While not solely responsible for addressing the country’s relentless opioid crisis, health systems are still wrestling with how to adequately address the problem.
The first wave of opioid-focused policies and care practice changes tended to focus on the outpatient and emergent care settings, but it is now time to create a comprehensive opioid stewardship program (OSP), one that extends across the full spectrum of care, including the inpatient setting, to curb opioid use, improve patient safety and explore new ways to effectively manage pain.
To help support best practices for the inpatient component of an OSP, we have designed a tool kit or “initiative” within our clinical decision support and surveillance program – Sentri7. The kit emerged from an ongoing collaborative effort with six diverse hospitals during which we tested and iteratively improved this OSP initiative. The process reflects how we consistently use customer engagement to inform innovation and meet the evolving challenges our customers face.
Here we will review the current state of the opioid crisis, our response to it, and where our initiative fits within a comprehensive OSP.
A persistent opioid crisis, an inadequate response
The opioid crisis is a complex phenomenon resulting from a mix of well-intentioned efforts to effectively treat pain, misunderstandings about the addictive nature of opioids, and unethical or ill-advised prescribing, which led to widespread addiction and a spike in overdose deaths. While prescription opioid use fueled much of the early crisis, the illegal distribution of synthetic opioids has caused a dramatic uptick in overdose deaths in recent years.1
Some health systems have responded with robust programs, but a July 2019 survey in the American Journal of Health-System Pharmacy (AJHP) found that only about 41 percent of hospitals have an OSP.2 Of those, few were leveraging the full power of their pharmacy team and technical tools to achieve and exceed the recommended level of oversight and intervention. A more recent survey was published in April 2020 (also in AJHP) that included 133 hospitals and used more stringent criteria for establishment of a formal opioid stewardship program. Sadly, the results showed at only 23% of those hospitals had an OSP in place.3
That has prompted calls for a response that matches the depth of the crisis. While the Joint Commission’s 2018 new and revised pain assessment and management standards for hospitals are currently the leading critical voice, some industry experts suspect CMS will soon offer enhanced incentives as well. The CDCs Guideline for Prescribing Opioids for Chronic Pain may be an example of a foundation for future regulatory actions.
Hospitals know they cannot ignore these calls. Perhaps that’s why a recent Vizient survey found that in the last year, nearly two-thirds of academic medical centers have increased their investment in opioid medication management.4 Yet rather than constructing a half-hearted response to another regulatory demand, they should recognize a comprehensive OSP as a promising continuing quality improvement opportunity, with corresponding benefits for patient safety, quality outcomes and potential cost reductions.
The components of a comprehensive opioid stewardship program
An emerging consensus among experts has found that comprehensive OSPs should include full-scale attention to prescribing patterns, identification and treatment of opioid use disorder, education of both patients and providers and effectively designed IT for more appropriate monitoring of opioid use for purposes of quality improvement.
The acute care setting must be prominent in such an effort, because as noted above, aspects of the opioid crisis began as an outgrowth of the challenges of effectively treating pain, especially in the aftermath of surgery and trauma. In addition, acute care settings are often associated with higher risks for opioid-related adverse events. Acutely ill patients may experience exacerbations of conditions like chronic obstructive pulmonary disorder, undergo procedures involving general anesthesia or concurrently receive drugs, such as benzodiazepines, that have additive effects with opioids on respiratory sedation.
Opioid data starts the dialog
Our collaborative began its multidisciplinary effort by brainstorming about the data we would need to illuminate current opioid use and pain management activities. This baseline data, mostly quantitative in nature, uncovers areas where quality problems may exist and generates questions that can engage key clinicians and administrators. As such, it is the starting point for a dialog about how to institute a full-scale inpatient OSP.
First, we decided on three different measurements for quantifying and describing opioid use at the level of the patient:
- Exposure: A count of any inpatient that received at least one dose of an opioid agent during an admission. This is a minimal threshold metric for opioid use. A converse of this metric would be to measure those patients that were not exposed to an opioid during an admission.
- Duration: Here we used “Days of Therapy” (DOT). This indicates how many days a distinct patient received a dose of opioid. The CDC uses a similar measurement for antimicrobials and the cumulative, normalized report is an indicator of general prescribing.
- Intensity: This is represented using average Morphine Milligram Equivalents (MME) per patient per day. This reflects trends in opioid agent selection (potency) and dosing.
Next, we focused on non-opioid or multimodal pain management issues.
- To ensure optimal use of non-opioid therapies, we measured patients that had orders for opioids without concurrent orders for NSAIDs, acetaminophen or other alternative agents (based on institutional preferences). We plan to expand this aspect of our tool to continuous peripheral nerve blocks related to orthopedic surgeries and other innovative, medication-centric approaches.
- Note: We also plan to expand our reporting to include the presence of non-drug treatments for pain such as massage, thermal- or cryo-therapy, essential oils, acupuncture and other alternative treatments.
These metrics reflect current approaches to pain management that place non-opioid therapies in the primary role with opioids used as supplements or secondary agents.
With that baseline in place, the aim is to see reductions in opioid use metrics and a rise in non-opioid use trends. The intent is not to reach zero use of opioids, but to reduce inappropriate and/or unnecessary use. To achieve those goals, hospitals can view each of these measures across the entire inpatient population and drill down to compare specific service areas and prescribers.
To improve patient safety, we tracked patients with MME/day values greater than 90 as well as the rate of naloxone administrations (both total administrations and also by unique patient) in a similar manner to the CMS measure of naloxone use within 24 hours of administration of an opioid agonist. We also tracked the rate of concurrent orders and administration of an opioid agonist and a benzodiazepine agent. With the increased availability of data on the multiple risk factors related to opioid adverse drug events, we are considering ways to use AI algorithms to generate a patient-specific single score risk-rating assessment for use in screening, as well as reporting.
Opioid prescribing data was tracked for all physicians/prescribers using average MME per patient per day values with ability to compare the highest values across prescribers as well as compare within specialties. We also provided average MME per patient per day values for the various care areas as well as a roll-up of overall MME use for the entire hospital with trends over time. This data helped identify areas where opioid over-use may be a concern.
Tools and processes complete the change
Having identified the necessary data, our next step was to get it to clinicians in a readily accessible and visual dashboard. We designed this dashboard with an understanding that while individual programs will differ, in nearly every hospital, pharmacy is ideally positioned to be the hub of the OSP. As the drug experts, pharmacists can manage the OSP at the program level – leading strategic efforts and communicating with multiple stakeholders – while also providing continual oversight for patient care related to opioid use and pain management.
Not Just Reports: Real-time Data Operationalizes Care Strategies
The Sentri7-based opioid stewardship initiative did not just provide a retrospective dashboard and analytics. It is also comprised of real-time surveillance monitoring patients 24/7 with AI-driven MME calculations.
Sentri7 tracks all opioid use, absence of multimodal therapies and opportunities for de-escalation. Most notably, two complementary MME-values are incorporated into rules to provide clinicians alerting around excessive use and provide context to pain management care. “MME-Current” is a real-time dynamic value that indicates the patient’s opioid use over the past 24 hours, while “MME-Calendar Day” provides a retrospective trend of recent historical use by showing total daily MME (or MED) values.
Of course, it’s important to remember that any IT tool is merely step one. Health systems and hospitals also must design efficient processes that clearly detail roles and responsibilities to ensure there is follow-through and accountability for everything from changing prescribing habits by making use of protocols to providing patient education around pain management. It is only this combination that will enable health systems to achieve genuine progress in beating back the opioid crisis they helped create.
- CDC. Drug Overdose Deaths in the United States, 1999–2016. Accessed Feb. 18, 2020 at https://www.cdc.gov/nchs/products/databriefs/db294.htm
- Pedersen et. al. ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education—2018. Am J Health-Syst Pharm.2019;76:1038-1058, https://doi.org/10.1093/ajhp/zxz099.
- Ardeljan LD et. al. Current State of Opioid Stewardship. Am J Health-Syst Pharm. 2020;77:636-643.
- Phelps et. al. A Survey of Opioid Medication Stewardship Practices at Academic Medical Centers. Hosp Pharm. 2019 Feb;54(1):57-62. doi: 10.1177/0018578718779005.