Prince’s death earlier this year brought this country’s opioid addiction into the public spotlight, but the problem has been building for years. Consider these startling facts:
*Americans consume 80 percent of the world’s supply of opioids.
*The frequency of deaths from opioid overdose tripled between 1999 and 2008.
*Drug overdose from prescription opioids is now the leading cause of accidental adult death in this country.
*Last year, Pennsylvania reported close to 3,400 overdose deaths, a 23 percent over 2014.
What’s especially troubling is that, unlike an illegal drug smuggled in from another country, the addiction “starts with a legal prescription,” said Jeanmarie Perrone, MD, of HUP’s Emergency Department.
To reverse this disturbing trend, a multidisciplinary task force comprised of providers from both Clinical Care Associates and the Clinical Practices of the University of Pennsylvania – Penn Medicine’s outpatient practices – has been developing strategies to decrease the overuse of opioids for chronic non-cancer pain. These approaches “will improve the care we provide for patients for pain and establish standardized processes for prescribing throughout the Health System,” said Michael Ashburn, MD, director of the Penn Pain Medicine Center.
Tracking Usage With Technology
Not many people realize how easy it is to become addicted to opioids. The drug’s physical properties often make it less effective when used over long periods of time. Some users become more sensitive to pain, which leads to using an increased dosage that, in turn, may not reduce the pain and increases the risk of harm. Basically, “the person needs to take more and more of the drug to get the same or less relief,” said Susan Day, MD, of General Internal Medicine.
And it’s extremely addictive. “A person can experience withdrawal symptoms after using it for less than two weeks,” Perrone said.
Patients hooked on opioids frequently go from doctor to doctor—and hospital to hospital—to get additional prescriptions to feed their addiction. Last month, at the Perelman School of Medicine, Governor Tom Wolf announced a new prescription drug monitoring program (PDMP) that will allow all in-state prescribers to access a patient’s prescription history within the state. Penn Medicine is taking this one step further, working with Information Services to create its own registry on Epic (Penn’s electronic medical record system) which will be used to track patients receiving opioid prescriptions. “The registry will collect information on all patients receiving opioids to better understand who is receiving them, why and how much,” said Ashburn, who played an important role in developing the PDMP. “It will also serve as a monitoring tool as we implement changes in care.”
The registry will be able to aggregate patient records that meet defined criteria, for example, patients with over 60 days of opioid prescriptions, and display patterns (such as the number of refills per patient or pills per prescription) by provider, by practice, by specialty, or even treatment location. While this information could be used to flag those who prescribe more than would be expected, “the goal is to identify physicians who are doing things well and emulate their behavior throughout the Health System,” Ashburn said.
Penn’s task force is also working with IS to use Epic technology to help providers follow the prescribing guidelines published by the Centers for Disease Control and Prevention, as well as state guidelines.
“We want to make sure we’re giving the right dose for the right time frame,” said Austin Williams, COO of the Office of the Chief Medical Officer. One project will accurately track the dose of opioid prescribed to ensure it is appropriate and within clinical practice guideline limitations.
Improving patient education is another strategy to reverse the trend. “We need to make sure more people aren’t inadvertently harmed by a lack of education on how addictive the drug is,” Perrone said. "Patients who continue to receive opioids for chronic non-cancer pain will need to sign a patient agreement after their third prescription, outlining the risks and benefits of the drug, as well as the processes in place to continue its use.” The document will be scanned into Epic so that it is accessible to all UPHS clinicians and potential prescribers.
Building on earlier work with CPUP’s Penn Internal Medicine practice at University City which explored improved coordination of care between pain management and primary care, Ashburn has started working with CCA’s Kennett Family Medicine practice on a pilot program to standardize the outpatient treatment for chronic pain management, based on practices used in Pain Medicine. “We want to make the process transparent throughout our practice,” said Megan Gaskill, MD. “Compliance is more difficult if the patient gets different sets of rules.”
As part of the pilot, patients on opioids will be more closely monitored, for example, brought in for regular office visits – and urine samples – and will need to sign the patient agreement stipulating, among other things, that they can only fill these prescriptions at that practice. “We want to stop these patients from hopping from practice to practice,” Gaskill said.
The goal is to eventually put these processes in place throughout all of Penn Medicine. “This is a high priority across all entities,” Day said. “We’re working for consistency in how we approach chronic opiate management and increasing communication to ensure we’re in sync.”
Educating Current Providers … and Those Coming Up the Ladder
Educating providers – and future providers -- is clearly an essential component in reining in opioid overuse. Perrone and Ashburn served on a task force consisting of representatives of state medical schools to develop core competencies that will be included in medical student education going forward. Another state task force will start work on similar training requirements for all physicians in graduate medical education training programs within the state. “These are a core group of skills we think all our physicians should have,” Ashburn said.
Penn has also co-sponsored with the Pennsylvania Medical Society two courses to educate practicing physicians, scheduled to launch this fall. One is an online five-session course and the other is an advanced two-day course at Penn. Neither is mandatory at this time but “there are two bills in the state legislature focusing on this topic,” he said.
Gail Morrison, MD, senior vice dean for Education in the Perelman School of Medicine, explained that educating medical students is not as easy as simply adding a lecture to their curriculum. To provide students with a “real life” experience, she sees the SOM using standardized patients – actors trained to act as real patients – in order to simulate a set of symptoms or problems. “Our current curriculum includes pharmacology as well as behavior modification and communication with patients but we can’t just lecture students on when they should use opioids and when not to,” said Morrison. “We want to show them the experiential part – the real difficulty of dealing with patients with a problem who are angry and crying because you’re not giving them what they want.”
Morrison also hopes to develop a joint curriculum with other schools within the University, such as Nursing and Social Work, with a link to the University of the Sciences. “This makes us unique,” she said. “Not a lot of universities are working together as a group like this.”