New prescribing algorithm, Pain Institute to be part of the solution
UH Clinical Update - March 2018
By Cliff Megerian, MD, President, UH Physician Network
In the past decade, there has been a nearly exponential escalation in the number of people dying from opioid overdoses. In fact, Ohio leads many other states when it comes to deaths from unintentional overdoses.
Opioid overuse and addiction is a result of how, in recent years, more and more people have been getting access to these drugs. Many who begin taking opioids as an appropriate prescription for pain nevertheless become addicted to opioids. Once in the throes of that addiction, they continue to seek them. When they can’t get them, they turn to illegal sources. From them, they get heroin, Fentanyl or synthetic opioids, some of which are 100 to 1,000 times more powerful than the opioid medicine they began taking as prescribed.
The result is often death.
The rise in these deaths from opioid abuse has been deemed a national public health emergency by the President of the United States. And we, as physicians, have come to realize that we can be part of the solution. At University Hospitals, we have decided to become a national leader in addressing this problem.
Here’s how we will do that. First, given the complexity of pain management and the challenges in complying with new regulatory requirements for opioid prescriptions, UH has implemented policies to educate and safeguard you from missteps in this increasingly scrutinized environment.
In addition to educating our physicians and providers on the new regulations for prescribing opioids, UH has also instituted additional guidelines to further enhance patient safety. Together, these efforts encourage a minimalist approach to prescribing, meaning that opioids are to be prescribed for a short time, with no refills. And whenever possible, there should be a concerted effort by all of us to first use alternatives to opioids for our patients. Prescription opioids still serve as an appropriate pain management therapy, but we must be pragmatic in our approach.
Second, Ohio law requires prescribers to certify that they have a registered OARRS (Ohio Automated Rx Reporting System) account, but we are taking that a step further and stipulating that our providers check OARRS prior to initial prescription of opioids or benzodiazepines and then at least once every 90 days.
Patient access to opioids from various sources is highly likely to contribute to accidental overdoses. For providers, it’s a simple process to check patients’ history through OARRS, to which you can link directly through our electronic medical record system.
We also realize the risks of potentially becoming a provider who overprescribes. These range from receiving an admonishment from the state of Ohio’s medical board all the way to criminal prosecution in the case of a patient’s death. U.S. Attorney General Jeff Sessions has instructed U.S. Attorneys’ offices in 12 states, including Ohio, to investigate overdose deaths as possible homicides. Physicians found to have been negligent prescribers could face criminal charges, as some physicians in other states already are.
The key to our strategy to safeguard you and enhance patient safety is the implementation of a Quality Assurance Chart Review (QACR) to review and assess our providers’ prescribing practices of controlled substances. We regularly monitor prescribing activity by analyzing opioid dosages. This allows us to know how many doctors are prescribing opioids, and it gives us a breakdown of patterns. When there is evidence of overprescribing or of not checking the state database, a meeting will be arranged with UH Clinical Risk Management, which will collaborate with the physician to design a plan that brings their prescribing back to a safe level.
Our UH leaders fully understand that these changes around opioids may lead to a change in practice patterns for some physicians. And for some patients, this will mean we need to decrease their opioid usage. That’s why we are in the midst of establishing the University Hospitals Pain Medicine Institute, for which we will soon be announcing a leader. This new institute will create a system-wide network centered on several major focus areas, all of which are interconnected.
First, a cogent and sophisticated by-the-book algorithm will be used by all of our caregivers in how and when they prescribe opioids. Again, this will lead to changes in practice patterns for some providers, but it also will lead to a decrease in opioid use for many patients who have become accustomed to having those medications.
Next, we’ll align our services to better serve patients who are using opioids, who typically fall into two groups: The first group is made up of people who have legitimate pain issues, which often are musculoskeletal. For those patients, we will enhance the interventional pain program, so that patients with legitimate musculoskeletal issues can be given other remedies to address the source of pain, such as injections or non-opioid interventions.
Then there is the second group – patients on opioids who already have an addiction or a psychiatric issue. We are offering a host of services throughout our organization to help them. These include detox programs and alternative health intervention programs at the UH Connor Integrative Health Network. They also include, in some cases, long-term strategies that use morphine analogs, which are safer alternatives to opioids. This portfolio of options will be overseen by Jeanne Lackamp, MD, Director of the UH Center for Behavioral and Addiction Medicine in our Psychiatry Department.
We also fully understand that solutions to the opioid scourge cannot be achieved by one institution. So we have joined with The Center for Health Affairs, Cleveland Clinic, Metro Health, the VA and St. Vincent Charity Medical Center to form the Northeast Ohio Hospital Opioid Consortium. The goal of the consortium is to share and implement evidence-based practices, promote policy change, and increase prevention efforts. Randy Jernejcic, MD, Chair of the UH Opioid Patient Safety Steering Committee, has been appointed the physician-chair of the consortium.
These approaches are coupled with our foundational principle of providing compassionate care. There are patients who currently use opioids but need to stop, and we will approach this with great care, offering holistic approaches for opioid de-escalation or detox, and using alternative pain management strategies.
We have a multi-faceted team in place at UH to support your efforts and now we look to you, our UH providers, to take a stance in helping to combat the opioid crisis.