Help­ing docs be smarter opi­oid pre­scribers

Modern Healthcare - - BEST PRACTICES - By Maria Castel­lucci

Back in 2013, Dr. Lawrence Green­blatt was con­cerned about the rise of opi­oid pre­scrib­ing in North Carolina.

As med­i­cal direc­tor of North­ern Pied­mont Com­mu­nity Care, a Med­i­caid man­aged-care or­ga­ni­za­tion run by Duke Health in Durham, Green­blatt no­ticed a sub­stan­tial in­crease in the num­ber of pa­tients who re­ceived opi­oid pre­scrip­tions and more re­ports of peo­ple over­dos­ing from painkillers.

Green­blatt’s con­cerns were rooted in the data. More than 673 peo­ple in North Carolina died in 2012 from an opi­oid over­dose, up from 300 in 2002. The is­sue in North Carolina re­flects an epi­demic that plagues the rest of the coun­try. More than 15,000 peo­ple died in the U.S. in 2015 from a pre­scrip­tion drug over­dose, ac­cord­ing to the Cen­ters for Dis­ease Con­trol and Preven­tion.

When Green­blatt took his con­cerns to the med­i­cal safety com­mit­tee of Duke Health, mem­bers agreed some­thing needed to be done. “They put me in charge of fix­ing the prob­lem,” he said.

Green­blatt, along with a team of health pro­fes­sion­als at Duke Health, im­ple­mented the Opi­oid Safety Com­mit­tee to change how out­pa­tient providers pre­scribe and dis­cuss opi­oid med­i­ca­tions with pa­tients.

“We were the first health sys­tem in the state to take a sys­tem­atic ap­proach,” Green­blatt said.

Un­der their plan, Duke physi­cians are asked to in­form pa­tients re­ceiv­ing opi­oid pre­scrip­tions about the dan­gers as­so­ci­ated with the drugs. Tak­ing it a step fur­ther, Duke Health cre­ated an agree­ment in which pa­tients pledge they won’t seek opi­oid pre­scrip­tions from other providers, give the med­i­ca­tion to any­one else such as a fam­ily mem­ber or friend, and agree to urine screen­ings at least ev­ery three months to mon­i­tor ad­her­ence and to de­tect use of il­licit drugs. Pa­tients will be cut off if they vi­o­late the pa­ram­e­ters.

“We want there to be a con­ver­sa­tion be­tween the provider and the pa­tient,” Green­blatt said. “No one ever starts out say­ing they want to be ad­dicted to pre­scrip­tion opi­oids.”

In ad­di­tion to the agree­ment, Duke Health cre­ated ed­u­ca­tional ma­te­ri­als for pa­tients to take home with them ad­dress­ing the side ef­fects and dan­gers of opi­oids when they are not taken prop­erly. A YouTube chan­nel was also cre­ated that in­cludes tes­ti­mo­ni­als from doc­tors who de­scribe how to re­spon­si­bly take opi­oids and the other op­tions avail­able to man­age pain.

Physi­cians are en­cour­aged to check the state’s pre­scrip­tion drug mon­i­tor­ing site be­fore they or­der opi­oids to en­sure their pa­tients aren’t al­ready tak­ing other painkillers pre­scribed by an­other provider. Doc­tors are also ad­vised to pre­scribe painkillers in smaller quan- tities. Pa­tients of­ten re­ceive bot­tles with 90 pills, even though the doc­tor only asked them to take about 20 over a cer­tain pe­riod of time. Leftover pills can be mis­used by the pa­tient or be handed out to fam­ily or friends, Green­blatt said.

De­spite physi­cian con­cerns that opi­oid over-pre­scrib­ing is a se­ri­ous prob­lem, Green­blatt ad­mits it’s been hard to get some doc­tors on board with the ef­fort. Physi­cians of­ten say they are al­ready bogged down by a full ros­ter of pa­tients and other ad­min­is­tra­tive bur­dens. “It’s hard to think about adding this to their cur­rent work­load,” he said.

To en­cour­age physi­cians to fol­low the guide­lines, Green­blatt and oth­ers spend a lot of time ed­u­cat­ing the doc­tors about the pro­gram’s im­por­tance for their pa­tients’ health and well-be­ing.

Prac­tices with a high num­ber of opi­oid pre­scrip­tions among the doc­tors are specif­i­cally tar­geted by Green­blatt and his team. They talk to them about how the pro­gram can be im­ple­mented in their daily prac­tice. Talks are even held for those who are part of cer­tain spe­cial­ties that use painkillers more fre­quently-such as or­tho­pe­dics or in­ter­nal medicine-to en­cour­age a more open di­a­logue. Green­blatt said doc­tors are en­gaged and ask lots of ques­tions at th­ese meet­ings.

Since the pro­gram be­gan, Duke has seen a steady de­cline in the num­ber of opi­oids pre­scribed.

Duke Health is now ex­pand­ing the pro­gram from just out­pa­tients to in­pa­tients as well. Green­blatt said the ef­forts will fo­cus on help­ing pa­tients ad­mit­ted to the hos­pi­tal with a his­tory of opi­oid use to treat chronic pain. He said those pa­tients usu­ally have more fre­quent read­mis­sions and longer lengths of stay, so it’s ben­e­fi­cial for the health sys­tem to man­age the pop­u­la­tion bet­ter.

“We are mov­ing in the right di­rec­tion and sup­port­ing clin­i­cians to do the right thing,” Green­blatt said.

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