Slowing the Opioid Crisis Begins in the Hospital

The opioid crisis has pillaged communities for more than 20 years, and new data show the problem is only getting worse. By many accounts, 2020 was the worst year yet of the opioid epidemic—the CDC reported more than 81,000 drug overdose deaths, including opioids—between June 2019 and May 2020.

There is a complex set of drivers for the disturbing numbers, such as the additional stressors of the COVID-19 pandemic, including mental health issues associated with fear of illness, financial strain, job loss, social isolation, and people living in a continual state of crisis. Understandably, yet unfortunately, the pandemic has taken attention away from many other serious health concerns, such as the opioid crisis and substance abuse.

This begs the question of how and where we can begin controlling the opioid problem. A logical first step would be to prevent unnecessary initial exposure that eliminates the downstream risk of abuse and misuse.

Although the opioid epidemic is a broad societal problem, health systems can play a critical role in the response. Because many patients are first exposed to opioids when they are in the hospital, limiting opioid prescribing in that setting can help gradually curb community use. Although opioids have been the first-line of treatment for moderate to severe pain in acute care, new data indicate that non-opioid drugs and non-drug treatment modalities can often manage pain effectively after surgeries and procedures with fewer adverse effects or, at least, reduce the amount and duration of opioids needed.

Opioid use and prescribing in the hospital are only a part of this problem, but it’s a facet that we can begin controlling better today. While the Joint Commission has made implementation of an opioid stewardship program part of its current pain standards, one study shows only 23% of hospitals have an opioid stewardship program (OSP) in place. In most cases, these programs are heavily focused on outpatient treatment areas and emergency departments.

With thoughtful use of opioids in the hospital, we can help reduce community exposure and downstream addiction that forms through unnecessary prescribing. Hospitals can take steps to begin implementing these changes in their facilities.

• Engage Leadership. Organizational leaders must make clear that they believe in the value of an OSP and provide resources to support implementation. Accreditation requirements from the Joint Commission and proven fiscal savings from OSPs can help get key stakeholders on board within your hospital.
  
• Take Advantage of Pharmacy’s Expertise. Although there are diverse ways for hospitals to put OSPs in place, in many cases, pharmacy is ideally positioned to be a champion. Giving pharmacy a leadership position in an OSP helps move it toward a system-level approach with full accountability.
  
• Optimize Data Usage. Data collection and analysis is a critical next step. It enables hospitals and health systems to quickly recognize where and how opioids are being used, identifies areas of concern for targeted improvements, and provides the foundation for a system-wide, continuous improvement program. It is also a central piece of The Joint Commission standards for an OSP.
  
• Identify Opioid Use Status. To ensure appropriate treatment for pain (agent selection, dosing, risk assessment), it is important to document the patient’s opioid use and type of pain before prescribing or dispensing opioids. Is the patient opioid naïve (no recent use) or tolerant? It is also vitally important to identify whether a patient has or is currently abusing substances, including opioids. Hospitals and health systems have struggled to operationalize screening, identification, and referral to treatment of patients with possible opioid use disorder.
  
• Operationalize Pain Management Strategies. Any OSP should review and update all care treatment plans and order sets that include pain management approaches to reflect best practices and current evidence. Integrating policies and protocols into clinical decision support tools, including computerized physician order entry (CPOE) and real-time surveillance, will improve prescriber adherence.
  
• Deliver Provider Support and Education. Physicians and other prescribers need significant support to help them transition to new pain management approaches that are not opioid-centric. This includes providing prescribers with data on their current prescribing habits, which can be helpful if practices are outside the expected range.

Given the burdens the health care system has borne over the past year, it is difficult to do anything but focus on COVID-19. But those who staff hospital emergency departments know better than anyone that the opioid epidemic has worsened in conjunction with COVID-19. It is essential for hospitals and health systems to act now to avoid confronting an even more massive crisis in the months and years ahead.

About the Authors

Richard Dion, PharmD, Pharmacy Clinical Program Manager for Clinical Surveillance & Compliance, Wolters Kluwer, Health, has 15 years of experience in the practice areas of medication use safety, pharmacy informatics and clinical decision support in varied settings. His experience includes academic medical centers, community hospitals and most recently as a member of the Wolters Kluwer clinical team.

Building on over 30 years of experience in healthcare, Steve Riddle, PharmD, MSIM, BCPS, FASHP, Pharmacy Consultant for Wolters Kluwer, Health, previously served as the Director of Clinical Development for Pharmacy OneSource/Wolters Kluwer, Health, where he would help develop and apply evidence-based content to support optimal quality in point-of-care delivery of health services.