An Epidemic Of Another Kind
A silver badge with interlocking lines at the top of a triangle represents awareness of drug overdose and its effects. Worn worldwide on August 31, the symbol demonstrates support to those fighting through addiction and others bearing the burden of grief from injury or loss. On that day—and every other day in the United States—44 people will die of overdose from prescription painkillers. These deaths have more than quadrupled in the past decade and a half. Today, more people die from prescription opioid overdose than from heroin, cocaine, and all other drugs combined, an alarming trend that led the U.S. Centers for Disease Control to declare it an epidemic in November 2011.
Opioids are medications that treat pain in many contexts, from post-surgical relief to chronic severe back pain to end-of-life care. Two of the most common forms are oxycodones, often sold under the brand names OxyContin® and Percocet®, and hydrocodones, sold as Vicodin®. Both are powerful narcotics. Americans are the number one consumer of these drugs, accounting for almost 100 percent of hydrocodone prescriptions and 81 percent of oxycodone prescriptions worldwide. In the United States, more than two million people are addicted to these medications.
These drugs became more readily available to patients in the late 1990s, and prescription rates nearly doubled between 1998 and 2013. This epidemic is the unintended consequence of policy and practice that was supposed to benefit patients and keep them safe. A solution to this kind of systemic problem that affects the health, social, and economic welfare of society requires a large-scale, comprehensive course of action. The health care delivery system is ground zero. This article describes how Kaiser Permanente, one of the nation’s largest not-for-profit health plans, is working to reduce opioid abuse among its more than 10 million members, and offers insight for the health care system as a whole.
How We Got Here
Beginning in the late 1990s, patient advocacy organizations began asking the medical community whether pain was being under-treated. In 1999, the Veterans Health Administration launched the “Pain as the 5th Vital Sign” initiative, urging doctors to assess pain at every visit. Soon, other major health care accreditation and regulatory authorities, such as the Joint Commission on the Accreditation of Healthcare Organizations, joined the movement to improve pain management.
At the same time, specialty societies, such as the American Geriatric Society and the American Pain Society, promoted the use of opioids for treating chronic, non-cancer pain. The prevailing wisdom among physicians, supported by research, reinforced the misconception that opioids would not create dependence or addiction and could be used safely for long-term treatment of pain. Pharmaceutical companies also aggressively marketed the drugs to providers and patients.
With all these forces at work, it is not surprising that physicians became more comfortable prescribing opioids for less severe pain. Fewer than 20 years after pain became the 5th vital sign, these changes in practice—while intended to improve pain management—have also led to a major increase in overuse, misuse, abuse, diversion, overdose, and death associated with these medications.
Kaiser Permanente’s Systemic Approach To The Epidemic
To combat this systemic quality problem, health care providers need a systemic solution. Kaiser Permanente began to develop such a solution after doctors reported that opioids were presenting safety issues. Kaiser Permanente’s approach includes seven “levers” to address the problem from multiple angles.
Evidence-Based Treatment Guidelines
Misinformation about the use of opioids for chronic, non-cancer pain was a key driver of widespread overuse and abuse in the U.S. Kaiser Permanente physicians developed up-to-date evidence-based treatment guidelines for the proper use of these medications. Guidelines include:
- Focusing on alternatives to opioid therapy as a first-line treatment for chronic, non-cancer pain;
- Providing non-drug treatment options (such as meditation, guided imagery, and Tai Chi);
- Treating patients with the lowest dose of opioids possible, for the shortest duration necessary (in general, less than a 100 mg morphine equivalent dose per day, with no more than a 30-day supply at a time);
- Monitoring patients at risk for opioid abuse via questionnaires, urine drug tests, and prescription history on state prescription drug monitoring databases;
- Recognizing “red flag” behaviors that suggest dependence, misuse, or abuse (such as the need for escalating dosages, requesting refills before they are due, or requesting name-brand drugs, which carry a high “street” resale value); and,
- Using documentation tools to ensure communication and collaboration within and across specialties.
Prescriber Education And Training
Treatment guidelines are supported by education and training at various levels throughout the system. Prescribers can easily access guidelines and other information on opioids via Kaiser Permanente’s online Clinical Library. Individual coaching is also available on how to have difficult conversations with patients who may be misusing their medications or who are requesting additional, unnecessary opioids.
Many at-risk patients do not know how potentially addictive opioids can be, so it is important to engage them early on about the safe use of their medications. To increase awareness, patients prescribed these drugs receive written educational materials and can view additional information on opioids through Kaiser Permanente’s online health record, My Health Manager.
Population Health Management
Identifying patients at high-risk of opioid misuse and abuse is crucial to using opioids safely. Because it is an integrated delivery system that includes inpatient, outpatient, and pharmacy care and coverage, Kaiser Permanente can use both pharmacy and electronic health record data to identify these patients, alert doctors, and refer patients to treatment for opioid dependence or addiction if needed.
The Role of the Pharmacist
Pharmacists play two important roles in Kaiser Permanente’s comprehensive approach to opioid management. First, they identify abusive drug seeking behaviors in patients. These include: requesting refills before they are due, submitting multiple requests for more medication, having multiple prescribers, or going to multiple pharmacy locations. Second, pharmacists monitor physicians who may be at risk of high prescribing.
Access to Coordinated Substance Use Treatment
Patients who become addicted to opioids require high-quality substance use treatment services. A multidisciplinary team comprised of primary care, specialists, addiction services, and behavioral health uses the electronic health record system to coordinate care across specialties.
Strong and visible leadership provides the support needed for physicians, pharmacists, and other clinicians to implement these strategies. Messaging from leaders and all members of the health care team ensures a consistent focus on patient safety.
The Impact: Best Practices Spread, Opioid Use Declined
Adoption of these strategies has led to a decline in use of opioids across most of Kaiser Permanente’s service area, which includes eight states and the District of Columbia. In Kaiser Permanente Southern California, an early adopter of opioid prescription reduction strategies, initial interventions were effective. OxyContin® (oxycodone) use declined 72 percent between January 2010 and December 2013. Additionally, the number of at-risk members on high doses of opioids (greater than 120 mg/day morphine equivalent dose) declined 29 percent between March 2012 and December 2013.
Looking at a more recent and broader measure across Kaiser Permanente’s entire service area, between December 2013 and July 2015, the average decline of morphine milligram equivalents per patient for all opioids was about 15 percent. (Note: the measurement of morphine equivalents enables potency comparison among opioids.) In spite of this success there is still much work to be done.
Addressing The National Epidemic
Of course, a single health care delivery system can only do so much to address an epidemic that lives beyond its walls and within the community it serves. In addition to focusing on internal processes and improvements, health care providers can ensure their clinical teams receive ongoing education on the safe use of opioids, which may be the single most important step to addressing the root causes of this epidemic. For the next generation of physicians, graduate medical education curricula should include more information on pain management and best practices for opioid treatment. For physicians currently in practice, continuing medical education has substantially increased the availability of safe opioid-prescribing courses.
A tremendous need also exists for public awareness about pain and pain management. Communities can come together to agree upon safe prescribing practices. For example, the Los Angeles County Prescription Drug Abuse Medical Task Force—a collaborative of physician and nursing groups, hospital associations, and public health and community clinic representatives—worked with 75 local hospitals (including Kaiser Permanente) to adopt a common set of opioid prescribing and treatment guidelines in emergency departments. Many of the State Medical Boards have also updated their pain management guidelines to incorporate the most current information on opioid use. Eventually, consistency in treatment guidelines across all types of care, from cancer to orthopedics, will allow for safer use of opioids.
Nearly every state has established prescription drug monitoring programs to track medication refills and prescribing patterns across all prescribers and pharmacies, whether part of the same system or not. However, these programs are only effective in reducing opioid use if they can provide information in real time, and if prescribers and pharmacists use them. Twenty-one states have passed laws requiring prescribers to register with prescription drug monitoring programs, and 24 states require prescribers to check databases under certain circumstances. States and health care organizations should continue efforts to make databases easier to access — such as integrating them into electronic health records and making data available among states.
Funding of federal and state programs will bolster these initiatives. In July 2015, the U.S. Department of Health and Human Services announced more than $100 million in funding for states and community health centers to help combat opioid abuse, encourage innovative treatment approaches, and expand treatment and services for substance abuse. The Obama Administration also provided funding to make the overdose antidote, Naloxone, a decades old drug, more available for emergency responders and private citizens, such as family members of addicts. However, it will take additional resources, time, and effort by both the public and private sectors to truly reverse the tide of the opioid epidemic.
Using the example of Kaiser Permanente’s experience in reducing opioid prescription rates, these interventions and others like it are extending from the federal level to states and communities. It will take this kind of systemic solution to solve this societal problem so that next August 31, we will have more lives to celebrate and fewer to mourn.