Akram Boutros, MD, president and CEO of The MetroHealth System, in Cleveland, offered this jarring observation at the association’s recent annual meeting: Opioids killed more Americans in 2016 than in the nearly two decades of the Vietnam War.
“We have to stop fixing blame and start fixing the problem,” he admonished. “That starts with us.”
Boutros joined Janice Nevin, president and CEO of Christiana Care Health System, in Wilmington, Del., to discuss the opioid crisis — and how essential hospitals can respond — during the June 22 closing session of VITAL2018, in San Francisco. The leaders agreed essential hospitals are uniquely situated to curb the opioid crisis.
“Hospitals are places where people who are suffering come and aggregate, but very often, there’s an addiction issue that is underlying the illness that we see,” Nevin said. “When they are there, it’s an opportunity to ask them if they’re ready and willing to think about treatment for addiction.”
She and her colleagues at Christiana Care call that opportunity a “reachable moment.”
“It may only be a brief moment [when] that person puts their hand up, but we need to be there when they do that, and take their hand, and then help begin them on their journey.”
To create those “reachable moments,” Christiana Care launched a universal screening process for admitted patients that provides medication-assisted treatment for those who screen positive and sets them on a pathway to recovery. The health system has connected two-thirds of its opioid use disorder patients to treatment, Nevin said.
Creating Infrastructure for Collaboration
Sometimes, reachable moments call for a culture change. Three years ago, Christiana Care restructured the health system from a traditional department structure to interdisciplinary service lines.
“It allowed us then to really think about…the journey of the patient in the system,” Nevin said. “It intentionally made for collaboration among departments and people [who] wouldn’t necessarily think to collaborate.”
Collaboration can allow for creative solutions to the crisis. “Top-down approaches — ‘you must do this, and you must do that’ — tend to be a bit of a challenge, particularly when you’re dealing with physicians,” Nevin said. “But when you say, ‘Here’s an issue, can you help us figure out how to solve it?’ they embrace that challenge.”
Emergency department physicians at Christiana Care did embrace that challenge. During the past six months, they’ve reduced narcotics prescriptions to half the national average. They’re focusing on setting clear pain management expectations with patients before the pain starts and exploring other pain management tactics, such as spirituality, meditation, and yoga. Physicians even have explored the use of virtual reality for pain management, a technique they’ve already used in the health system’s cancer center.
Re-evaluating Prescribing Practices
While Boutros believes in the power of setting ambitious organizational goals, he agrees change must start on the front lines, especially regarding opioid prescribing practices.
“The role of the medical staff leadership cannot be understated,” he said.
MetroHealth in July 2017 created an Office of Opioid Safety to oversee education, advocacy, and improved treatment. The office trained 76 physicians in administering medication-assisted treatment and created physician-, practice-, and subspecialty-specific dashboards to collect data on prescribing practices. This data indicated that just 7 percent of the health system’s physicians in the palliative care, cancer, and pain management departments were responsible for 50 percent of pills prescribed.
Direct engagement with these physicians has helped them to decrease their prescriptions. Health system leaders also created a workflow in the system’s electronic health record to flag instances when physicians at high risk for prescribing are paired with patients at risk for addiction. Physicians prescribing high amounts of opioids are urged to provide additional prescriptions for naloxone. Residents and emergency room physicians undergo training in the hospital’s simulation center, where they work with speaking mannequins to learn how to respond to patients who request more pain medication. MetroHealth’s 18-month effort to reduce opioid prescriptions resulted in a savings of 3 million pills per year, Boutros said.
Leveraging Community Partnerships
Though physicians can make a difference through prescribing practices, they can’t stop the opioid crisis alone. Both Christiana Care and MetroHealth have worked with community partners to provide education and treatment to prevent overdoses.
Christiana Care’s Project Engage provides early intervention for hospital patients and referrals for substance use disorder treatment. Peers in recovery work as Engagement Specialists, who meet with patients at the bedside and use motivational interviewing techniques to empower them to seek treatment. Christiana Care partners with local counseling centers and insurers to create a discharge plan and ease the transition into treatment. A new initiative, the Community Substance Overdose Support System, will expand these resources beyond hospital walls by creating a response team to visit patients at home after an overdose.
The health system also has worked with eBrightHealth, an accountable care organization comprising local hospitals and primary care providers, to share best practices. Above all, Nevin and other leaders are focused on engaging patients and community members on the front lines.
“If we don’t sit with the people who are impacted and the other people in the community who are doing the work, and put ourselves at the table as a partner, we won’t come up with some of the right solutions for our community and our state,” Nevin said.
MetroHealth’s community engagement begins with Project DAWN (Deaths Avoided With Naloxone). This program serves 40 Ohio counties by providing training and free naloxone kits to opioid users, those in recovery, and those who may witness an overdose. Boutros estimates that Project DAWN has saved 1,400 lives.
The health system’s advocacy led to the 2014 passage of an Ohio law that permitted all first responders to carry naloxone, a right previously restricted to advanced paramedics. Supported by a grant from the U.S. Department of Health and Human Services Substance Abuse and Mental Health Services Administration, MetroHealth launched a First Responders Project to provide naloxone to at least 95 percent of law enforcement agencies in Cuyahoga County by January 2019. The health system also is working with the Cleveland Metropolitan School District to educate teachers about the signs of addiction and to potentially offer naloxone in schools.
Overall, Boutros and Nevin see the opioid crisis as part of a larger collection of social issues — issues they’d like to see emphasized in medical education.
“It’s a whole community ecosystem issue,” Nevin said. “As a leader, the more we can deeply understand the complexities of those issues, I think the better position we’ll be able to play our role in whatever some of those solutions might be.”
Is your hospital making strides to fight the opioid crisis? Share your initiatives by emailing firstname.lastname@example.org, and we may feature you in an upcoming blog post.