Every day, another revelation, statistic, or heartbreaking story related to the ongoing opioid epidemic keeps the crisis on the front page. The Centers for Disease Control and Prevention (CDC) estimates that 30 Americans die from an opioid overdose each day, and one in five people reports knowing someone struggling with an addiction to illicit opioids or prescription pain medications. The CDC also places the economic burden of the crisis — including the costs of health care, rehab, lost productivity, and criminal justice — at about $78.5 billion a year.
It’s a lot to digest, but while it may seem like a problem too complicated to tackle, Penn Medicine’s multidisciplinary opioid task force continues to make strides in research, prevention, and compassionate treatment, with staff from Pennsylvania Hospital playing key roles in this vital work. Research led by Zarina S. Ali, MD, MS, an assistant professor of Neurosurgery, was recently published in Journal of Neurosurgery: Spine describing the use of Enhanced Recovery After Surgery (ERAS) protocols and their success in optimizing patients’ care before, during, and after surgery.
The ERAS pathway includes pre-op interventions such as improving patients’ nutrition and physical activity, helping them try to quit smoking, and setting expectations about surgery and aftercare. ERAS also focuses on alternative pain management by using methods like local anesthesia and Tylenol in place of traditional opioids. Getting patients up and moving early and having them drink clear carbohydrates before surgery and chew gum afterward can also improve outcomes.
Reaching Out to Colleagues and Community Members
Suzanne Brown, MS, RPh, director of Pharmacy Services, notes that the hospital has actively been streamlining prescribing practices, including replacing paper prescriptions with e-prescriptions sent directly to the pharmacy to prevent loss or forgery. She is also an enthusiastic promoter of the state’s prescription drug monitoring program (PDMP), which allows prescribers and pharmacists to keep track of prescription histories. The Outpatient Pharmacy carries the overdose-reversal medication Narcan — accessible without a prescription — and soon, she hopes to introduce a prescription drop-off kiosk where people can safely dispose of their leftover pills to ensure they aren’t abused. Brown’s top priority, though, is opening employees’ eyes to the pervasive nature of the crisis and educating staff on the safety nets and resources in place if they’re concerned a colleague is diverting opioids.
“Controlled substances are part of our work, part of our routine, but we have a level of trust in our colleagues because our culture is very collaborative — of course we can assume a coworker properly disposed of unused medications! But while it’s easy to think diversion ‘can’t happen here,’ drug abuse isn’t something that just happens on the streets,” Brown said. “It’s not just a subset of ‘drug dealers’ and ‘drug buyers.’ Elderly patients become dependent on their prescriptions. Members of the community unknowingly overdose on fentanyl. Drug-seeking clinicians have ample access. Everyone is susceptible, and everyone plays a role in combating the epidemic and supporting those in need of help.”
In addition to preventing patients and staff from developing a dependence by minimizing exposure to opioids whenever possible, PAH staff are also working diligently to treat patients and members of the community already struggling with opioid use disorder (OUD). As they hit the streets 365 days a year, Maryanne Bourbeau, MS, manager of Hall-Mercer’s Targeted Case Management Program, and members of her team identify vulnerable individuals using opioids and direct them to the medical, psychological, and community resources they need. As part of their work with the city’s Department of Behavioral Health, each outreach worker carries two cartridges of Narcan with them at all times, though they’ve fortunately used them very infrequently. By meeting addicted individuals where they are, the outreach team is able to humanize the struggle and offer hope and direction.
The Impact of Interdisciplinary Efforts
Kevin M. Baumlin, MD, FACEP, chair of Emergency Medicine, and Ellen McPartland, MSN, CRNP, CNS-BC, Stroke Program Manager Nurse Practitioner serve as co-chairs of the PAH OUD Task Force, and were tasked with coordinating all of the hospital’s efforts and sharing health system-wide initiatives. For Baumlin and McPartland, eliminating the stigma around addiction is key, and they’ve found a very receptive audience in their PAH colleagues.
“We’re trying to make it clear that the people who come to us with OUD are individuals with an illness, and we as clinicians can help them. We have a responsibility as providers to treat this patient population like any other, and it’s been really important to us to get that conversation going,” Baumlin said. “We’re treating this like a team sport across the hospital and the health system. Physicians, nursing, pharmacy, social work — we can only make a difference if we do this together.”
Baumlin and McPartland currently see between one and five patients a day who have overdosed, are experiencing withdrawals, are detoxing, or come to the Emergency Department for another reason but present with an opioid addiction. After these patients are identified, staff engage them in a discussion about medication assisted treatment using suboxone, connect them with follow-up resources in the community (pregnant women are encouraged to go to the Dickens Center at HUP), and link them with a social worker and certified recovery specialist at PPMC to ensure a “warm hand-off” before discharge. They are also developing an advanced screening process that will more accurately capture the data surrounding OUD patients so they can enhance their services accordingly.
For McPartland, one recent patient’s story stands out as an example of the importance of this challenging work. “This man had been escorted in by the police with an infected wound, but it was clear he was also going through withdrawals. He’d been arrested for a petty crime. If we can treat the real problem, the addiction, we can also play a part in preventing the rest of these issues… Anyway, I knew once he left, he’d be processed at the police station for hours and would be highly uncomfortable. I got him started on suboxone and had a certified recovery specialist talk to him,” she said, pausing for a moment. “If I’d only addressed his wound and he’d gone to jail in withdrawal, it’s likely he would have left craving heroin and easily could have overdosed. If I can prevent one person from dying from an overdose, it’s all worth it.”