Examples of Change Strategies to Best Position Wisconsin Health Systems in Reducing Drug Abuse

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1 Examples of Change Strategies to Best Position Wisconsin Health Systems in Reducing Drug Abuse Amy Zosel, MD, MSCS Medical College of Wisconsin Wisconsin Poison Centers

2 The Problem Wisconsin is battling the critical public health epidemic of prescription opioid misuse, abuse and diversion. Unintentional opioid overdose has surpassed motor vehicle crashes as the leading cause of accidental death here and nationally. 80% of heroin use starts with prescription opioids. National Vitals Statistics System 2012

3 Change Strategies Integrating PDMP Use Into Workflow Implementing Prescribing Pathways/Protocols Opioid-free Zones

4 Physicians are ready for change! Emergency Department-based Opioid Harm Reduction: Moving Physicians From Willing to Doing. Compared to prior studies, emergency medicine physicians had increased willingness to perform OHR interventions, although few actually do. Knowledge, time, training, and institutional support were all barriers. Influential factors that may move physicians from "willing" to "doing : dissemination of supportive research evidence professional organization endorsement ED leadership opinion addressing time, knowledge, and institutional barriers. Acad Emerg Med Apr;23(4): Samuels et al.

5 Emergency Department (ED) Opioid Prescribing Pathway In 2013, an opioid prescribing pathway for patients with chronic pain presenting to the Emergency Department (ED) was implemented to reduce the inappropriate use of opioids while providing appropriate and compassionate medical care. Many rounds of review Physician consensus Leadership support

6 Emergency Department (ED) Opioid Chronic pain only Prescribing Pathway Excludes sickle cell pain and cancer pain Incorporates using EMR and PDMP Opioids in the ED as well as prescriptions for discharge to home Scripting for providers attached

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9 Emergency Department (ED) Opioid Prescribing Pathway Assessment Retrospective cohort study of consecutive patients. Included patients presenting to the ED with acute and chronic pain complaints before and after implementation of the pathway. chronic abdominal pain and chronic back pain = pain present for greater than three months acute pain = acute long bone fracture Six-month implementation period Medications administered, dosing and demographic data were collected from the EMR.

10 Emergency Department (ED) Opioid Prescribing Pathway: Opioid administration in the ED 266 chronic pain patients before and 263 chronic pain patients after pathway implementation. 163 acute pain patients before and 170 after pathway implementation. Before pathway implementation, there was no statistically significant difference in the mean morphine equivalent dose administered for chronic or acute pain patients. After pathway implementation, there was a decrease in morphine equivalent dose administered to chronic pain patients (p = ) but not to acute pain patients (p = ).

11 Emergency Department (ED) Opioid Prescribing Pathway: Opioid administration in the ED The number of patients with chronic pain who received one or more opioid prescriptions upon discharge from the ED decreased by 13.52% (p = ). In the acute pain cohort, no significant differences were found in the number of patients who received opioid prescriptions upon discharge (p = ). However, the number of pills per prescription decreased by 2.49 (p = ) and the morphine equivalent per prescription decreased by (p = ).

12 Emergency Department (ED) Opioid Prescribing Pathway: Conclusion After the implementation of an opioid prescribing pathway for chronic pain patients in the ED, there is a decrease noted in opioids administered to patients with chronic pain both in the ED and prescriptions on discharge. In patients presenting with acutely painful conditions, there was overall no decrease in opioid administration to patients in the ED.

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14 Opioid-Free ED "We know two things to be true: All chronic pain starts with acute pain. And all addiction starts with the first dose." "So if we can stop acute pain from becoming chronic pain, and if we never gave an opioid, no one would become addicted. Opioids have their place in pain management. Serious trauma, pre-surgical pain, and terminal cancer all may require opioid painkillers. Dr Rosenberg, Chair of EM St Joseph s Hospital

15 New Jersey Opioid-Free ED Launched in the ED in early January patients treated with alternative protocols since then that previously would have been treated with opioids: kidney stones acute low back pain broken bones acute headache and migraine pain. The alternative program uses: targeted non-opioid medications trigger point injections nitrous oxide ultrasound-guided nerve blocks.

16 Benefits of Unified Approach to Opioid Prescribing Across Systems Supports decisions Cohesive and consistent message to patients Patient expectations may be managed better Takes me versus you out of equation May be especially helpful for mid-level providers

17 Potential Barriers to Systems Change Likely requires extra training Provider inconsistency and utilization of tools Providers may feel their autonomy is challenged May overload systems without the same policy Patient satisfaction score may decrease