Inside UCHealth Emergency Departments, physicians have deliberately been addressing an opioid crisis that is sweeping Colorado and the nation.

In a state where 357 people died in 2017 as a result of opioid pain medication overdoses, multiple state and national efforts are underway to prevent patients from becoming addicted to opioids and provide more access to care for patients who already are addicted.

“We’re limiting the number of narcotics that people are given and we give them alternative resources and choices to opioid therapy,’’ said Dr. Kelly Bookman, senior medical director for UCHealth Emergency Services.

 

In Colorado Springs, for instance, at UCHealth Memorial Hospital, physicians in one year reduced by one metric ton the number of opioids prescribed. At UCHealth Yampa Valley Medical Center in Steamboat Springs, the number of opioids prescribed dropped by 40 percent in six months. And in the emergency room at UCHealth University of Colorado Hospital in Aurora, prescribing rates have fallen by 37 percent.

The reduction in pills prescribed is the result of a multi-faceted effort across UCHealth’s 10 hospitals to provide patients with effective pain relief while driving down the number of prescriptions written for opioids, which are highly addictive and are difficult to stop using for some people. In some cases, Bookman said, a person can develop a tolerance to opioids in as little as three days.

“We want to help be part of the solution to this problem,’’ said Dr. George Hertner, chief of emergency medicine for Memorial Hospital. “We are still addressing a patient’s pain but avoiding using narcotics when possible. We’re limiting the number of narcotics that people are given.’’

UCHealth’s multi-faceted effort incudes:

• Participating in the Colorado Prescription Drug Monitoring Program, which helps reduce prescription drug misuse, abuse and diversion and helps physicians make more informed decisions when considering prescribing or dispensing a controlled substance to a patient.
• Embedding of a clinical support tool into the everyday workflow for physicians and advanced practitioners. The tool allows physicians to see alternative medications to treat pain. If opioids are needed for acute pain, the number of pills prescribed is limited. Included in the database is scripting for physicians so they may clearly communicate why a medicine other than an opioid is being prescribed, and how it is effective and less addictive than an opioid.
• Prescribing buprenorphine for patients who are addicted to opioids and indicate they would like to stop taking opioids. Patients who are prescribed buprenorphine do not get a feeling of well-being or a high from the medication, making it ideal for treating narcotic addiction.
• Participating in 2017 in the Colorado Hospital Association’s Colorado Opioid Safety Pilot, a study that was conducted in 10 hospital emergency departments (EDs) over a six-month span with a goal of reducing the administration of opioids in those EDs by 15 percent. The hospitals achieved a 36 percent reduction in the administration of opioids during those six months, as well as a 31.4 percent increase in the administration of alternatives to opioids (ALTOs).
• Administering a random drug screening program for all physicians, advanced practice providers and all UCHealth employees who work in positions or areas that give them access to opioids. UCHealth is one of the first systems in the nation with a random drug screening program that includes both employees and providers.

In emergency departments across UCHealth, physicians and advanced providers are having more conversations with patients to talk about the benefits of not prescribing too many opioids.

Gary Kushner, who broke four ribs and sprained his ankle last summer in a motorcycle accident, experienced first-hand how UCHealth is limiting the number of opioid pills prescribed in the Emergency Department at University of Colorado Hospital. Instead of receiving a script for dozens of pills, Kushner was prescribed six pills of oxycodone. His care provider told Kushner that he could call back if he needed more pills, but the goal was to get Kushner through the early days, when the pain was most severe.

Kushner is the executive director of UCHealth’s CeDAR – Center for Dependency, Addiction and Recovery. He thanked his caregiver and told her: “We need to be doing this, unapologetically, for every patient.’’

“I remember not too long ago, you’d have a root canal at a dentist’s office, and you’d receive a prescription for 30 hydrocodone, with two or three refills,’’ Kushner said.

That kind of over-prescribing has contributed to a national opioid crisis. Nationwide, an estimated 11.8 million people misused opioids in 2016, including 11.5 million pain reliever misusers and 948,000 heroin users, according to the National Survey on Drug Use and Health. A White House Council of Economic Advisers analysis said the opioid epidemic cost between $293.9 billion and $622.1 billion in 2015, with a preferred estimate of $504 billion.

At Memorial Hospital Central, the busiest emergency department in Colorado, one of the key questions physicians think about when a patient has pain is whether the pain is considered acute.

If a patient comes to the emergency department with a broken ankle, for instance, there is, indeed acute pain. Hertner said that in that case, as in Kushner’s, the patient would receive  enough medication to manage the initial bout of pain.

“I’ve broken a lot of bones,’’ Hertner said. “The first day or two, it hurts, but after that, the pain is really manageable and reasonable. You don’t need a month of narcotics to take care of your ankle fracture. You need the initial pain addressed, and a plan from there.’’

The plan could include immobilization, ice, inflammatory control medications and a follow-up appointment with a primary care physician.

Patients who have chronic pain and come to the emergency department complaining of back pain or tooth pain, are generally not prescribed opioids.

“The treatment should reflexively be not to give them a narcotic, it should be to treat the underlying disorder and give them support to take care of it rather than to continue to contribute to the risk of dependence or an addiction,’’ Hertner said.

When a patient comes to the emergency department who is identified as having opioid addiction, a different kind of conversation unfolds. Patients may self-identify as being addicted to opioids; a provider may deem them at risk, or a nurse can do SBIRT – screening, brief intervention and referral to treatment. For patients who are addicted or at risk for addiction, a social worker intervenes and conducts a more in-depth screening.

“Our grant (through the Colorado Office of Behavioral Health) for that started this year, and we have increased social work resources to bridge the gap in treatment for people in emergency departments, which is really to give people a warm handoff to the community providers,’’ said Dr. Jason Hoppe, associate professor at the University of Colorado School of Medicine’s Department of Emergency Medicine.

If a patient is at risk and is interested in receiving buprenorphine, the emergency physician writes a prescription for the medicine and a social worker schedules a follow-up appointment with a physician in the community, typically within three days.

UCHealth also has tools in place to provide data to physicians on how many opioid pills are being prescribed. Memorial, Hertner said, saw a vast reduction in the pills prescribed by providing positive feedback to physicians, showing them their prescriptive habits and how they compare with their colleagues.

“Physicians are competitive and if they are an outlier, then they want to be more consistent with their colleagues, and that was kind of a tipping point where we had a huge reduction,’’ Hertner said.

Hertner said he believes that has reduced the number of patients who repeatedly come to emergency departments seeking pain medications.

“It’s not that we stop taking care of them or treating them or seeing them, it’s just that we are treating them appropriately,’’ Hertner said. “It’s not to say that we don’t write prescriptions for narcotics. We still do, but we are really diligent about providing them to the right people for the right reasons.