MetroHealth takes multifaceted stance in opioid battle

As the opioid epidemic claims the lives of tens of thousands of Americans every year, MetroHealth has been fortifying its battle against the crisis, accelerating its work within the past couple of years.

Dr. Joan Papp has been one of the physicians in the system leading the charge. She, like millions of Americans, knows someone who's struggled with opioid misuse and addiction. Seeing family members struggle with prescription opioid misuse had a "big impact" on Papp.

"I felt like there was a lot of stigma around it, and I didn't think that we had a comprehensive approach to the most serious of all adverse effects of opioids: for one, overdose death," said Papp, an emergency physician who serves as medical director of MetroHealth's Office of Opioid Safety. "And we certainly weren't taking a comprehensive look at it systemwide. And I felt like maybe I'm the person to do this, because I had a perspective that other people may not have."

Today, MetroHealth is taking a multifaceted approach to combat the opioid crisis, from prevention to education to treatment to legal remedies. The system has joined various task forces, supported awareness campaigns and worked to train providers and law enforcement. It has helped push for state legislation to increase access to the overdose-reversing drug naloxone, pursued litigation against opioid drug manufacturers and marketers and curbed opioid prescribing among its providers, slashing prescriptions by 3 million opioid pills over an 18-month period.

Last year, the health system created an office dedicated to much of this work: The Office of Opioid Safety.

"That's huge leadership for them to do that," said Scott Osiecki, CEO of the Alcohol, Drug Addiction and Mental Health Services (ADAMHS) Board of Cuyahoga County. "They're actually taking this very seriously—not that the other hospitals aren't, of course. But they really want to make sure that the community understands the dangers."

Overdose reversals

Papp saw the dangers firsthand in the emergency department, where patients would come through the door experiencing an overdose, withdrawal or other medical complications from drug use or addiction, regardless of whether patients recognize it.

Overdoses were the first space in which Papp felt she could make a difference by providing a dose of naloxone, a drug that blocks or reverses the effects of opioid medication overdose. She wanted to get naloxone into the hands of everyone who might need it.

Thus started Project DAWN (Deaths Avoided With Naloxone), which launched in 2013. It was Papp's first initiative in opioids and the system's second major effort, following a mother and child dependency program.

Papp and the system spent four years integrating Project DAWN throughout the system and community, building five walk-in naloxone distribution sites, integrating it into the EDs and stocking the system's inpatient and retail pharmacies. MetroHealth helped get naloxone for county law enforcement and partnered with Cleveland EMS to distribute naloxone on the trucks and start a walk-in clinic.

In tandem, the system advocated for changes in state law to increase access to naloxone. A few years ago, MetroHealth was successful in getting a couple of laws passed that, among other things, allowed police officers to administer naloxone, allowed nonphysician trained opioid educators to distribute naloxone and enabled those not at personal risk to get their hands on a naloxone kit.

By the end of 2018, Project DAWN will have distributed an estimated 12,000 naloxone kits since its inception. More than 1,800 overdoses have been reversed with these kits—a conservative estimate that only accounts for those reversals reported to the system. MetroHealth trained its own police department on how to administer naloxone, and has in the past few months already reversed roughly a dozen overdoses at the hospital.

Education and prevention

Having gotten naloxone out in the community, Papp said the system also looked to treatment and prevention efforts and ways to develop an educational curriculum for providers and others. The Office of Opioid Safety, which now has a dozen employees, provides education and training to county law enforcement, to physicians and to the community.

At this point, most physicians in the system have gone through mandatory education on safe opioid prescribing, use, storage and disposal. The system also offers monthly lunch-and-learn programs centered around opioids, as well as an optional simulation program in which providers conduct a visit with an actor and work through how to discuss difficult, common scenarios around opioids.

In late August, the system announced it is taking legal action as part of a multidistrict litigation against opioid drug manufacturers and marketers, looking to hold them accountable for the increasing costs MetroHealth will continue to incur as a result of the opioid epidemic.

For about a year, MetroHealth has had an opioid executive committee that meets regularly to review prescribing data for the hospital, to determine trends, to see if progress is being made and to identify which providers might need additional resources or education on prescribing.

The system has established a number of tools in the electronic health record to make it "easier for prescribers to do the right thing," Papp said. For instance, it lowered the default number of pills that come up when selecting a prescription to a recommended, safe number of pills. MetroHealth established alerts for doses over recommended guidelines, for any prescriptions that are dangerous to prescribe with other medications the patient is on and for patients who may be at risk of addiction, guiding them to alternative medications, lower doses or other options. The system also has an alert to recommend that providers co-prescribe naloxone with any opioid prescription.

These efforts, along with provider education, have culminated in the system drastically lowering the number of opioid pills it's prescribing. MetroHealth doctors and nurse practitioners prescribed 3 million fewer opioid pills over an 18-month period, reducing the number of opioid pills prescribed for acute pain by 62% and for chronic pain by 25%.

Treatment

With all of MetroHealth's education, advocacy and prevention efforts, it is still treating many patients struggling with addiction. And the system is working to expand those efforts, most recently with its acquisition of Recovery Resources, announced in early October.

The acquisition of the community-based outpatient behavioral health services organization gives MetroHealth patients access to specialized care for behavioral health and disorders from Recovery Resources professionals, and Recovery Resources clients will have access to the health system's services, including primary and preventive care.

Recovery Resources' work adds to MetroHealth's other efforts in treatment, including a small medication-assisted treatment program that opened about a year and a half ago. There, providers prescribe buprenorphine or suboxone to treat opioid use disorder.

MetroHealth in the past year and a half has ramped up the number of providers able to prescribe suboxone, offering a handful of workshops. Today, there are 81 providers who have completed the eight-hour mandatory training to be able to prescribe and manage patients with suboxone or buprenorphine.

And the support doesn't end there. The system has partnered with Ascent ED, which connects emergency department patients with peer supporters. It also launched quick response teams, made up of a MetroHealth social worker and a police officer, to respond to the home where an overdose occurred within seven days to provide resources and direct pathways to treatment and education, as well as naloxone kits. If the overdose survivor is prepared to enter treatment, the teams will coordinate that process.

The system is looking to build upon all of the various programs that have been started in recent years, said Emily Metz, manager of the Office of Opioid Safety at MetroHealth. She said it's important for the system to tackle the opioid epidemic from numerous approaches, because "these are our patients."

"And it's not only our patients, but it's our staff, too," she said. "This epidemic touches every part of our society. It's an epidemic. So we're devoted to responding to the needs of our community, and this is one of the most emergent needs out there."

"MetroHealth takes multifaceted stance in opioid battle" originally appeared in Crain's Cleveland Business.