Over this past year, I have engaged in hundreds of conversations, both internally and externally, about the opioid crisis. Each day, more than 115 people in the United States die from an overdose. The opioid epidemic is truly an issue that is blind to race, religion, socioeconomic status or geographic location.
According the Centers for Disease Control and Prevention (CDC), rural areas are impacted even harder with overdose deaths surpassing those in urban areas. As many as 74 percent of farmers having been directly impacted by the opioid crisis. Before joining Cerner, I practiced in a rural farming community and sadly witnessed this tragedy many times.
The public health impact is just one aspect to consider. The CDC estimates that the total economic burden of prescription opioid misuse in the United States is $78.5 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.
So where to begin? I recall a line from one of my favorite books, Lewis Carroll’s Alice in Wonderland: “Begin at the beginning,” the King says, “and go on till you come to the end: then stop.”
How did we get here?
The use of opioids for medicinal purposes dates to the early 1900s with their misuse and abuse not surprisingly starting shortly thereafter. By the 1920s, doctors were very aware of their highly addictive nature.
The crisis we are currently facing can be traced back to the release of OxyContin in 1996. With that release came a carefully crafted promotional campaign using modern marketing techniques that implied there was a minimal downside. At the same time, there was a push to recognize pain management as the fifth vital sign, and a quality of life measure. As a result, prescriptions for opioid-based painkillers skyrocketed in the late ’90s and throughout the early 2000s.
Recently, a rise in heroin and synthetic opioid use have led to a second and third wave of overdose deaths. We know now that 80 percent of people who use heroin first misused prescription opioids. (For further reading, see Dreamland: The True Tale of America's Opiate Epidemic, where author Sam Quinones comprehensively outlines the factors behind the current state.)
Challenges facing health care providers
Health care providers, motivated to relieve suffering, can appreciate the benefits that opioids provide. Safely prescribing these medications is a complex undertaking because the individual pharmacologic profiles, while generally similar, have nuanced physiologic effects and toxicities. Also, so-called “opioid-naïve” versus “opioid-tolerant” patients have significantly different safe dosing ranges. The bewildering array of unique agents available with all their dosing schedules and permutations of pills, tablets and transdermal delivery add to the complexity.
We also know that between 20 to 30 percent of patients will misuse these medications. What can be done to mitigate that risk? Additionally, how do physicians account for those who take the medication as prescribed, yet still become addicted?
Strategies to start addressing the opioid epidemic today
I like to conceptualize the problem this way: These are the behaviors of a clinician and a patient playing out in the environment of care. Understanding the behaviors will continue to take time, but looking at the current environment is something we can do now.
Here are some examples I have encountered that improve the “environment” of care:
The ocean of unused medications just sitting in medicine chests across the nation is a major public health concern, since it is a ready supply for misuse. A community wide strategy for removing this should be a priority.
Default settings in EHRs around orders can lead to excessive prescribing. Many organizations are removing and rewriting order sentences to encourage better prescribing. In some cases, this is required to meet state mandated law.
Leveraging morphine milligram equivalents (MMEs)
One way to better represent the potential toxicities of a narcotic is to express its effects compared to morphine. This is known as the morphine milligram equivalent or MME. A clinician well-versed in the dosing of morphine can then better prescribe a different agent when needed. The MME is the so called “metadata” for that medication, which a computer system can use for many purposes beyond the point of care decisions.
Tracking the MME for a given patient can help in predicting problematic use and even the likelihood of overdose. The utility of this extends well beyond the prescribing clinician: It could prevent a death.
The D-Free ED initiative
Some medications simply don’t seem to be a good idea in some instances. That is particularly true for the use of hydromorphone (Dilaudid). It is associated with adverse outcomes such as respiratory depression, the need for resuscitation and the use of the anti-narcotic agent naloxone.
During a recent call on Cerner’s Opioid Crisis Response Center, MedStar Health operating in DC and Maryland outlined how they approached the goal of a Dilaudid-free ER. After provider training and education about alternative medications and approaches, MedStar removed Dilaudid from the medication dispensing machines in their emergency departments. Providers did still have the power to order Dilaudid if they felt it was needed. This “speed bump” in the process worked, and cut down on the number of Dilaudid prescriptions.
Enhanced access to care
I risk understating it when I say that surviving an accidental overdose can be a motivational wake-up call. When a person becomes open to treatment for opioid addiction, the environment of care must be ready. Ideas here include greater and immediate access to medication assisted treatment programs, first dose suboxone (a medication used in treating narcotic addiction) in the ED and the use of “peer” coaches (people in recovery themselves and trained to assist a patient in their journey).
Patients who remain in denial may still survive an overdose if naloxone is readably available. This is really a change from the environment of misuse and is the underpinning of the U.S. Surgeon General’s recent recommendations to make the drug widely available to family, first responders and others without a prescription.
The large gap in our basic understanding
These are just a few “can do now” projects that mitigate the inadvertent complicity of health care providers in the problem, connect patients earlier to treatment and strive to prevent fatal overdoses.
While we are still far away from understanding the fundamental questions of addiction, it is certainly welcome news that the National Institute of Health announced it is doubling its budget for opioid addiction research to $1.1 billion. Additionally, the CDC has designated more than $40 million in additional funding to strengthen prevention efforts and better track opioid-related overdoses at the state level.
Even more welcome is the current administration’s proposal to add $13 billion over the next two years toward efforts to combat the opioid epidemic. As this funding becomes available to each state, I expect to see expansion of many existing programs to meet the need, though whether this will be enough remains to be seen. Some advocates believe that anything less than the $32 billion a year the U.S. spends to fight the spread of HIV/AIDS will still fall shy of the mark.
When will the opioid crisis end?
So, when will we see an end to the opioid epidemic? This question, on the surface, is as absurd as literally interpreting most of lines from Alice in Wonderland. We will, as the King says, “go on,” because that is the journey in health care. Part of the work that I do at Cerner focuses on how the field of medical informatics can better inform and assist providers and patients alike in this epidemic.
I try to remember that there really is no right place to begin, nor any clear place to end (or, as the King says, “then stop”). The challenge is to stay motivated by the journey and incorporate as quickly as possible any new understandings discovered along the way. A not-so-absurd line from Alice in Wonderland may be applicable here: We will all need to be curious and curiouser if we hope to curb the opioid crisis.
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