Multi-Step Prescribing System Cuts Down Opioids, Increases Naloxone

Ankita Sagar, MD

The methods by which pain management can be diagnosed, assessed, and treated can be improved to optimally minimize opioid prescribing. As presenting physicians at the American College of Physicians (ACP) 2019 Internal Medicine Meeting in Philadelphia, PA, noted in a discussion, much of that plan hinges on approach pain as a biopsychosocial issue, not a biomedical issue.

Implementing a facility-adopted strategy to reduce opioid prescriptions for chronic pain would now provide entire health networks to better their own efforts to combat the epidemic. And Northwell Health has shown a proven, adoptable model.

In a presentation at ACP 2019, Ankita Sagar, MD, chief resident at Northwell’s North Shore University Hospital, explained that a suggested prescription opioid overdose at 1 of the healthcare system’s primary care practices led to a new quality initiative that sought uniform judicious opioid prescribing for patients with chronic pain in the non-cancer and non-hospice primary care practices.

“That caused a lot of internal reflection for not only the provider themselves, but for the clinical leadership, and we decided to venture on this journey,” Sagar said.

Their efforts were also driven by widescale opioid abuse metrics: approximately 2 million Americans are affected by opioid use disorder, 46 die from prescription-related overdoses daily, and approximately 52-71 opioid prescriptions are written per 100 residents in Northwell’s hometown state of New York.

Sagar’s team sough to decrease chronic opioid prescription volume for chronic by 40% in just 6 months, while also increasing overdose deterrent therapy naloxone co-prescriptions by 40% in the same time span. The data were tracked among 235 of the healthcare system’s primary care practitioners—including physicians, nurse practitioners, and physician assistants.

The team compiled opioid prescription data from electronic medical records (EMRs). Prescribing guidelines were set by the Opioid Management Steering Committee (OMSC) at Northwell Health, and reviewed and adopted by Medicine Service Line leadership.

The plan also sought outliers—care providers prescribing a volume greater than 1 standard deviation above the mean volume of prescriptions over a period of time—through EMR dashboard. Outlier providers were subjected to randomized chart audits over 30 days, and any outliers that returned concerning results resulted in three-dimensional approach of clinician, interdisciplinary team, and patient focus.

The outlier training approach included a dissemination and review of the set prescribing guidelines, naloxone training, registered nurse (RN) training, cross-specialty partnerships, and patient outreach and follow-up visits. Sagar described the approach as a “deep dive into their charts and practice to make sure that if there is a concern, it is rectified.”

In the 4 months prior to the intervention, a total of 515 chronic pain patients were prescribed opioid therapies 1082 times. Following intervention, just 382 patients had been prescribed opioid therapies 750 times.

Though Sagar and her colleagues were failed to reach 40% reduction goals for number of opioid prescriptions (31%) and number of patients receiving opioid prescriptions (26%), their naloxone co-prescribing results were exponentially improved. Their 108 naloxone co-prescriptions was a 120% increase from the pre-intervention count of 49.

Sagar said the team is in the process of collecting feedback from involved clinicians, as well as patient outcome results. They intend to begin including morphine milligram equivalents for patients with chronic pain on the system’s EMR, and to implement a better understanding of how referral recommendations may play a role in opioid prescribing rates for chronic pain.