Every month or so, my Facebook feed floods with photos of someone I knew in high school whose life (one of 115 each day on average) was cut short by an overdose. Every week, my mother – who works in a medical center specializing in addiction treatment – mentions that yet another friend of a detoxing patient drove by the facility and flung a baggie of heroin out the window to “tide them over.” Every day, I scroll through endless headlines about the impact of this nationwide crisis on the economy (a $78.5 billion/year cost, according to the CDC), the shifting priorities of healthcare, the devastated communities and families watching loved ones bounce between jail cells and hospital beds, the children born with neonatal abstinence syndrome – seemingly everything and everyone.
I’m not the only one: one in five Americans reports knowing someone struggling with an opioid addiction. But while it may feel too massive a problem to tackle or too overwhelming to even comprehend, experts in many corners of Penn Medicine are at work combatting the deadly toll, including the physicians and researchers of the Center for Health Incentives and Behavioral Economics (CHIBE) at the Perelman School of Medicine.
As one of two Roybal Centers on Behavioral Economics and Health nationally funded by the National Institute of Aging of NIH, CHIBE combines psychology and economics with clinical expertise in an effort to understand why individuals make certain decisions that impact their health and how to leverage their findings to advance policy, improve health care delivery, and encourage healthy behaviors among patients and best practices among clinicians. All those elements combine in their efforts to curb prescription opioid misuse.
“With how far-reaching and complex the opioid crisis is, it has been a challenge to determine effective approaches to reducing opioid utilization. It is vital to test new approaches to accelerating innovation,” said Kevin Volpp, MD, PhD, a professor of Medicine and Medical Ethics & Policy and the founding director of CHIBE.
One such program is the REDUCE study, led by Amol Navathe, MD, PhD, an assistant professor of Health Policy and Medicine and associate director of CHIBE, and Mitesh S. Patel, MD, MBA, MS, an assistant professor of Medicine and Health Care Management and director of the Penn Medicine Nudge Unit. Backed by a $600,000 grant from the Donaghue Foundation, Navathe and Patel are collaborating with the Sutter Health System in northern California to assess whether shifting the default options of electronic health records (EHRs) can effectively decrease the number of opioid pills physicians prescribe, and whether sending monthly reports comparing prescribing patterns among physicians can “nudge” them towards lower rates of prescribing.
The three-year REDUCE study will examine over 50 emergency department (EDs) and urgent care centers and 24 hospitals operated by the Sutter Health System, and will focus specifically on patients seeking treatment for relatively minor conditions like sprains and lower back pain.
“Physicians know guidelines exist about opioid dosages and durations, but translating evidence-based knowledge into practice can be difficult when in a patient encounter,” Navathe said. “Our goal isn’t to introduce new standards, but to subtly nudge physicians to fit their prescribing patterns back into the established guidelines, prescribe lower doses of opioids for shorter durations, and opt for alternative treatments when possible.”
This study builds upon a proof of concept led by M. Kit Delgado, MD, MS, an assistant professor of Emergency Medicine and Epidemiology. Delgado and his colleagues assessed the prescribing patterns of two of Penn Medicine’s EDs and found that patients were often receiving 30 or more opioid tablets (even for minor injuries) when 10 to 12 would have sufficed. In response, they sought to nudge physicians to prescribe smaller quantities consistent with guidelines by creating a new, lower default option of 10 tablets in the EHR.
The REDUCE study launches Delgado’s findings to the next level by combining the reduced default strategy with peer comparison feedback and implementing them across a large health system in a region hit particularly badly by the opioid epidemic.
Forging New Ground with the CTSA
Given the urgency of the opioid epidemic, the latest round of connected health pilot programs run by CHIBE in conjunction with Penn’s Clinical and Translational Research Award (CTSA) – which is based at Penn’s Institute for Translational Medicine and Therapeutics (ITMAT) – prioritized pilot projects focused on reducing harm from opioids. As Volpp noted, “If the ideas we test are sufficiently bold, some will likely be unsuccessful, but that’s okay if across projects we make progress.”
Delgado has also led a project focused on collecting feedback over the phone from patients prescribed opioids after orthopedic surgery in order to determine how they are managing their pain and how many pills they have left. This work was a springboard for one of the CHIBE studies chosen as CTSA pilot.
Zarina Ali, MD, an assistant professor of Neurosurgery, and Anish Agarwal, MD, MPH, an Emergency Medicine physician, have teamed up with Delgado to “right size” EHR defaults and reduce opioid prescribing, taking cues from Delgado’s phone screening and Ali’s experience sending pre- and postoperative text reminders via the “Engaged Recovery at Penn” program and Penn’s Way to Health software platform for behavioral interventions, which is jointly run by CHIBE and the Penn Medicine Center for Health Care Innovation.
“The goal is to make the prescribing process more evidence-based and personalized. Recognizing that one size does not fit all, our goal is to get a sense of the general baseline need for opioid medications after specific procedures and then to tailor our prescribing practices towards this data,” Ali said. “Ultimately, we hypothesize that this will result in more informed, data-driven opioid prescribing patterns.”
The trio has split their focus between patients undergoing elective surgical procedures within Orthopedics and Neurosurgery and on ED patients with acute painful injuries by evaluating their pain and measuring their total opioid consumption through simple text messages sent a few days after discharge. Understanding patient behavior will enable the team to gain a clearer view of what the “right size” is for specific procedures, integrate that adjusted default in the EHR, and thus nudge physicians to reduce their prescribing rates so there are fewer pills available for misuse.
“By collaborating across departments and leveraging healthcare IT, mobile health, and behavioral economics, we hope to limit the amount of pills going out in an effort to curb the problem early on,” Agarwal said. “Our goal is to help other physicians work smarter, not harder, by developing an easily scalable strategy that can be implemented in other departments and hospitals.”
CTSA Funding Makes Three More Programs Possible
Zachary Meisel, MD, MPH, MSc, an associate professor of Emergency Medicine, and Marilyn Schapira, MD, MPH, a professor of Medicine and physician at the Corporal Michael J. Crescenz VA Medical Center, are in the process of combining behavioral economics, shared decision making, and narrative persuasion in order to develop a “decision support tool” that will better focus conversations between patients and providers onto non-opioid treatment options for acute pain.
“Treating acute pain amidst a nationwide opioid crisis can create huge challenges because it can seem like the options are ‘risk dependence vs. don’t treat pain.’ As we develop the prototype, our goal is to make the tool simple to use at the point of care so the focus is on alternatives,” Meisel said. “We want to facilitate conversations between the patient and provider, while also overlaying a nudge into the design of the interface like a preselected option or a carefully organized list with the desired choice listed at the top.”
Between the patient-provider discussion and the subtle influence inherent in the tool’s presentation, Meisel and Schapira hope that priming patients to request alternatives pain treatments will result in a decrease in opioid prescriptions and improved patient outcomes. While their program specifically focuses on patients presenting in the ED, the desired simplicity of the tool should make it easy to roll over into other healthcare settings and to additional patient populations.Other CHIBE researchers are focusing on chronic rather than acute pain. Peggy Compton, PhD, RN, FAAN, an associate professor of Psychiatric and Mental Health Nursing, and Manik Chhabra, MD, a clinical associate of Medicine, noted that rates of chronic pain and daily opioid use are higher among veterans than among civilian patient populations, despite recommendations by the CDC and the Corporal Michael Cresenz VA Medical Center (VAMC) that chronic pain be treated with opioid-sparing approaches.
Under the direction of Chhabra, the VAMC recently organized a patient-centered primary care program to help veterans at high risk for addiction or overdose to decrease their opioid use and instead utilize non-pharmacological approaches like increased physical activity to reduce pain. Using the funding, Compton and Chhabra will examine if combining health technology and behavioral incentives is effective in managing chronic pain. The 40 enrolled participants will be split into two groups, with one group receiving their usual care, while the other group receives enhanced care (text message reminders, activity trackers, etc.), plus lottery-based financial incentives to meet personalized weekly participation goals in physical activities like yoga or tai chi.
“I don’t want the takeaway of this program to be, ‘never prescribe opioids’ or ‘never use opioids to treat pain,’ because many patients successfully use them to effectively treat their chronic pain,” Compton said. “The goal is instead to minimize reliance on opioids by promoting alternative ways to treat pain. Through our clinic, we hope to see increased physical function and mobility in the participants, which we hypothesize will lead to concomitant decreases in pain and opioid usage.”
While the implications of these studies extend far past Penn Medicine’s campuses, one study is being conducted specifically in the Philadelphia community. Carolyn Cannuscio, ScM, ScD, an associate professor of Family Medicine & Community Health and director of research at Penn’s Center for Public Health Initiatives, Alison Buttenheim, PhD, MBA, an associate professor of Family & Community Health and Health Policy, Maggie Lowenstein, MD, MPhil, a general internist and National Clinician Scholar, and Rachel Feuerstein-Simon, MPA, MPH, a research manager at Penn, have been working with the Free Library of Philadelphia and the Philadelphia Department of Public Health to assess the needs of library staff – who are often treated like de facto social workers by patrons in need – and provide community health specialist training. In particular, they are aiming to increase the number of first responders who are prepared to reverse an opioid overdose through nudges like text messages and commitment pledges that encourage acquiring, routinely carrying, and learning to administer naloxone. While the Healthy Library Initiative and this connected study primarily focus on supporting library staff, Penn Medicine employees should be on the lookout for a call to participate!
“Are people concerned that there will be a ‘blemish’ on their insurance record if they purchase naloxone? Are high co-pays a concern? Is it even available at certain pharmacies?” Cannuscio wonders. “We’re trying to identify the behaviors associated with carrying it so we can address these bottlenecks and ensure people know they can’t hurt someone by intervening with naloxone. It’s easy to feel overwhelmed by the scale of the epidemic, but each one of us can and should be engaged and feel empowered to intervene.”