The sheer scope of America’s opioid crisis—more than 40,000 opioid overdose deaths just in 2017, and more than 2 million addicted—almost defies comprehension. Many of us know one or more of the people that those horrifying numbers represent. We all want to help.
While fewer than half of those deaths were due directly to prescribed painkillers, according to the National Institute on Drug Abuse, the role that prescription medication plays in the overall crisis is significant and complex. The pain is real: more than one in ten U.S. adults live with chronic pain. But so is the abuse: 11.5 million Americans over 12 reported misusing prescription opioids in 2016.
Healthcare providers, seeking to do a better job of pain management and misled by a pharmaceutical industry that was soft-pedaling the dangers of addiction, helped plant the seeds of the crisis by adopting more liberal prescribing guidelines for opioids starting in the 1990s. Today, providers have both an obligation and an opportunity to stem the crisis and help its victims.
A complete solution is multi-faceted and will involve significant changes in laws and regulations, funding, and training, as this list of American Hospital Association priorities clearly shows. However, information technology available now can enable bold steps to curb over-prescribing, track the flow of opioid medications and keep them from falling into unauthorized hands, and recommend alternative treatments. As we acquire more information, new algorithms may help us predict which patients are most at risk to become addicted, improving our ability to target the use of these drugs to where they’re most needed and least likely to cause lasting harm.
There’s no shortage of resources to help us, from the CMS roadmap issued in June to the guide released in November by Electronic Health Records Association’s (EHRA) Opioid Crisis Task Force. EHRA is owned by Healthcare IT News parent HIMSS.
The EHRA guide – CDC Opioid Guideline Implementation Guide for Electronic Health Records – is filled with highly practical advice about how to use EHRs, today, to support clinicians and provider organizations in following each of the 12 prescribing guidelines developed in 2016 by the Centers for Disease Control. Health organization leaders should also monitor the activities of the recently formed Opioid Task Force of the College of Health Information Management Executives (CHIME).
The EHRA guide identifies these areas where properly configured EHRs can help:
- Remind clinicians of prescribing guidelines and drug interactions, alert them when they should avoid prescribing opioids, and supply patient education information.
- Automatically calculate the lowest effective dose, based on the patient’s weight, past exposure to opioids, and other factors
- Help clinicians monitor patients’ opioid use on an ongoing basis
- Help clinicians identify and track patients with opioid use disorder
- Support the ability of the clinician to refer a patient with a problem to addiction recovery resources
- Enable health systems and physician practices to analyze opioid prescribing patterns across the organization
Most major EHR vendors are members of the EHRA, and the guide received input from the American College of Emergency Physicians, the American College of Physicians, and the American Medical Association. Many vendors have already started implementing tools to help their clients follow the CDC guidelines. (Our organization, Cerner Corp., released its free opioid toolkit in October.)
But there’s only so much the clinician can do at the bedside or during an office visit. A fully effective strategy to combat opioid abuse needs arrangements and relationships that span providers and the community. When patients with an opioid addiction finally are ready to seek treatment, they can’t wait a week for a psych bed or three months to see a substance abuse specialist: if their provider organization can’t give them access to those things, it needs to know who can, and make the connection ASAP. It’s essential for clinicians to have access to the information other organizations may have on a patient’s opioid use; provider leadership must put necessary information-sharing agreements in place.
In our opinion, the following areas are ones where the top leadership in a healthcare organization must play a key role in leveraging information technology:
Tracking overall prescribing patterns and driving out variation. Prescribing clinicians should understand how they compare with their colleagues when it comes to prescribing opioids, and where they are falling into harmful habits. We worked with a provider organization where we reviewed data showing that one physician prescribed far more opioids than anyone else on the staff. The hospital administration pointed out that he was a pain and palliative care specialist, thinking that alone would explain the variation. And it would have—if we hadn’t excluded his pain and palliative care patients from the analysis. His prescribing habits from his palliative care practice had spilled over into how he treated his other patients, resulting in overprescribing. It took seeing how he compared with others to help him review and start changing his patterns.
Sharing information among organizations. State-level prescription drug monitoring programs (PDMP) are helpful for tracking which patients have received prescriptions for controlled substances, to prevent them from doubling up through multiple physicians or hospitals. PDMPs would be more helpful if providers, particularly those with multi-state service areas, could search reliably across state lines. There are gestures being made in that direction — 45 states are now cooperating to share PDMP data through the National Association of Boards of Pharmacy Interconnect Program — but a federal-level effort is needed to solve interoperability problems nationwide.
However, PDMPs were invented to solve one specific problem: an important one to be sure. But they are virtually worthless for the most urgent opioid-related patient-care issues: identifying people most at risk for addiction and those with active opioid use disorder, curbing overprescribing, or providing substance abuse treatment and effective non-opioid pain treatment. Sharing information about patients’ experience with opioids and addiction, whether or not they have active prescriptions, is absolutely essential. This sharing could be accomplished through state and regional health information exchanges and applications that aggregate patient data across providers. That information is, rightly, hedged with privacy safeguards both federally and at the state level, and it will take close collaboration with policymakers to figure out how to share information among providers in ways that help patients without compromising their privacy. Healthcare leaders should make it a top priority to participate in that conversation and push for action.
Promoting drug take-back programs. A significant percentage of opioid abuse begins when someone, often a teenager, takes leftover opioids prescribed for someone in their family. If your organization has a DEA-approved collection site, make sure clinicians instruct patients on its location and hours and remind them to dispose of their unused medications promptly, following up as necessary. If it doesn’t house a collection site, clinicians should provide patients with information for the nearest one. There is no reason why every patient-care area shouldn’t have signage like this FDA poster, making drug take-backs an everyday idea like washing hands or getting a flu shot. Reminders about take-back programs can also be highlighted through provider patient portals. Unlike so many solutions to difficult problems, this one costs almost nothing except a few tweaks to clinical reminders and some focused institutional will.
Creating institutional policies that minimize the number of opioids in circulation. Fewer patients will have leftover opioids if they receive fewer pills to begin with. Some studies show that up to 90 percent of patients who receive opioid prescriptions don’t finish them, and a substantial number don’t even start them. Providers should look at instituting protocols to reduce the number of pills in an initial opioid prescription, with an option to request a refill if necessary. Prescription data will show how many patients filled that second prescription, allowing the protocol to be adjusted if necessary. Opioids should also be removed from automatic ordering: for example, for post-surgery pain. When queried, patients may reveal that they don’t want or need the medication. Even if they do, the few minutes the clinician spends considering the prescription may lead to a smaller initial number of pills and some valuable patient education on use, storage, and disposal. This protocol from Intermountain Healthcare may provide a starting point for discussion.
Expanding access to substance-abuse treatment services. Adequate access to services is an essential part of an effective opioid abuse reduction strategy. There’s no quick, easy, inexpensive solution to the shortage of services in many areas. But at a minimum, all healthcare providers in a given service area should explore ways to coordinate access to the substance abuse services they offer, so that if there is an empty bed or a counseling slot available, a referring organization can locate it without delay.
As our prowess at applying analytics increases, we are likely to see predictive analytics that can use a wide range of variables to identify individuals who have elevated addiction risks and/or may be struggling with recovery. These variables will include core clinical data, family history, social determinants, and genetic data.
Opioid addiction is a very complex and difficult challenge. Addressing this challenge requires societal, political and organizational will and resources. Information technology can play an important role, using electronic health records, clinical decision support, analytics, patient portals, interoperability and the expansion of our clinical information systems to incorporate social determinants of health. We in the healthcare community have the tools and the data to make a significant impact on our country’s tragic opioid abuse epidemic.
John Glaser is senior vice president of population health at Cerner, where Michael Fadden is the chief medical officer.
Healthcare IT News is a HIMSS Media publication.
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