Since alarms first began going off about a rising number of opioid-related deaths in the U.S., Nebraska has lowered opioid prescriptions by 32%. Local experts are calling the decline, between 2013 and 2018, a good start.
“Hospitals are listening and paying attention,” said Margaret Woeppel, the Nebraska Hospital Association’s vice president for quality initiatives.
Locally, individual health systems are also reporting signs of progress.
- CHI Health has reduced or eliminated opioids from a number of surgical procedures. Although numbers vary from procedure to procedure, one official estimated that Creighton University Medical Center-Bergan Mercy has reduced the drugs for all surgeries by 50% or more.
- Methodist Health System scaled back total prescribing across the organization, including inpatient and outpatient, by 750,000 pills from 2017 to 2018, a reduction of 12%. The bulk of reductions have come through its outpatient clinics.
- At Nebraska Medicine, the number of opioid medication orders per 1,000 patient days decreased by 35% between July 1, 2016, and March 31.
- Faith Regional Health Services in Norfolk tallied reductions in inpatient opioid use of about a third from December through February after launching a new acute pain assessment and management strategy. It de-emphasizes the 1 to 10 pain score patients are familiar with and adds objective signs of pain such as heart and respiratory rates.
Nationally, the number of opioid prescriptions decreased by more than 80 million between 2013 and 2018, a 33% drop, according to a recent update by the American Medical Association. Every state, in fact, has seen a decrease over the past five years.
“The bottom line is everybody’s working on this,” said Dr. Chad Reade, an internal medicine doctor at Methodist Physicians Clinic. “This is an all-hands-on-deck kind of effort.”
To be sure, there’s still work to be done, particularly when it comes to take-home prescribing. Efforts to curb opioid prescribing were prompted by the recognition nationally that prescription drugs were contributing to overdose deaths. Many patients’ first exposure to opioids comes with a medical procedure.
“If we can reduce it or avoid it, we’re ahead of the game,” said Dr. Myles Gart, Faith Regional’s director of acute pain management.
When the push started, federal and state agencies issued guidance and limits, as did insurance companies and pharmacies. Last fall, the Nebraska Hospital Association followed with a toolkit for its members that also included recommendations.
Those efforts continue today as policymakers and clinicians seek a balance between adequately managing patients’ pain and overprescribing.
Dr. Ken Zoucha, an assistant professor of psychiatry at the University of Nebraska Medical Center, said the next step will be to reduce deaths due to overdose.
Local health systems are taking a variety of approaches in their efforts to cut back, including reducing the use of opioids before, during and after surgery, and revising and standardizing orders for pain medications. They are also emphasizing alternatives such as non-opioids and comfort measures, including icing and music therapy for pain relief, and educating patients about pain. Also expanding is the use of local and regional anesthesia.
Officials say such approaches are working.
“We saw that when we prescribe more appropriate regimens for pain, we can simultaneously decrease our use of opioids and improve our patients’ pain control,” Dr. Sarah Richards, medical director of patient experience at Nebraska Medicine, said in a statement.
Methodist Health System has also taken a multistep approach. One piece is a database that can be used to monitor prescribing and alert providers if a patient’s dosage is getting too high, said Dr. Ann Polich, vice president for quality and performance improvement.
Methodist, among other steps, has eliminated the use of ranges in prescribing, particularly with drugs for patients who are being discharged to go home, Polich said.
Two pills every four hours works out to 12 pills in 24 hours. One pill every four hours adds up to 6 pills during that time.
“We were able to cut that in half pretty easily,” Polich said.
But the largest share of reductions has come through the system’s clinics, where doctors deal primarily with chronic pain, Reade said.
“Opioids can’t in general get pain to zero when you’re talking chronic, non-cancer pain, so the goal is to get the pain to an acceptable level where they can achieve their functional goals,” he said.
Nationally and locally, more providers are also tapping state databases of drugs dispensed to people, known as prescription drug monitoring programs. Such systems help prevent doctor-shopping as well as accidental overprescribing in patients who see multiple doctors.
The American Medical Association report indicated that almost 2 million health professionals are registered to use state-based monitoring programs, a 290% increase from 2014.
Since Jan. 1, 2018, all prescriptions dispensed to Nebraskans must be entered into the state’s monitoring program. From January to May, Nebraska providers made more than 240,000 queries, more than double the number during the same period in 2018.
A change to Nebraska law that went into effect last month will allow health systems and pharmacies to embed the prescription drug monitoring program directly into their electronic medical record systems. It will also allow Nebraska to exchange data with other states.
In Iowa, the State Pharmacy Board in January began distributing quarterly report cards on prescribing to providers. “That’s great feedback for prescribers,” said Elizabeth Becker, director of performance improvement and quality at Jennie Edmundson Hospital in Council Bluffs.
Surgical patients have been a particular focus when it comes to reducing narcotic use, a trend that began before opioid overdose was recognized as an epidemic.
Hospitals are using protocols that involve multiple means of attacking pain in a growing list of surgeries. The protocols typically involve relying more heavily on non-opioids such as Tylenol, ibuprofen and the nerve drug gabapentin, often starting before the procedure begins.
Dr. Oleg Militsakh and fellow head and neck surgeons at Methodist began testing such protocols in 2015. Between 2015 and 2017, Militsakh saw the proportion of thyroid patients who went home after surgery with a prescription for opioid painkillers decrease from 40% to 2%.
Since July 2017, the Methodist group has offered the protocol to all head and neck surgical patients. Militsakh still prescribes opioids if patients need them. But he prescribes smaller doses for a shorter period of time.
Dr. Mark Reisbig, a CHI Health anesthesiologist, said CUMC-Bergan Mercy has reduced or eliminated opioids in a number of surgeries.
Moms who deliver by caesarean section, for instance, used to get Percocet as needed after surgery for pain. Now the hospital gives ibuprofen and Tylenol on schedule around the clock. Scheduling such drugs rather than waiting until patients request them is another increasingly common method of addressing pain.
Most moms now don’t require opioids after the procedure, he said. While the hospital doesn’t yet have official data, Reisbig said, obstetricians tell him that they’re sending 75% less opioids home with their patients. CHI Health is now expanding the protocol to other hospitals.
While opioids dull the pain of surgery, patients may awaken with grogginess, nausea and other side effects, all of which can keep them in hospitals longer and slow their recovery. They can also slow breathing, sometimes to dangerous levels. Pain teams also visit medical patients, following the same principles.
“It’s really exciting,” Reisbig said. “It’s really changed the recovery for our patients.”
Becker, the Jennie Edmundson official, said obstetricians there made similar changes last summer. Patient satisfaction stayed the same.
“The more media coverage we’ve had on this crisis, the more engaged and aware patients are, and they proactively want to protect their own health,” she said.
Nor are hospitals relying just on medication.
Jennie Edmundson has placed laminated comfort menus at the bedside, part of an initiative with other Iowa hospitals. The menu lists alternatives to medication — a different pillow, going for a walk, aromatherapy — that patients can request as alternatives to pain medication, Becker said.
With the changes has also come a need to educate patients about the value, safety and efficacy of such approaches.
Militsakh said the most important part is letting patients know that providers will be there to manage their pain.
Health systems are now providing that preparation beforehand.
“A big part of pain management is actually management of anxiety and of expectations,” Militsakh said.