One of the most poignant reminders of the opioid scourge is the increasing number of young people in newspaper obituaries and the vague descriptions of their last moments: “died unexpectedly,” “died suddenly,” or “died at home.” There is increasing opportunity to bring coordinated attention and efforts to stem the tide on the opioid epidemic given the recent declaration of the opioid epidemic as a public health emergency in the United States. Drug overdoses now outpace motor vehicle accidents as the leading cause of accidental deaths in the U.S., with 52,404 fatal drug overdoses in 2015. Deaths from opioids are driving this trend: there were 20,101 overdose deaths related to prescription pain medication and 12,990 related to heroin in 2015, according to the American Society of Addiction Medicine.
New data from the Centers for Disease Control and Prevention (CDC) show that while the total amount of prescription opioids dispensed in the U.S. declined between 2010 and 2015, there was great geographical variation in prescribing. In 2015, the most recent year for which there are data, six times more opioids per resident were prescribed in high-prescribing counties versus the lowest-prescribing ones. This variation highlights a lack of consistency in prescribing habits — and in provider education and protocols.
Every day, clinicians see firsthand the devastating effects of the opioid epidemic on patients, families, and communities. How clinicians provide care to patients who are opioid-dependent or have overdosed, how they think about and prescribe opioids, how they connect patients to treatment resources, and how well they are collaborating with other stakeholders in this work are all key to better treatment, results, and recovery.
Advancing Provider Education in Five Areas
To provide better care for patients with opioid use disorder and those at risk for developing it, clinicians, as well as medical students and residents, need to be educated in five areas: 1) screening patients; 2) prescribing appropriately, including using prescription drug monitoring programs (PDMPs); 3) communicating with patients about pain management alternatives; (4) the effectiveness of naloxone and substance use treatment options, including medication-assisted treatment (MAT); and 5) understanding and addressing bias and stigma.
While the clinician-patient relationship may be the most powerful force for addressing the opioid crisis, all stakeholders, including health care organizations, state and local health departments, law enforcement agencies, schools, and community organizations need to work together to affect change. Hospitals and health systems must fully support clinicians in helping connect patients to resources, treatment, and the help they need. Hospitals and health systems could support clinicians in connecting patients to social support and appropriate treatment.
The first step in confronting the opioid epidemic is recognizing the disease. Frontline providers have a responsibility to better screen for opioid use disorder by understanding the societal and physical risk factors of the most vulnerable patients. One major risk factor is demographics: non-Hispanic white males from rural or lower socioeconomic backgrounds suffer from opioid use disorder at higher rates than any other group. Other key risk factors include a history of substance use disorder, chronic pain, and mental illness. By recognizing these risk factors, providers can structure pain management plans — including non-opioid treatment methods — to enhance patient safety without reducing overall effectiveness. Asking a few screening questions can make a difference in a patient’s life. Effective screening tools are available for providers to identify patients at high risk for opioid use disorder and help treat and educate these patients. Two examples are:
- The Substance Abuse and Mental Health Services Administration’s (SAMHSA) guide, “Screening, Brief Intervention, and Referral to Treatment” — an evidence-based approach that helps providers quickly recognize addiction and treat patients or refer them to more comprehensive treatment.
- National Institute on Drug Abuse (NIDA) Drug Screening Tool, a worksheet with a checklist and suggested script, which providers can use to screen patients for drug use, determine a patient’s “substance involvement” score, and respond with feedback, support and/or referral.
To address the variability in prescribing practices, hospitals and health care systems should ensure that clinicians and staff have the appropriate resources at their fingertips, including prescribing guidelines, patient education materials on the risks of opioids, and information on non-opioid pain treatment. With these resources, providers can help obviate the long-term use of opioids, prevent opioid use disorder, and restrict the availability of opioids for illegal theft or resale.
Resources for educating patients include:
- A CDC/American Hospital Association (AHA) handout that helps foster communication with patients about the risks of using opioids and how patients can manage their own opioid use and non-opioid treatment options.
- Taking Opioids Responsibly for Your Safety and the Safety of Others, a guide from the Department of Veterans Affairs’ National Pain Management Program that provides patient information on long-term opioid therapy for chronic pain.
- Effectively Communicating with Patients about Opioid Therapy, a CDC webinar for clinicians on how to apply principles of motivational interviewing and a six-step process that supports clinical judgment when conflict arises.
- High-Alert Medications: Consumer Leaflets with Safety Tips from the Institute for Safe Medication Practices — educational materials customized for 11 high-alert medications, including warfarin and oxycodone.
In addition to providing the appropriate resources, hospitals should consider monitoring prescribing and periodically reviewing findings with clinicians to understand their practices and identify areas for improvement. Studies have shown that opioid prescribing decreases through this process.
Patients receive better-informed care when clinicians can easily access prescription drug monitoring programs. PDMPs, which collect data on patients’ prescription drug histories and the identities of prescribers and pharmacies, have emerged as an effective tool in fighting the opioid epidemic. Every state has created one of these programs. Medical directors should consider policies that require clinicians to check the PDMP before writing an opioid prescription. Many hospitals are working to integrate PDMP information into their electronic health records, and despite the hurdles, it is imperative that EHR vendors, states, and providers work together to make this information available in clinician workflows. Better integration of these databases into health information technology systems will also improve data sharing across states. The AHA supports federal efforts to increase this type of interoperability.
Providers are now more frequently prescribing non-opioid therapies for people with chronic pain, with the exception of patients with cancer or at the end of their life. Therapies include counseling, cognitive behavioral therapy, and non-opioid medications.
Resources on non-opioid treatment methods include:
- CDC Recommendations for Non-Opioid Treatments in the Management of Chronic Pain — a webinar that offers information on identifying the most appropriate treatment options and assessing the value of exercise, education, and non-opioid drug treatments.
- Alternatives to Opiates (ALTOSM) program, launched in January 2016 at St. Joseph’s Regional Medical Center in Paterson, New Jersey, which uses targeted non-opioid medications, trigger point injections, nitrous oxide, and ultrasound-guided nerve blocks to tailor pain management needs to patients.
Expanding Access to Naloxone
In recent years, the federal government, state and local agencies, and not-for-profit organizations, as well as hospitals and health systems, have worked to expand access to naloxone — an opioid countermeasure — by distributing kits and training physicians and first responders to administer the drug. Naloxone’s efficacy is incontrovertible: from 1996 through 2014, it has reversed more than 26,000 overdoses.
Some providers think that naloxone promotes risk-taking behaviors and prolongs addiction. Others believe that prescribing naloxone will expose them to malpractice claims. But there is no evidence to support these concerns. Affordability can be an issue, however. Some insurance companies do not cover naloxone, and the manufacturer has increased its price dramatically in the last several years.
Partnerships between hospitals, community organizations, and law enforcement have been effective in expanding access to naloxone, coordinating treatment and care, and saving lives. These collaborations must increase.
In Hampton, Virginia, Sentara CarePlex Hospital is working with local police to offer training on using naloxone and providing supplies of the nasal spray. And in Dixon, Illinois, as in other communities around the country, a local hospital and police have partnered to implement Safe Passage, a program that allows people with substance use disorder to surrender drugs and paraphernalia to police without fear of arrest. Then, police and the hospital partner with local treatment centers to coordinate treatment for these individuals.
Improving Access to Treatment
A promising evidence-based approach to opioid use disorder is medication-assisted treatment (MAT), which uses a combination of medications, counseling, and behavioral therapies. Recent statutory and regulatory changes have expanded access to MAT by increasing the number of patients each provider can treat and allowing specially trained nurse practitioners and physician assistants to prescribe buprenorphine, an opioid used in MAT.
MAT resources include:
- The Substance Abuse and Mental Health Services Administration’s free pocket guide for physicians, “Medication-Assisted Treatment of Opioid Disorder,” which discusses several types of approved medications, screening and assessment tools, and best practices for patient care.
- Providers’ Clinical Support System for MAT (PCSS-MAT), a national training and clinical mentoring project, which provides effective, evidence-based clinical practices in preventing, identifying, and treating opioid use disorder.
- Project ECHO – Opioid Addiction Treatment recruits family nurse practitioners and physician assistants to receive additional training and experience in behavioral health treatment, such as how to screen patients for several disorders, including opioid use disorder.
- AHA case study, “Tackling the Opioid Crisis in a Rural Community,” describes how Bridgton Hospital, a 25-bed critical access hospital in Maine, partnered with Bridgton Family Practice and Crooked River Counseling to use MAT and treat patients suffering from opioid use disorder, with strong results.
Understanding Bias and Stigma
As we seek solutions to the opioid use disorder epidemic, we also must understand the underlying stigma and biases that we can unwittingly bring to the treatment of patients. While the epidemic affects people of all ages, races, and socioeconomic backgrounds, some caregivers have mistaken ideas about what an addict “looks like.” These misconceptions result in some patients being denied needed care.
Recently, several stories have surfaced of patients with sickle cell disease, a condition that affects mostly African Americans, having difficulty accessing needed pain relief. A study in Pain Medicine showed that 63% of nurses perceived patients with sickle cell-related pain to be drug seekers. In reality, only 10% are estimated to have opioid use disorder, the average rate for those with chronic pain.
Also, there are situations where patients avoid care because of the fear of how they might be treated given the stigma of addiction. It is imperative that clinicians, hospitals, and health systems better understand and address bias and stigma.
Helpful resources addressing stigma include:
- Colorado ACEP 2017 Opioid Prescribing & Treatment Guidelines, which address the challenges associated with stigma.
- Addiction, Stigma, and Discrimination: Implications for Treatment and Recovery, a webinar discussing what can be done to address and reduce stigma to enhance the quality of care for patients with opioid use disorder.
- The Role of Shame in Opioid Use Disorders, an online module focusing on recognizing and treating shame in patients with opioid use disorder.
Leveraging a New Toolkit and Learning Collaboratives
The AHA has developed a toolkit to arm hospitals and health systems with the most current resources, case examples, and guidance to help curb the opioid epidemic. The resources mentioned in this article are included in this toolkit, as well as additional information and examples. We invite clinicians and hospital professionals to offer suggestions and case studies for review. We will update the toolkit as new materials become available.
All of these educational tools and resources can be amplified by participating in learning collaboratives organized by state and national organizations in order to share best practices and learn from each other. Providers are well positioned to bring community groups and hospitals together to address the opioid crisis, including advocating for more treatment resources.
Providers face challenging situations and difficult decisions as they identify and treat individuals with opioid use disorder. But if providers are armed with screening tools, knowledge about proper prescribing, alternatives to opioids and treatment options, and an understanding of bias and stigma, they will be better equipped to treat patients and transition them to appropriate follow-up care. Hospitals, health systems, and other stakeholders — critical partners in winning the battle of saving lives — must support the work of clinicians.
The authors would like to acknowledge the assistance of Cynthia Greising, Priscilla Ross, and Evelyn Knolle of the American Hospital Association.