Despite several federal and state efforts to combat the opioid epidemic, opioid overdose remains one of the nation's pressing health care problems. Nearly 1,000 people present to emergency rooms daily requiring treatment from opioid overdose.^[1] Approximately 90 deaths occur daily because of opioid overdose,^[2] and 2 million Americans are dependent on prescription opioids. The majority of those opioids can be traced back to prescriptions, which are the main source fueling the epidemic. Several guidelines have been put in place to try to prevent these numbers from escalating.^[3] However, with the new mandates and requirements, concerns surround limiting access to opioids for those who are in legitimate need along with burdening the health care system with new regulations that are time consuming and labor intensive.

“Confronting the opioid epidemic is a large undertaking that requires a multidisciplinary team approach.”

The UT Southwestern and Parkland Health Care System Experience

Our efforts to address those concerns started in 2013 at the University of Texas Southwestern (UTSW) and Parkland Health Care Systems (PHS). Our initial goal was to assess our institutional status, opioid prescribing patterns, and risk assessment. Our project progressed to ensure our compliance with the new Centers for Disease Control and Prevention (CDC) opioid prescribing guidelines and Texas State Medical Board (TMB) opioid prescribing rules. Our focus revolved around transforming the electronic medical record (EMR) to alleviate the burden on opioid prescribers while ensuring proper assessment and monitoring. Through these efforts, we hope to maintain access to opioids for those in need while providing tools for adequate, effective, and time-efficient monitoring, leading to an overall improvement in patient outcomes and opioid safety.

PHS emergency room (ER) encounters 15–20 patients with suspected opioid overdoses monthly who require treatment with naloxone and subsequent admission. We conducted a retrospective cohort review of 385 of those patients' charts from January 2012– December 2014. Patients with chronic opioid prescriptions (OP) were more likely to have been previously diagnosed with mental health, cardiovascular, pulmonary, endocrine, or central nervous system disorders than those without OP (Figure 1). Nearly equal percentages of patients with and without OP had prior histories of substance abuse and were also equally likely to have positive urine drug screening (UDS) for cocaine during ER visit. Patients with OP were more likely to have presented to the ER for suspected overdose than those without prescriptions. It was noted that 66% of patients with OPs, of which 19% also had histories of substance abuse, had received no UDS in the 12 months prior to their ER admission (Figure 2).

This led us to conclude that we need a system-wide change that addresses opioid prescribing and patient monitoring. With support of the leadership at UTSW and PHS, two multidisciplinary teams were formed: the Opioid Workgroup at UTSW and the Opioid Stewardship Team at PHS. The teams consist of hospital executive leaders, pain management, primary care, pain pharmacists, medication safety personnel, quality improvement personnel, business analyst managers, medical informatics officers, and nurses. The objectives were to initiate and maintain a coordinated multidisciplinary effort that promotes the appropriate use of opioids, reduces opioid adverse effects, and improves patient outcomes.

Both institutions furnished an opioid policy detailing the requirements that ensure adherence to the CDC and TMB guidelines. Both institutions worked with EPIC system team builders to create an opioid registry and an opioid dashboard/ pain navigator. The registry contains all patients with ICD-10 diagnosis for chronic pain, and it will be used to feed our opioid dashboard/pain navigator (Figure 3) for monitoring UDS, controlled substance agreements, and concomitant use of illicit substances, benzodiazepines, or alcohol.

To establish a baseline assessment, we identified all chronic pain patients in our ambulatory clinics at PHS. Patients were identified by ICD-10 code while excluding those with cancer pain. Patients with chronic pain diagnosis represented 37% of our ambulatory patient population, of which 9.4% are on chronic opioids (Table 1).

Prior to our education implementation, we assessed the percentage of patients with completed opioid agreement/consent signed, risk assessment tools documented on file, UDS over the past 12 months, suicide risk screen assessment, and history of drug and alcohol abuse. We found that the majority of patients had a suicide risk assessment on file (91.6%), whereas only a quarter of the ambulatory chronic pain patients on opioids had a UDS within the past 12 months, despite 16.6% having a history of illicit drug use and 25.9% having a documented history of alcohol abuse (Table). An understanding for the need and the value of opioid abuse risk assessment tools was lacking, as reflected by the low percentage (1.6%) of patients having an opioid risk assessment tool or addiction behavioral checklist completed on record. Our goal is at least 90% compliance in all fields when reassessed in 12 months.

Several breakout workgroups targeted different areas pertaining to opioid safety. Areas with significant progress include:

1. Education to providers on the chronic opioid practice policy and CDC and TMB regulations. The educational process on campus is an ongoing effort, with our target audience starting with medical students. Quarterly lectures focus on nonopioids, coanalgesics, nonpharmacologic options, equianalgesic dosing of opioids, interpretation of UDS, and interesting case scenario presentations.
2. EPIC embedded smart phrases for the documentation of the new mandated requirements. Such phrases facilitate documentation and ease the process of prescribing in high-flow, busy primary care clinics.
3. Designing an opioid dashboard/pain navigator, which includes an informed consent and opioid agreement, UDS, and opioid risk assessment tool or addiction behavioral checklist.
4. Collaboration with other institutions nationwide through participation with Centers for Medicare and Medicaid Services, transforming clinical practice networks through collaborative projects, thus sharing our experience.
5. The toxicology workgroup is standardizing toxicology essays among all three teaching hospitals and re-evaluating toxicology order sets to unify, simplify, and ensure cost effectiveness.
6. The addiction workgroup is increasing patient access to medication-assisted treatment and increasing the number of providers who are buprenorphine licensed by providing certification classes on campus.

Conclusion

Confronting the opioid epidemic is a large undertaking that requires a multidisciplinary team approach and a system-wide change to ensure a meaningful impact. The new prescribing regulatory requirements place an increased burden on prescribers who are at higher risk for frustration and burnout. An integral part of the solution lies in using EMRs, thereby facilitating and standardizing documentation and simplifying opioid prescription practices while improving monitoring.

Funding Statement: This work was supported in part by National Institutes of Health/National Center for Advancing Translational Sciences grants KL2TR001103 and UL1TR001105 from the UT Southwestern Center for Translational Medicine (Dr. Kandil). Section Editor: Dalia Elmofty, MD Enas Kandil, MD, MSc Assistant Professor Anesthesiology and Pain Management University of Texas Southwestern Medical Center Dallas, Texas

References

1. Crane EH. Highlights of the 2011 Drug Abuse Warning Network (DAWN) findings on drug-related emergency department visits. Updated February 18, 2013. https://www.samhsa.gov/data/sites/default/files/DAWN127/DAWN127/sr127- DAWN-highlights.htm. Accessed December 16, 2017.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–1452.
3. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Recomm Rep. 2016;65(1):1–49.