Best Practices in Transforming Chronic Pain Care

The number of opioids prescribed in the Untied States was approximately 3 times as high in 2015 as it was in 1999.¹ But, as the opioid epidemic continues, research shows there hasn’t been a change in the amount of pain reported by Americans.²

“There is a significant lack of clinical data supporting the long-term benefits of opioids, but on the contrary, there is substantial evidence demonstrating the risks,” said Gerard Greskovic, RPh, director of Geisinger Health’s award-winning Chronic Pain Clinic and other Ambulatory Clinical Pharmacy programs (see sidebar). “Over time, patients can develop a tolerance to the effects of opioids, which can lead to a continual cycle of increasing dosage, and subsequently, a greater risk of dependency or overdose.”

Research shows the rise in opioid prescribing that began in the 1990s has been a driver of the epidemic. In 2016, the CDC published its guidelines for opioid prescribing to improve the safety and efficacy of pain care and reduce risks of long-term opioid use.

To support healthcare organizations in meeting these guidelines, the Cardinal Health Foundation initiated a new Generation Rx grant program, Best Practices in Pain Medication Use and Patient Engagement. The Foundation engaged Greskovic and his colleague, Laney Jones, PharmD, MPH, assistant professor at Geisinger’s Center for Pharmacy Innovation and Outcomes, to provide guidance to the grantees as they work to reduce the use of opioids for non-cancer pain and to improve patient outcomes.

“The grant recipients are attacking the opioid epidemic from many different angles,” Greskovic said. “All of them are finding that this work requires the engagement of multi-disciplinary teams, including physicians, pharmacists, nurse practitioners and others. And they’re all learning from each other as they make progress toward helping patients manage pain and improve their quality of life with fewer opioids.”

Below are highlights of 3 healthcare organizations that, with the support of Cardinal Health Foundation funding, have made strides in improving pain management and patient outcomes while prescribing fewer opioids.

Reducing Opioids Prescribed for Pediatric Patients

Nationwide Children’s Hospital, Columbus, Ohio

Adolescent opioid use is a major public health concern in the Untied States.³ Research has shown that children who use opioids, either medically or non-medically, before their high school graduation are at 33% greater risk of opioid misuse as adults.⁴ In addition, pediatric patients often are prescribed more opioids than they need to manage acute pain, and typically use less than 50% of opioids prescribed,⁵ leaving plenty of unused opioids accessible for potential misuse by friends or family members.

In 2016, Nationwide Children’s Hospital—one of the country’s largest pediatric health care and research centers—established a multi-disciplinary Opioid Safety Task Force that includes physicians, nurse practitioners, pharmacists, community educators, and quality improvement specialists.

The Task Force first conducted a system-wide survey of all prescribers and learned that the quantity of opioids prescribed at discharge varied widely, from doses for several days to enough for several weeks. Prescribers in the pediatric surgery, orthopedic surgery, and ENT departments were writing the most opioid prescriptions. On average, prescribers were writing 25 doses per patient.

“We also found that prescribers weren’t providing enough opioid safety education for patients and families,” said Erin McKnight, MD, MPH, a pediatrician who co-chairs the Opioid Safety Task Force with Sharon Wrona, DNP, CPNP-PC, director of Comprehensive Pain and Palliative Care Services.

Among the Task Force’s initial goals was to decrease the average number of doses per opioid prescription at discharge by 20% and increase the percentage of patients engaged in opioid education from near zero to 60%. They created physician resources, including guidelines for safe prescribing and an opioid prescribing decision tree. “We really want prescribers to use over-the-counter medications instead of opioids whenever possible,” said Sonya J. Sebastian, PharmD, BCACP, a pharmacy clinical coordinator who serves on the Task Force.

The team also created easy-to-understand opioid safety materials for patients, printed in English, Spanish and Somali, and an educational video. Clinicians review these materials with patients and families at discharge; nurses make a note of the education in the patient’s electronic health record (EHR).

The Task Force began by analyzing the number of opioids prescribed at discharge after laparoscopic appendectomies in pediatric surgery. Initial data showed these patients were prescribed an average of 10 doses. Nurses contacted the families post-discharge and learned that patients, on average, used fewer than half the opioids they’d been prescribed. As a result, the department updated its practices: today, patients are prescribed an average of 4 doses post-discharge.

With Generation Rx support, the Task Force has recently begun working with prescribers in orthopedic surgery, collecting data on the average number of doses prescribed at discharge, educating prescribers, ensuring patients receive opioid safety education and providing a lock box for every opioid prescribed. When patients and families return for the first outpatient visit, 7 to 10 days post-surgery, they complete an electronic survey that asks how many doses were prescribed, whether they filled the prescription and how many doses they took.

“The data we collect helps us identify appropriate ways to decrease the number of opioids prescribed,” McKnight said. “Responses also help us tailor our patient education for the most impact.”

To date, the Opioid Safety Task Force has helped drive a system-wide reduction in doses prescribed at discharge, with the average number trending toward 17 (down from 25 in early 2016). “The amount of opioids we dispense each month has dropped fairly dramatically,” Sebastian said. In addition, 50% of patients and families are now engaged in opioid safety education.

“The team monitors patient satisfaction with their care and patient quality of life,” Wrona said. “We continually evaluate our work, and set new goals for providers and patients.”

Improving Pain Management to Reduce Risk

Johnstown Free Medical Clinic, Johnstown, Pennsylvania

The Johnstown Free Medical Clinic provides primary healthcare services to uninsured and under-insured patients in western Pennsylvania, a region hit particularly hard by the opioid epidemic. Johnstown sits in Cambria County with a population of approximately 130,000; in 2016, 180 people in the county died of opioid overdose. “The opioid epidemic has touched one out of two families in this area,” said Rosalie Danchanko, the clinic’s Executive Director.

With a staff of 7 employees and 140 volunteer medical professionals, the clinic serves more than 800 patients a year.

“We work with a very challenging population in terms of opioid misuse,” said Loretta Opila, MD, the clinic’s Medical Director. “Our patients’ interaction with healthcare tends to be inconsistent. They come to us from other providers when they lose a job or lose their insurance. Many don’t have transportation, so it’s difficult for them to keep doctors’ appointments, and many of our patients have chronic pain.”

In fact, more than 13% of the clinic’s patients have opioid prescriptions for chronic pain. In 2016, the average opioid prescription was for a dose of 95.2 morphine milligram equivalents (MME) per day for more than 146 days. Danchanko and her team established two key goals: reduce the number of chronic pain patients on opioid medication by 20% and reduce the average dose per person to less than 50 MME per day for fewer than 90 days.

The clinic doesn’t have an EHR system, so to increase opioid safe prescribing practices, they began maintaining a prescription order form exclusively for opioids in each patient’s paper file. This form includes such detail as co-morbid conditions, concurrent benzodiazepines and alcohol consumption, previous history of opioid use or abuse, and an MME calculating table.

For chronic pain patients who have not yet been prescribed pain medications, clinicians focus on non-opioid treatments, including ibuprofen, diclofenac gel or the use of a transcutaneous electrical nerve stimulation (TENS) machine. Through various community partnerships, the clinic also provides free access to alternatives, including physical therapy, yoga and chiropractic or psychological consultation.

When a prescriber determines that a patient’s best option for managing pain is an opioid, the patient is assigned a multi-disciplinary team that includes a physician, nurse, pharmacy or dispensary staff and a social worker to develop a customized pain management plan. The patient receives coaching about what they can expect from the medication and options for long-term pain management. Patients receive opioid safety education from a written guide and a video, and pharmacy staff dispense a lock box with every opioid prescription.

In between visits to the clinic, social workers follow up with the patients by phone, when possible, to discuss any concerns about their prescriptions. All patients on opioids are asked to participate in monthly group meetings where they can learn from providers and from other patients’ experiences.

To those patients on high doses of opioids, the clinic dispenses naloxone and training on how to use it.

To date, the clinic has reduced the number of patients on opioids by about 25% and has started to see a reduction in per-patient dosage. “We will continue to work with patients to find effective alternative treatments whenever possible, so that fewer are at risk of misuse or addiction,” Danchanko said. “If we can help them manage their pain even a little better, we know they will have a better quality of life.”

Reducing Opioid Prescriptions for Patients in the Emergency Department

The MetroHealth System, Cleveland, Ohio

MetroHealth is a public healthcare system that serves Ohio’s Cuyahoga County, where the rate of opioid overdose deaths in 2016 nearly doubled that of the previous year. With the goal of more effectively combatting the crisis, MetroHealth opened its Office of Opioid Safety in 2017.

Under the direction of emergency medicine physician, Joan Papp, MD, the Office of Opioid Safety offers education to providers and to the community, including communication tools to help providers better connect with at-risk patients and resources to help patients with pain management and addiction recovery. Dr. Papp is also the founder and medical director of Cuyahoga’s Project DAWN, a community-based overdose education and naloxone distribution program, which is also housed in the Office of Opioid Safety.

Dr. Papp and her team help providers in the emergency department (ED) reduce opioids prescribed. Though treating pain in the ED is key to delivering compassionate care, a 2017 New England Journal of Medicine article⁶ showed a link between being treated by “high-intensity” opioid prescribers (those in the highest quartile for opioid prescriptions per patient) and long-term opioid use. “Evidence suggests that if we can prevent or limit initial exposure to opioids in the ED, fewer patients will develop long-term opioid use or misuse,” Dr. Papp said.

Dr. Papp and her team began by assessing how many opioid prescriptions each ED clinician wrote to identify high-intensity prescribers. They’ll share blinded results with the clinicians, so they can see how they compare to their peers. “Raising this awareness is an important first step in reducing opioids prescribed,” said Trish Gallagher, CPMSM, CPCS, MetroHealth’s Director of Professional Affairs.

The Opioid Safety team’s goals are to reduce opioid prescriptions per patient encounter in the ED by 10%, and reduce the average morphine equivalent by 10% for each high-intensity provider. To achieve these goals, the team developed a set of prescribing and education tools, including:

• A safe opioid prescribing education module, required for every ED physician
• Targeted interventions to help prescribers develop comprehensive patient care plans
• Provider scripts to guide patient discussions
• Detailed order sets with non-opioid medications for common pain complaints
• Tools within the EHR system to support safer clinical decisions based on CDC guidelines
• User-friendly resources for patients

Patients’ pain and function scores are recorded at the ED visit. Nurses follow up with all patients treated by a high-intensity provider by phone within 24 hours of the visit to assess opioid use and/or other pain treatment, pain level, functioning and recall of the opioid safety education.

Dr.Papp and her team will share their progress in the ED with leaders and prescribers throughout MetroHealth. In 2018, they plan to drive similar initiatives in palliative care, family medicine and other opioid high-use departments.

“It takes time, effort, and many resources to change opioid prescribing,” Gallagher said. “It truly requires the commitment of the entire institution.”

Geisinger Pharmacists Battle the Opioid Epidemic

“Pharmacists are absolutely on the front line in the fight against the opioid epidemic,” said Gerard Greskovic, director of Geisinger’s Chronic Pain Clinic. “It’s imperative that we work in close collaboration with our clinician colleagues and continue to find new ways to combat this issue.”

Through its Chronic Pain Clinic, Geisinger has created a model that replaces the fragmented systems of care that chronic pain patients are often required to navigate. The clinic’s six pharmacists practice in 15 primary care and specialty care sites throughout Pennsylvania and support more than 2,100 patients in their efforts to better manage their pain. The pharmacists also provide significant clinical and educational support to Geisinger’s physicians.

For all chronic pain patients, pharmacists create treatment plans, provide education and support in goal-setting, perform medication reconciliation and pill counts and communicate with other care provider and refer patients to other services, as appropriate. Pharmacists also monitor patients closely for potential misuse by ordering drug screens, performing risk assessments, and checking the Pennsylvania’s prescription drug monitoring program (PDMP) at each visit and before prescription refills.

Last year, Geisinger also opened two Medication Assisted Treatment (MAT) clinics where Medication Therapy Disease Management pharmacists are embedded in multidisciplinary teams that provide comprehensive primary care, behavioral healthcare and medication management services. They work closely with addiction-trained providers, have frequent in-person follow up visits with patients, review urine toxicology screen results, check the PDMP, communicate with prescribers and refer patients to other specialty services, if appropriate.

They also educate patients on the proper administration of medication therapy, and educate physicians on opioid addiction and the MAT clinic services. A third MAT clinic is expected to open this year.

“We hope, long-term, that MAT clinics serve patients and the community so well that we’ll no longer need them,” Jones said. “Then we can use these resources for other healthcare issues.”

Greskovic added, “We understand this is a long-term battle. Our work will continue to evolve as we develop new, innovative strategies to reduce opioids prescribed, and to care for those who struggle with misuse.”

Dianne Radigan is the vice president of community relations for Cardinal Health. Molly Culbertson is a communications business partner of community relations for Cardinal Health.

References

• Centers for Disease Control and Prevention Vital Signs: Changes in Opioid Prescribing in the United States, 2006—2015. MMWR. 2017; 66(26);697—704.
• Chang H, Daubresse M, Kruszewski S, et al. Prevalence and treatment of pain in emergency departments in the United States, 2000—2010. Amer J of Emergency Med 2014; 32(5): 421-31.
• Meier EA, Troost JP, Anthony JC. Extramedical use of prescription pain relievers by youth aged 12 to 21 years in the United States: National estimates by age and by year. Arch Pediatr Adolesc Med. 2012;166(9):803—807.
• Miech R, Johnston L, O'Malley PM, et al.: Prescription opioids in adolescence and future opioid misuse. Pediatrics 2015;136:e1169-1177.
• Groenewald, Cornelius B., et al. Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012. Pain 157.5 (2016): 1021-1027.
• Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med 2017; 376(7):663-673. doi: 10.1056/NEJMsa1610524.