MetroHealth cuts opioid prescribing by 3 million pills

MetroHealth System's doctors and nurse practitioners prescribed 3 million fewer opioid pills in the past 18 months by implementing new technology and instituting some cultural changes.

The Cleveland-based hospital network released the results of its Opioid Prescribing Initiative on Friday. The program launched last year to promote better opioid stewardship among clinicians and to advocate against the misuse and abuse of such drugs throughout the community. The efforts resulted in 33% fewer opioid prescriptions compared with the previous 18 months. That includes a 62% drop in prescriptions for acute pain and a 25% cut in prescriptions for chronic pain.

Speaking to Modern Healthcare prior to the announcement at its annual meeting, MetroHealth President and CEO Dr. Akram Boutros said the plan involved using electronic health records to track clinicians' prescribing habits and flag patients who were at risk of addiction.

The effort is part of MetroHealth's response to the opioid epidemic which killed 720 people in Ohio's Cuyahoga County last year, according to a report from the county's Medical Examiner's Office.

Ohio has seen some of the highest drug overdose mortality rates in the country, ranking second behind West Virginia in the rate of drug OD deaths in 2016, according to the Centers for Disease Control and Prevention.

"We were able to identify high-risk patients for addiction by looking at internal and external data for things like patients who move to multiple providers, patients who have large amounts of pills provided to them, and those with a history of coming into an emergency room before a prescription should have been out," Boutros said. "These are all indications of being addicted to opioids."

The system's EHR recommends non-opioid alternatives and lower opioid dosages as well as other non-pharmaceutical options for treatment. It also alerts clinicians if they should add a naloxone prescription when opioids are prescribed. Boutros said naloxone prescriptions have risen by 5,000% in the past three months. MetroHealth has saved more than 1,500 people since 2013 by distributing free doses of naloxone through a regional program called Project DAWN (Deaths Avoided with Naloxone).

The EHR has access to the state's prescription-drug monitoring programs and that allows clinicians to more easily check on a patient's prescribing history prior to administering an opioid. The monitoring program's collection of prescription data tells prescribers when a patient has been overprescribed or has sought multiple prescriptions.

While the use of prescription-drug monitoring programs has grown in recent years, some clinicians fail to use them regularly because in many instances it requires them to use a terminal outside of their EHR, which can be timely and disrupt daily workflows.

"We've been tackling the opioid epidemic for a long time. Not until recently, did we recognize that providers can do a lot more," said Boutros, who estimated that the country could reduce the number of opioids prescribed in the U.S. by 4 billion pills a year if everyone achieved the same results as MetroHealth over 18 months. "For us it was seamless, easy, thoughtful, collaborative and did not put patients at risk."

MetroHealth provided extensive training on treating patients with acute and chronic pain through alternative options. A simulation program would allow providers to practice how to talk with patients who may be seeking opioids.

A growing number of health systems have shifted their focus from opioid treatment to preventing addiction altogether by imposing five- or seven-day supply limits on painkillers for acute pain not associated with cancer.

But MetroHealth's initiative goes further in those efforts. Last July, the system opened its Office of Opioid Safety and this week launched a new Pain and Healing Center to bring together different therapies such as acupuncture, infusion, reiki and neurological treatments to help patients handle their pain. Psychology and psychiatry services are also offered.

Boutros said the system has also expanded access to opioid treatment. MetroHealth can begin medication-assisted treatment in the ER and over the past year has gone from two to 78 physicians certified to prescribe buprenorphine, which is used to treat addiction.

Late last year the system began working with an organization that hires recovering addicts to help counsel patients who come into the ER with drug addiction. They are on call at the hospital 24/7. Patients who agree to enter treatment are immediately taken by Uber to a rehabilitation treatment facility and are accompanied by the counselor. Boutros expected about 6% of patients would enter recovery as a result of the program over the past six months, but the result has been 25%.

In April, the system's Office of Opioid Safety began deploying two quick response teams made up of social workers and law enforcement to visit overdose patient at their homes in an effort to convince them to go into residential treatment.

"That is a very different relationship between law enforcement and patients who are addicted," Boutros said. "We just focus on this as a disease and not a character weakness."