Peyatt, a clinical nurse specialist and pain expert at Emory University Hospital, used the playbook as a guide to set five council objectives:
  • Educate staff on the risks of opioid use and alternative strategies for managing pain.
  • Measure ordering and prescribing behaviors with the goal of decreasing the amount of morphine milligram equivalents/day that are prescribed, by provider and across the organization.
  • Modify provider behavior to improve standardization and reduce patient harm as measured through a reduction in adverse events related to opioid use (hospital admissions and emergency room visits).
  • Educate and effectively manage patients who have opioid and substance use disorders.
  • Reduce the operational burden on providers who prescribe opioids and manage patients who require them. Steps include e-prescribing (to curb unlawful duplication of written prescriptions) and full compliance with Georgia's Prescription Drug Monitoring Program (PDMP), which tracks controlled substance prescriptions statewide.
To help meet these objectives, the council established a repository of opioid-related initiatives, including one pertaining to dosing recommendations for post-operative pain that was developed at Johns Hopkins. Penny Castellano, chief medical officer for Emory Clinic and a council co-leader, is leading this effort with a pilot project in general surgery, orthopaedics, and gynecology/obstetrics.

"As part of this initiative, we've developed a dashboard and shared it with the council's MD champions, who serve as liaisons to physicians in their respective divisions, to evaluate alignment with the Johns Hopkins recommendations for select procedures," says Castellano. "Each division receives a report at the physician level. The pilot initiative has prompted conversations in these departments and will become a quality improvement project goal for residents in general surgery."

The council is making progress in other areas as well. Under state law, for instance, patients treated for pain must sign an agreement that requires them to use and store prescriptions responsibly. Patients who violate the agreement risk being discharged from a pain clinic or a physician's care. "We had 10 versions of a pain agreement previously," says Norman. "Now we have it down to one."

Providers now can use the electronic medical record to access the state PDMP portal more easily. E-prescribing directly to retail pharmacies is being piloted in oncology, palliative care, and psychiatry to improve tracking of prescriptions for opioids. The PDMP can detect when a provider is overprescribing or a patient is filling the same prescription at several locations.

For years, clinicians have relied on a traditional number scale that asks patients to rate pain from one (low) to 10 (high). To better assess pain, EHC's pain management committee has endorsed use of a functional pain scale systemwide. The scale rates pain based on behaviors (i.e., is the patient in good spirits and sleeping well versus acting out and crying). The functional pain scale is being piloted at Emory Johns Creek Hospital.

"Pain is subjective and often difficult to quantify," says Peyatt. "Effective management of pain remains an important indicator of the quality of care provided to patients. Focusing on function rather than a number provides patients and clinicians with a multidimensional means for assessing pain. We are changing our focus to how pain impacts a person's function."

Other projects include standardizing prescribing and protocols for patient-controlled analgesia devices and creating an electronic dashboard to track prescriber habits at the provider and patient level. Physicians in orthopaedics, gynecology/obstetrics, and general surgery are piloting the color-coded dashboard, which allows them to see prescribing patterns over time to determine discrepancies in practice and when a patient requires more of a drug than others typically use.

Patient education is paramount. The Opioid Stewardship Council wants every patient to know what to expect regarding pain and how to manage it safely. It seeks to standardize protocols for pain management, including limiting the number of opioids prescribed (a few days' supply instead of a month's worth), and using multimodal pain management (nonopioid medications, exercise, acupuncture, and massage). It also looks at policies and practices to monitor opioid usage and waste and how best to assist an employee who has a substance use disorder.

These steps and more are aimed at preventing patient continued use of prescriptive opioids 90 days or more after major or minor surgery, which happens in 6% of cases, according to a New England Journal of Medicine study. "That's a lot when you look at the number of patients across our system," says Norman.

In late April, EHC joined with 125 organizations in support of the National Academy of Medicine's Action Collaborative on Countering the U.S. Opioid Epidemic. Its purpose parallels that of the Opioid Stewardship Council.

As Norman wrote in a statement of support for the NAM collaborative, EHC will contribute and share solutions "through clinical practice, research, and education in an effort to combat the opioid epidemic for our patients, families, health care professionals, and the communities we serve."--Pam Auchmutey

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