Opioid stewardship program focuses on alternatives in pain management

Patients who undergo elective surgery at Scripps Mercy Hospital San Diego receive handouts that describe pain expectations after the procedure. Nurses go over the paperwork with patients as well. The handouts tell patients to expect pain and that any painkiller provided will not completely eliminate discomfort.

These moves are part of the Opioid Steward Program, a systemwide effort at Scripps to educate patients and medical staff on appropriate use of opioids and alternative medications. The program, which was unveiled in early April at Scripps Mercy and will be rolled out soon across all five hospital campuses, is a way for Scripps to help stem the tide of the opioid epidemic— something that’s hit California hard in recent years. In 2016, 2,012 people died by opioid-related overdoses. The number of heroin deaths hit 597 in 2016, up 65% since 2012.

“Our goal is to return patients to healthy function as soon as possible without putting them at risk for opioid dependency—this means taking advantage of all other pain management options before considering opioids,” said Dr. Valerie Norton, chief operations executive at Scripps Mercy Hospital San Diego.

Some patients are told to use natural techniques like deep breathing, massages and distraction—watching a movie, for example.

Scripps nurses and physicians also explain why they decide to prescribe alternatives and their benefits. Patients are told that avoiding opioids can shorten the length of a hospital stay, lower the possibility of complications and eliminate risk of addiction, said Lisa Thakur, senior vice president of ancillary operations at Scripps and the administrative lead of the opioid stewardship program.

So far, patients have been receptive. “We are finding if there is patient education upfront, it improves patient experience,” she said.

That kind of buy-in is important, since the industry’s role in over-prescribing opioids was partly driven by patients’ expectations that pain after surgery must be completely eliminated.

Now at Scripps, patients are advised to use ibuprofen or ice packs before reaching for painkillers. They’re also told to start with the lowest dose and taper off the drug after three days.

Thakur said there’s a reason why surgical patients were targeted. Roughly 6% of surgical patients who received an opioid become addicted.

Scripps plans to distribute the handouts to patients across all sites including emergency departments and urgent-care clinics in the coming months. The system is also creating a video for patients to watch during their pre-operation appointment or in the hospital after surgery.

Physicians are also being asked to change their behavior. They must complete an online educational module on safe and appropriate opioid prescribing techniques. It advises physicians to exhaust all options before prescribing an opioid; to prescribe no more than 30 doses per patient and to discuss with the patient the best ways to taper off the opioid.

Thakur, Norton and other leaders of the program have been traveling to sites across the health system to promote non-pharmaceutical techniques such as ice or heat, physical therapy and meditation. The on-site visits also include training on multimodal pain management, which involves prescribing patients non-opioid medications like acetaminophen initially and then small doses of opioids as needed.

Additionally, the program has changed the role of pharmacists at Scripps, Thakur said. Doctors are encouraged to ask pharmacists to review cases to ensure they are prescribing the best drug regimen. Several pharmacists are also part of the team leading the rollout of the opioid stewardship program.

Physicians have been enthusiastic about the changes so far, Thakur and Norton said.

“Physicians and nurses are saying we should have done this years ago since we have an epidemic across the country on our hands,” Thakur said.

The next step is one that physicians are particularly eager to take—helping treat patients with chronic conditions who have become dependent on opioids. ●