As the fight against opioid abuse continues, Indiana’s hospitals and other providers are launching prescribing guidelines and community engagement efforts as a key strategy.
Indiana first adopted opioid prescribing rules for physicians back in 2014. This effort, led by the Prescription Drug Abuse Task Force formed by Attorney General Greg Zoeller, was targeted towards treatment of chronic pain patients. More recently, however, IHA began working with other stakeholders and Governor Pence’s Task Force on Drug Enforcement, Treatment, and Prevention on guidelines for acute pain prescribing. In partnership with the Indiana State Medical Association (ISMA), IHA staff first tackled standards for emergency rooms, drawing from work in others states, the Indianapolis Coalition for Patient Safety and member hospitals, such as Marion General Hospital.
Marion General Hospital’s candid self-evaluation of its prescribing record and subsequent series of physician education initiatives led to a prescribing policy built from scratch. The result was new guidance for physicians focused on more judicious use of opioids, says Ann Vermilion, administrative director of medical staff services. In two years, the number of pills per prescription declined and the percentage of emergency patients leaving with opioid prescriptions fell from 21 percent pre-launch to 12 percent after 18 months.
“We wanted a policy where we could be sure that our patients who were still in pain had an avenue that we could provide them the best quality care to relieve their pain, but it also provided a backbone and some procedures that we could [invoke] if we weren’t believing they were being honest with us about their pain,” says Vermilion. Even for those deemed in need, the emergency department decided it no longer would write a prescription for 15-25 pills. Instead, the new approach centered on bridging the gap between the emergency department visit and the time it would take to see a specialist treating the cause of the pain, usually two to four days.
But as Marion General and other hospitals formulated and enforced more restrictive policies on opioid dispensing, a logical consequence began to emerge. “If patients (who are simply drug-seeking) can’t get those opioids through a provider, they’re going to go on the street to heroin,” says Warren Forgey, president and CEO of Schneck Medical Center, Seymour. Schneck has taken steps to govern use of opioids in the emergency department and at a pain center.
These communities now organize to address the full spectrum of drug abuse issues—from opioids to heroin and beyond. Schneck initially established a task force with the intent to make it community-wide, and it has since grown to include local law enforcement, county and state level policymakers, judges and a variety of social support agencies. Addressing the most immediate concerns–overdoses–the hospital provided police with the life-saving drug naloxone and trained them to administer this emergency reversal agent. Forgey reports that several lives have already been saved through this effort.
Marion General formed a substance abuse team comprising all not-for-profit social support agencies in Grant County, says Vermilion. A subcommittee of this team examined the need for data collection in light of rising heroin overdose numbers. Another group focused on preventing outbreaks of HIV and hepatitis C. In Wayne County, the community-wide information sharing and action committee that Reid Health organized is straightforwardly named “Heroin is Here,” says Craig Kinyon, president and CEO of the Richmond facility.
Unfortunately, the path forward through treatment, withdrawal and sustainable recovery can often be fraught with shortages–of will, of financial means, of therapeutic capacity. “The first hurdle has been willingness to get off drugs,” says Forgey. “Family members will take someone fresh from an addiction episode to the hospital seeking treatment, but many of these patients say they don’t want it.” Despite family concerns, the addict, once stabilized, often walks out with no desire to go through detoxification.
Alternatively, “if they do decide they need to go through some treatment phase, the resources are limited,” Forgey points out. “There’s just not a lot of capacity in the local community, even within the region.” And among the limited number of providers available, “it just seems like the nature of the situation, that is oftentimes, patients that have a need for this have no means to pay for it.” Thankfully, the Pence administration expanded coverage in 2015 through the Healthy Indiana Plan (HIP) 2.0 program, bridging the gap to thousands in need of service at a critical time.
Treatment can be expensive–an entire course of care lasting up to 16 months can cost about $15,000, which includes three phases, beginning with detoxification and followed by monthly injections of a drug called Vivitrol to prevent a lapse back into drug use. “What must follow all that is counseling, and the counseling is going to be intense and needs to be continuous and should develop into support groups,” says Kinyon of Reid Health, which has researched the recovery continuum. That includes addressing the problems and choices that led to and perpetuated the addiction.
Once past the stages of treatment and withdrawal, the next challenge is to provide adequate health care and counseling support for those who want to turn their lives around. The U.S. Department of Health and Human Services is recognizing that need, announcing earlier this year that it is releasing $94 million in new funding to 271 community health centers nationwide, aiming to increase substance abuse treatment services, including medication-assisted treatment.
The funding is one of 10 administrative actions the Obama administration said it was taking to address the rise in both opioid and heroin abuse, reallocating existing money and proposing more extensive funding in the administration’s 2017 budget plan. The $1.1 billion plan would expand access to treatment, advance prescriber education, encourage safe pain management approaches, accelerate research on pain treatment, expand telemedicine in rural areas and improve housing support for those in recovery.
If that funding survives the budget process, it’s still “only a fraction of what’s needed,” says Kinyon. The devastating impact of opioid abuse has caused more deaths from overdoses than in car crashes.
Hospitals have to do what they can despite the barriers, says Michael Everett, CEO of Scott Memorial Hospital in Scottsburg. “Rather than be distracted by our challenges, we’ve come together–our medical staff, our community partners, our employees here–and we’ve tried new and innovative ways to make our community members have access to health care, but also give them the support they need to live healthy and productive lives.”
Scott Memorial has supported local organizations, such as Get Healthy Scott County and the Coalition to Eliminate Abuse of Substances (CEASe), and it leased a well-situated physician clinic that had become vacant as a satellite facility for LifeSpring Health Systems, a Jeffersonville behavioral health organization.
Since one of the biggest barriers is to get addicts to want to quit, Wayne County is leveraging the use of supportive counselors at the local needle exchange program, says Kinyon. “You’re hoping that somebody is at that point where they find themselves coming to the center, exchanging needles, maybe questioning, ‘Where’s my life going? How long can I keep doing this? How long can I live like this?’ and be at that point there they want to talk. You’ve got to be where they are because they’re hard to find and [might not] come back again. So sometimes you get one shot at them.”
The balancing act of appropriately providing prescriptions to manage pain while maintaining patient safety is no small task, but standardized guidelines can help provide a general approach. A set of eight guidelines for opioid prescribing in Indiana emergency departments takes into account practices developed within the state, as well as policies adopted in other states. Developed by IHA and ISMA, the emergency department guidelines are supported by the Indiana Chapter of the American College of Emergency Physicians and the Indianapolis Coalition for Patient Safety and were endorsed by the Governor’s Task Force on Drug Enforcement, Treatment, and Prevention. The IHA board of directors passed the Prescribing Guidelines Resolution, which encourages all hospitals to adopt the emergency department guidelines as part of an overall Safe Prescribing campaign. IHA and ISMA plan to develop best practices and guidelines addressing treatment of pain in other hospital settings, as well.
For a national perspective on the epidemic, join IHA Oct. 6-7 at the Annual Membership Meeting to hear from Sam Quinones, American journalist and author of Dreamland: The True Tale of America’s Opiate Epidemic. Quinones will share his story of finding hope in the Midwestern town of Portsmouth, Ohio, where citizens are turning away from dependence and toward economic and municipal self-reliance, and with that, recovery. Attendees will also learn how the health care community of Portsmouth responded to the epidemic from Kendall Stewart, M.D., chief medical officer of Southern Ohio Medical Center. Stewart will focus on several practical strategies hospitals can embrace to assist their communities in responding effectively to this growing threat to public health. Register today at IHAannualmeeting.org.