The depth of the opioid crisis cannot be overstated.
More than 165,000 people died from opioid-related overdoses between 1999-2014, with an additional 33,000 fatal opioid overdoses occurring in 2015, according to the Centers for Disease Control and Prevention. In August, President Donald Trump officially declared the crisis a national emergency.
Hospitals and healthcare systems serve on the front lines in this crisis every day and are being called upon to do what they can to stop drug abuse. But as they evaluate how they can stem the epidemic, many face a dilemma because pain management is a key component of patient satisfaction scores. And in today’s value-based care world, these scores are tied to provider reimbursement rates. Conversely, the over-reliance on addictive opioids as a first-line defense in treating pain is elevating providers’ liability exposures in the event their patients are harmed.
To protect their revenue stream and reduce their liability exposure while simultaneously delivering on the single most important goal—patient care—hospitals and healthcare providers must develop comprehensive risk management strategies to address the misuse and abuse of opioids. The following interventions are recommended to help safeguard prescribing practices and help minimize patient harm and associated liabilities.
Designate a clinical leader responsible for the oversight of pain management and opioid prescribing for the organization
Identifying a strong leader (or possible co-leaders) is a cornerstone of a successful opioid risk management prescribing plan.
Their primary responsibilities would include collecting data on pain assessment and management practices; tracking type and efficacy of pain interventions and timing of assessments; monitoring duration of opioid prescriptions and assisting prescribers and pharmacists with access to prescription monitoring programs; and investigating potential misuses including high doses.
Educate clinicians at all levels about safe opioid use.
This is critical to reducing risks associated with abuse levels. Topics to focus on include pain assessment and management, and the importance of educating patients about the risks associated with opioids, such as physical dependence and addiction.
Develop specific guidelines for safe opioid prescribing and dosage for post-operative and chronic pain.
While no two patients are alike, the CDC has a vast library of resources available to providers, including information about how to calculate safe doses for daily opioid use.
Once guidelines are established, embed decision support programs and alert systems within electronic medical records.
Screen and assess patients upon admission using standard tools for pain or risk of pain based upon diagnosis, planned treatments and risks for respiratory depression.
Screening patients who could be at risk of opioid abuse is also critical. Factors that elevate a patient’s pre-disposition to abuse, according to Opioid Prescribing: Clinical Tools and Risk Management Strategies, include: personal or family history of substance abuse, history of sexual abuse, and the patient’s current life situation, as well as the presence of certain mental diseases, abuse-prone environment and stress.
Promote the use of multi-modal pain treatment.
The CDC and pain management experts recommend that providers consider different treatment modalities for pain management such as non-opioid treatment alternatives that could include a more holistic pain management approach.
The National Center on Addiction and Substance Abuse is home to a number of resources for providers and patients alike, including information about alternatives to opioids.
Provide written and oral education to patients on safe opioid treatment.
It is imperative that providers openly communicate with patients the benefits and harm of opioid therapy, including the potential side effects. This includes a frank discussion about the risk of dependence or abuse.
Articulate realistic expectations and goals of treatment with patients.
Similarly, it is important that patients and providers are on the same page when it comes to the intended goals of opioid treatment.
Drafting a patient agreement that is signed by the patient and provider prior to the start of treatment can be a helpful first step in establishing and communicating shared goals. It can also serve as a reference point for follow-up care visits.
Draft a protocol for handling patients with drug-seeking behavior who present in the emergency department.
When assessing a patient for drug-seeking behavior, there are several red flags providers should consider. These include certain pronounced drug side effects, ranging from drowsiness and constipation to confusion. Additionally, certain behavioral patterns can also be indicative of drug-seeking behavior including a history of “doctor shopping,” repeatedly running out of medications, and changes in personality or social behaviors. Providers should also monitor for possession of numerous opioid medication bottles and any suspected theft of prescriptions or prescription pads.
Continuously monitor patients who receive patient-controlled analgesia (PCA) through electronic devices.
PCA is a widely used, effective method of opioid administration, especially for post-operative pain management; however, PCA use is associated with serious risks. With more than 13 million patients each year receiving PCA in the U.S., the Physician-Patient Alliance for Health & Safety (PPAHS) experts say that between 20,000 and 676,000 will experience opioid-induced respiratory depression. The PPAHS has several tools and resources available to help providers monitor for these risks.
Establish clear procedures for the prevention and detection of controlled-substance diversion.
The theft of drugs and controlled substances by healthcare professionals is a serious problem that can lead to patient harm and jeopardize patient safety. It is essential that hospital and healthcare systems have a robust system in place to identify and investigate suspected diversion as rapidly and efficiently as possible. They also must implement policies and procedures that enable a standardized and effective response to confirmed diversion.
Diane Doherty is senior vice president at Chubb Healthcare. She can be reached at [email protected]