Contact email

sweiner@bwh.harvard.edu

Overview

This program at an academic health system utilized an organizational-level opioid stewardship program coordinating multi-disciplinary efforts in order to reduce inappropriate opioid medication prescriptions and to better integrate behavioral health care for patients struggling with opioid use disorder.

Department

Department of Medicine

Collaborators

Scott G. Weiner, MD, MPH
Christin N. Price, MD
Alev J. Atalay, MD
Elizabeth M. Harry, MD
Erika A. Pabo, MD, MBA
Rajesh Patel, MD, MPH
Joji Suzuki, MD
Shelly Anderson, MPM
Stanley W. Ashley, MD
Allen Kachalia, MD, JD

Status/Stage of Development

Planning

Funding Sources

Funding was provided by an internal competitive fellowship comprised of philanthropic donations.
Additional funding sources came from the hospital’s physicians organization and a research fund for operational expenses and hiring a project manager.

National/Policy Context

The rates of opioid prescription have reached an epidemic level in recent years. These prescriptions are most prevalently written for patients discharged from emergency departments and patients undergoing surgical treatment. While many health systems are responding to the epidemic with opioid-related initiatives, variation in practice patterns continue to impede curtailing opioid prescriptions.

Local/Organizational Context

At the Brigham & Women’s Hospital, many physicians and directors were leading independent opioid-related initiatives. In order to improve communication and share resources, the opioid stewardship program (OSP) was founded as an umbrella entity overseeing all opioid-related initiatives.

Leadership

Scott G. Weiner, MD, MPH – Director of Brigham Comprehensive Opioid Response and Education Program

Project Research + Planning

  • This project comprised of multiple interventions:
    • Creating an organization-wide opioid management program
      • Since there were already many individuals working on opioid-related initiatives, this project sought to create an umbrella “opioid stewardship program” (OSP) to organize all projects and facilitate collaboration. 
      • Senior leadership in the health system were asked to become executive members. This was important for legitimizing the program’s work and also providing high-level direction. 
      • At the same time, the project leaders utilized a grassroots approach that sought to include all related projects and teams. For example, one of these groups was focusing on creating an electronic health record order for standardizing inpatient pain treatment across the Brigham. 
      • The opioid stewardship program also ensured compliance with state and local laws that were pertinent to opioid-related initiatives. 
    • Creating a prescribing task force
      • The Prescribing Task Force was responsible for creating safe prescribing guidelines for clinicians and was led by a pain management physician and primary care physician. 
      • The group created 2 guideline documents for inpatient and outpatient settings in regards to managing acute pain and chronic pain. 
      • In addition, the OSP created a peer-review committee to review prescribing patterns of individual clinicians in a standardized and non-biased fashion. 
    • Creating an Addiction task force
      • The Addiction Task Force sought to improve care for patients with opioid use disorder (OUD) who utilize acute care settings and were likely to be readmitted after discharge.
      • The Addiction Task Force created the “bridge clinic” for OUD patients to receive longitudinal recovery. In order for clinicians at this clinic to prescribe buprenorphine, all clinicians must be up-to-date with their Drug Enforcement Administration (DEA) X-waiver.
    • Creating an education initiatives task force
      • This task force established an “Opioids Grand Rounds” program that convened every 2 months. The commissioner of the Massachusetts Department of Public Health served as the inaugural speaker, generating excitement about the program and granting legitimacy. 
      • The OSP is working to educate providers and create guidelines on the use of buprenorphine for OUD. 
      • The Education Task Force is also developing a curriculum to train staff on the Clinical Opiate Withdrawal Scale (COWS).

Tools or Products Developed

    • Clarity Reports: Reports within the hospital’s Epic EHR used to measure prescription quantities as a metric
    • SmartForm: An opioid prescribing form for outpatients on chronic opioids. 
      • Documents patient’s primary opioid prescriber, indication for opioids, appropriate risk assessments, and other key information. 
      • This form works with the EHR to automatically track prescriptions and alert providers on safe practices. 
    • EHR order set: Creation of an acute non-cancer pain management order set in the EHR
    • Benchmarking reports: Reports that provide data on individual prescribers’ prescribing habits

Training

  • At the Bridge Clinic, primary care physicians, hospitalists, and emergency physicians completed an eight-hour course to obtain a DEA X-Waiver for a special license to prescribe buprenorphine. 
  • Staff received on-demand videos and documents on the Clinical Opiate Withdrawal Scale (COWS) as a training resources

Tech Involved
  • Electronic medical record
  • Prescription Drug Monitoring Program
  • Web-based application
  • Website
Team Members Involved
  • Administrator
  • Case Management
  • Physicians
  • RNs
  • Social Worker
Workflow Steps

  • OUD patients can visit the bridge clinic to receive more care while they are in recovery. When patients arrive, they can request medical and psychiatric care. 
    • Patients can obtain prescriptions for buprenorphine and work with a recovery coach and resource specialist for additional counseling and resources. 
    • AFter receiving care, patients are connected to the most convenient longitudinal recovery program either in the hospital or in the community. 
  • Patient-oriented education focused on promotion of medication take-back programs where patients can return unused medications to pharmacies for safe disposal. At the hospital outpatient pharmacy, patients can also obtain naloxone without a prescription from their provider. Naloxone training is also available for the public and is led by the OSP.

Outcomes

  • Number of fatal and nonfatal overdoses in patients receiving prescribed opioids
    • Overall Schedule II opioid prescribing decreased from 8,941 prescriptions in July 2015 to 6,148 in April 2018.
    • Number of unique patients receiving an opioid prescription each month decreased by 28.7%.
    • Prescriptions containing greater than 90 morphine millimeter equivalents (MME) also decreased.
    • Prescriptions for buprenorphine/naloxone as treatment of OUD increased.

Future Outcomes

  • The following metrics are in development:
    • Number of inpatient opioid-related adverse events
    • Overdoses for patients covered by Brigham’s primary care physicians
    • Characteristics of postoperative opioid prescriptions
    • Compliance with PDMP queries
    • Best practices for patients on chronic opioids

Benefits

  • This program helped to bridge opioid-related efforts across multiple initiatives at the Brigham AMC. These initiatives have led physicians to prescribe nonopioid medications as a first-line treatment of pain before moving forward with high risk opioid medications.
  • This program also encouraged safe use and monitoring of prescribed opioids while also cooperating with guidelines from society and the government.
  • Patients had more available resources to learn about OUD and greater access to receive treatment.

Intervention-Specific Challenges

  • One challenge this project faced was caring for inpatients with medical problems resulting from OUD. For instance, caretakers had difficulty addressing ongoing use of injection drugs even after heart valve replacements and discharging patients home on peripherally inserted central catheter lines for long-term antibiotics. The OSP is currently working to form multidisciplinary teams to create protocols for these issues.
  • Upon reflection, the OSP would have liked to include nursing to a greater degree from the start of developing the program.
  • Tensions between different groups needed to be addressed. For instance, primary care physicians would refer patients in pain to pain clinics for opioid prescriptions. However, pain specialists would prescribe non-opioid modalities first. This therefore resulted in a mismatch in expectations between providers and patients.

Glossary

Schedule II Drugs: Schedule II drugs, substances, or chemicals are defined as drugs with a high potential for abuse, with use potentially leading to severe psychological or physical dependence.

Sources

  • Weiner SG, Price CN, Atalay AJ, Harry EM, Pabo EA, Patel R, Suzuki J, Anderson S, Ashley SW, Kachalia A. A Health System-Wide Initiative to Decrease Opioid-Related Morbidity and Mortality. Jt Comm J Qual Patient Saf. 2019 Jan;45(1):3-13. doi: 10.1016/j.jcjq.2018.07.003. Epub 2018 Aug 28. PubMed PMID: 30166254.
  • Drug Scheduling. United States Drug Enforcement Administration. https://www.dea.gov/drug-scheduling

Innovators
  • Scott G. Weiner, MD, MPH
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