The opioid crisis is one of the most pressing public health issues of our time, but hospitals and health systems are rising to the challenge with exciting developments and innovative solutions. The Hospital for Special Surgery in New York has been a leader in this arena, having established a Controlled Substances Task Force in 2016.
Seth A. Waldman, MD, director, Division of Pain Management, Hospital for Special Surgery, discusses the opioid prescribing processes that need to change to achieve cultural transformation in pain management.
Q: What led HSS to create its Controlled Substances Task Force in 2016? What specific, measurable goals did the task force set?
A: Over the decade prior to the creation of the task force, we noticed an increasing volume of patients coming to our hospital for routine surgery who were already on opioids, some of them high dose, and those patients required additional care to manage their pain. This led to an increased length of stay, discharge on higher doses of pain medication, higher levels of postoperative pain, and sometimes poor surgical outcomes and patient dissatisfaction. Care teams were making significant efforts to identify patients on opioids prior to surgery but they lacked control over this process as it was relatively decentralized. With the growing presence of the opioid epidemic in the media, and the publication of the CDC opioid guidelines in early 2016, we found an opportunity to develop a formal program with the support of the hospital’s surgeon-in-chief and the CEO.
The task force set several specific goals at that time. The first goal was to ensure that all staff received standardized education regarding safe opioid prescribing, risk mitigation strategies, compliance with the law and documentation. We also implemented guidelines to standardize and reduce our opioid “output” into the community. We began mandating preoperative pain screenings for at-risk patients across the services, and began tracking metrics related to prescribing, documentation and effective preoperative pain evaluation on postoperative outcomes.
Q: As a result of the task force’s efforts, what findings/initiatives were incorporated into the work of the hospital?
A: The most important finding was that challenges we previously assumed were difficult or impossible were, in fact, not. Processes to reduce exposure to opioids were at first met with resistance as some people felt the changes would slow the admission process for elective surgery, cause patient dissatisfaction, increase the number of postoperative phone calls and make pain more difficult to control in general. Instead, we decreased the exposure to opioids by using new ways to reduce postoperative pain such as multimodal analgesia and anesthesia. Now, we can perform preoperative timely pain evaluations without slowing the progress of elective surgery. Additionally, we’ve decreased length of stay and improved pain scores and patient satisfaction by taking a more proactive approach to pain control.
Our new hospital workflow includes monitoring individual clinician prescribing and documentation, notifying clinicians of the relative dose of prescribing, obtaining patient-prescriber opioid agreements, and directing at-risk patients with complex preoperative pain problems to have the proper evaluation and treatment plan in place prior to elective surgery.
Q: What were the biggest challenges associated with the transformation in work processes and culture? How did HSS overcome those speed bumps?
A: By far the most important challenge was obtaining the support of our administration, specifically our surgeon-in-chief and CEO, without whom none of this would have been possible. It was critical that physicians at our hospital knew we had the support of the highest levels of administration. With that support, we were able to work with the physicians, initially with some reluctance, to implement new policies for patient safety. Simultaneously, we implemented an EHR at our hospital in 2016, which made it possible for us to not only standardize prescribing and documentation practices, but also to monitor compliance.
Q: How has HSS used data to track its progress and identify areas of opportunity? What is one area more hospitals/healthcare settings should be measuring to ensure safe pain management and avoid overprescribing opioids?
A: We are tracking data with respect to individual clinician prescribing, service and procedure prescribing, documentation (including whether clinicians are employing risk-mitigation strategies such as the opioid contract, toxicology screening and state prescription-monitoring databases), compliance with preoperative pain evaluation, length of stay and patient satisfaction, to mention a few.
I think the most important step we’ve taken to identify problems has been to compare clinicians by specialty, prescription volume, and diagnosis or surgical procedure to identify outliers who may require additional education regarding safe prescribing practices.
Q: What accomplishments or changes have you seen since HSS began tackling the opioid crisis are you most excited/optimistic about?
A: By far the most exciting change has been the degree to which the culture of our hospital has transformed. Physicians and surgeons outside the pain management division have taken these principles to heart and are actively engaged in our opioid stewardship process. Some have even launched related clinical and research initiatives. I am very excited that these processes have become “hard-wired” into our hospital, which will lead to further improvements in patient safety. Additionally, I’m optimistic that these changes can be implemented in any healthcare system.
Q: What is one thing you wish more people, including healthcare professionals, knew about opioid prescribing and safe pain management?
A: Opioids themselves are not evil, and specific medications that have been demonized, such as OxyContin or methadone, are not to blame for harm to patients. Presently, opioid pain medications represent our best treatment options for certain circumstances, and modern medical and surgical treatment would not be possible without them. That said, opioids are also extremely potent and potentially dangerous medications with insidious effects, including tolerance, addiction and opioid-induced hyperalgesia, not to mention the more acute effects such as respiratory suppression and overdose death. Opioids must be used with care and respect to minimize harm to each individual patient, and to reduce public health issues. It is cruel and unnecessary to completely avoid the use of opioids on principle, however their use should be limited to necessary circumstances, at as low a dose as possible, for as short a time as possible, and then discontinued in such a way as to minimize the negative effects of withdrawal.
Join Waldman and Magid at the 2020 Congress on Healthcare Leadership, March 23–27, to explore alternative ideas for delivering meaningful solutions to reduce opioid abuse and related deaths during, “Thursday Hot Topic 2—Opioids: Frontline Solutions for Today and the Future.”
More resources:
- Choice Education Program: Behavioral Health Challenges, Strategies and Solutions: The Business Case for Meeting Community Needs
- Healthcare Executive Article: The Opioid Crisis: A Shared Responsibility (Login required)
- Thought Leadership Blog Post: What the Opioid Crisis Is Costing Us