The public health crisis spawned by the explosion in opioid prescriptions over the past decade has been well chronicled. The avalanche of addictive medications has cost tens of thousands of lives, hollowed out whole communities, depleted the workforce, spurred commitments for emergency federal funds, and pitted some states hard hit by the scourge against drug manufacturers.
Now a survey of the damage leads to other thorny questions: How to help the millions of patients who still rely on opioids to manage their pain while reducing their risk of dependence? And as restrictions on opioid prescribing tighten, what can providers to do to steer patients suffering persistent pain toward safer alternatives?
A strategy is emerging at UCHealth, where providers serving University of Colorado Hospital on the Anschutz Medical Campus are developing tools to help clinicians make better-informed decisions about treating their patients’ pain. Their ally is the Epic electronic health record (EHR) and the vast repository of data that lies within it. It’s a joint effort that brings together physicians, pharmacists, information specialists and others committed to protecting patients while ensuring they receive appropriate treatment. The work complements a major effort to reduce the number of opioids prescribed in UCHealth’s emergency departments and direct patients to alternative treatments.
Finding middle ground
It’s a delicate balance, said Katy Trinkley, associate professor in the Department of Clinical Pharmacy at the University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences. Trinkley worked until recently with clinicians in UCH’s Internal Medicine Clinic on the Anschutz campus, helping to ensure the safety of patients’ medications, including opioids. In the Internal Medicine Clinic, she saw firsthand providers face the challenge of treating patients’ chronic pain safely and helped develop a pharmacist-managed chronic pain clinic. Trinkley co-authored an August 2017 article that details the work.
“People need pain relief and support without jumping straight to opioids,” Trinkley said. “As pharmacists, we are well-positioned to know when it is appropriate to prescribe them and how to reduce their use.”
One problem for busy providers under pressure to reduce opioid use is a lack of time and administrative resources, Trinkley added. To address that, she’s moved into clinical informatics, finding ways to use data from the EHR to aid providers treating complex cases that often involve not only pain but also medical comorbidities and mental and behavioral health issues.
“We’re trying to identify new tools in the electronic health record to close care gaps or optimize care,” Trinkley said.
One example now in place: a “morphine dose calculator” that is programmed into the EHR. The tool allows providers to quickly convert the amount of an opioid, like oxycontin, that a patient takes to its morphine equivalent. That produces a number the provider can use to judge risk of addiction, overdose and side effects like constipation and dizziness that can complicate care.
Also in the works is a “pain summary button” that will pull and assemble information from the EHR about a patient’s pain medication history and display it discreetly. It’s a way to standardize and gain a more objective picture of an individual’s pain history, Trinkley said. Another project close to completion is a registry of the thousands of patients treated with opioids at UCH and the patterns of those prescribing the medications – a key to finding ways not only to reduce opioid use but also to improve the quality of care, Trinkley said.
“The registry is important to help providers understand the patient population and begin to understand their prescribing practices,” said Dr. Peter Smith a family medicine specialist with UCHealth who has helped to develop a variety of tools for primary care physicians managing chronic pain patients. Smith said the registry will also help to assess how well providers and practices meet guidelines set by the Centers for Disease Control and Prevention guidelines for prescribing opioids for chronic pain.
Smith pointed out that screening patients and assessing their risk of harm from opioids is difficult because of the number of potential factors involved. The opioids themselves are potentially addictive, of course, but conditions as diverse as anxiety disorders, depression, obesity, liver and kidney problems and regular use of alcohol, sedatives and other drugs are additional risk factors.
It’s difficult to imagine a clinician in any practice making that assessment in a relatively short visit, but there is now electronic help available, said Smith, who began work on a project to ease the burden with Dr. Richard Altman, an internist at UCHealth’s Lone Tree Medical Center. Altman, who is also a trained computer programmer, created an application that quickly scours far-flung corners of a patient’s medical chart for the opioid medication risk factors Smith describes. The final product is neatly packaged in 10 to 15 lines of easy-to-scan summary text.
“It’s an opioid risk assessment tool,” Altman said. “Providers use their clinical judgment to decide on the next step for treating their patients.”
Throwing a flag
Altman said the program is available to “anyone seeing patients with pain, which is just about anyone.” An individual provider can use it simply by typing the dot phrase “.OPIATERISK” in the EHR, or it can be embedded in an Epic note or SmartPhrase so that it pops up automatically. Its first major adopter, he said, is the Medication Access and Renewal Center (MARC), which works with providers and patients on medication-related tasks. The MARC’s protocols include using the tool for every patient who has a refill request for an opioid medication, Altman said. If the risk assessment is high, the MARC notifies the prescribing provider, who is better positioned to make an informed decision about the safest course of treatment.
“It helps to give feedback as you go,” Altman said, noting that aside from the MARC he’s gotten anecdotally positive feedback about the tool’s usefulness in addressing the pervasive problem of treating chronic pain safely. Simply severely restricting or eliminating access to opioids won’t meaningfully address it, he said.
“The challenge is that pain is real and pervasive in everyday life,” Altman said. “Opioids are seen by physicians and patients as a very useful tool in combating pain. Unfortunately, they are addictive, dangerous and not known to be effective in the long term for chronic pain.”
Getting a provider “the right information at the right time in a format that is readable,” Altman said, can help them clarify with patients their goals of care, like regaining the ability to walk without debilitating pain. With that, providers might guide patients to non-narcotic treatments like physical therapy, acupuncture, and analgesic creams that can “help them regain their lives,” he said.
Tracking take-home meds
Meanwhile, a five-year National Institute on Drug Abuse-funded clinical trial now underway at UCH led by anesthesiologist Dr. Karsten Bartels, is looking at fine-tuning opioid-prescribing after surgeries. Bartels published a small study in 2016 of patients sent home with opioids after surgery. One question: how many did they take? It turned out many of them took only a small number: five of a 30-day supply, for example.
The initial study also raised the question of what happens to all those unused pills. How are they stored or disposed of?
“It’s good not to be wasteful,” Bartels said. “And if these medications are being stored in medicine cabinets, they are potentially available for non-medical use.”
The current study surveys three groups: women after cesarean sections; general gastrointestinal surgery patients; and thoracic surgery patients. They are surveyed once a week for four weeks about how much of their medications they used and how they stored them.
“We want to decide who needs what rather than a one-size-fits-all solution,” Bartels said. “We’re trying to find out how much opioid medication a patient actually needs and take that information and put it into practice.” The idea is not simply to reduce the number of opioids prescribed, he emphasized, despite that impulse being “where the pendulum is swinging” in health care.
“We have to be careful not just to limit the number of medications, but rather to give patients what is appropriate,” Bartels said. “We have to identify patients with different pain requirements. That goes in both directions. There are patients who will need no opioids, but there are patients who do need them in higher doses than is commonly prescribed. We have responsibility to all of those patients.”
Bartels said he’d like to see the study results translate to clinical decision support for surgical providers deciding on appropriate pain management for their patients as well as educational tools for patients. He notes that patients get plenty of attention to their pain levels while they are hospitalized. That includes offering them non-opioid medications. The guidance shouldn’t end when they go out the door, he said.
“My goal is to extend this kind of comprehensive approach when patients are discharged home,” he said.
Good tools take time
The promise of clinical decision support in managing opioid use – or addressing any health problem – should not obscure the resources required to build tools that will help providers improve patient care, said Miranda Kroehl, PhD, assistant director of the Center for Innovative Design and Analysis (CIDA) at the Colorado School of Public Health. Kroehl has worked with Trinkley since 2014 and was a co-author of the 2017 paper detailing the pharmacist-managed chronic pain clinic.
Kroehl and her fellow biostatisticians at CIDA help researchers like Trinkley design studies that are most likely to produce data that answer specific questions. “We have to define the expectations and the realities of the study upfront,” Kroehl said.
For example, if the goal of a pilot is to reduce opioid use, the researcher must define a reasonable period of time to gather enough data to assess and measure the results. Even with that information in hand, the researcher would have to define what he or she considers a significant reduction. And of course every study must be designed with the available resources in mind.
If the work yields new decision-support tools, they should be designed to complement, not complicate, providers’ patient care, Kroehl added. For example, “best practice advisories” that pop up to alert a provider to a clinical consideration are common in the Epic EHR – and sometimes a source of frustration.
“Clinical decision support is a great and challenging way to interface with providers at the point of care,” Kroehl said. “But they are still an intervention. We have to make sure not only that the tools work but also that providers are using them.”
The prickly problem of pain
Smith also sees major challenges that remain despite the progress made in helping primary care physicians work with their chronic pain patients. Many patients also struggle with mental and behavioral health issues, substance use disorders, and trauma, with scant societal resources to address them.
“We often are dealing with patients caught in the middle of these problems,” Smith said.
In addition, the patients Smith and his colleagues see frequently present with less than clear-cut symptoms or a straightforward problem like a sprained ankle.
“We’ve gotten better at using alternatives to opioids to address acute pain,” he said. “But we get many patients with vague concerns that are not attributable to specific ongoing biologic damage.” He explained that in some cases chronic pain is attributable to a single cause, like degenerative disease. Very often, however, patients may continue to suffer long after one would expect the pain to end.
“In these cases, the brain may have lost its ability to know the body has healed,” Smith said, comparing the problem to a smoke alarm ringing constantly.
“It’s a disconnect between the actual tissue damage and the pain experience,” he said. “As a physician, it’s a challenge to help patients develop insight into that problem without making them feel that their pain is being discounted.”
Decision-support tools and programs aside, Smith stressed the importance of removing the stigma often attached to people struggling with chronic pain and opioid use. He noted that a number of UCHealth primary care practices now schedule a minimum of four focused visits per year for patients who use opioids regularly for pain.
“We’re trying to socialize the idea of a dedicated visit for chronic pain,” Smith said. “We don’t say to patients with diabetes, ‘Oh, by the way, let’s manage your diabetes as an afterthought at the end of your visit for three other problems.’ We have dedicated visits for patients with diabetes.”