A physician details strategies all providers — not just those in emergency departments who traditionally have been on the front line — can use to accelerate addressing the epidemic.
According to the Centers for Disease Control and Prevention, drug overdoses are now the leading cause of unintentional death in the United States, with more than two-thirds of those because of opioids. The opioid epidemic has devastating effects, and its impact can be felt in all corners of our society and health care system.
With the White House extending the public emergency status in April 2018 for the second time, there are opportunities for all health care providers — not just those in emergency departments who traditionally have been on the front line of the battle — to implement specialty-specific strategies and accelerate the rate at which the crisis is combated.
Specialists such as emergency medicine clinicians, hospitalists, anesthesiologists and women’s and children’s providers, among others, provide crucial care to patients and play a significant role in curbing the opioid epidemic. When equipped with the appropriate resources, they can provide the highest quality of care to all patients, including those who suffer from acute and chronic pain, have an addiction or are at risk for opioid misuse and abuse. Specialty societies and multispecialty health care organizations with national footprints are making strides in this area by providing specialists with the education, tools and best practices they need to drive material change at scale.
Emergency medicine specialists: Emergency departments serve as a safety net for the U.S. health care system and disease states. With pain being the most common presenting symptom of patients seeking emergency care, emergency medicine physicians have served as the first line of defense in reducing patients’ exposure to and potential subsequent misuse of opioids. To help patients manage their pain in the ED, alternative treatments to pain medication, such as those in St. Joseph’s University Medical Center’s Alternatives to Opiates Program, have proved effective and are promoted by groups such as the American College of Emergency Physicians. These strategies include stabilization of injuries, ice application, local compression, local trigger point injections and regional nerve blocks. Clinicians also can administer nonopioid medications like ketamine, transdermal and intravenous lidocaine, nitrous oxide gas and acetaminophen.
For the department overall, best practices such as standard approaches to pain assessment, team-based rounding, treatment planning and bedside patient education, as well as real-time identification of patients at risk of addiction with appropriate referral, can be effective. Additional efforts to reduce patients’ access to opioids include reducing opioid prescriptions at discharge with alternative pain medication management, short courses of opioid prescriptions when necessary, removing commonly abused opioids from ready availability in the ED, and implementing “no refill” policies when appropriate. While these methods have proved effective, efforts should extend beyond the ED.
Hospital medicine specialists: Hospitalists are integral to providing high-quality, patient-centered care and managing patients’ medication therapies. As such, the industry recognizes the specialty’s ability to help address the opioid epidemic. In fact, the Society of Hospital Medicine has developed programs like the Reduce Adverse Drug Events Related to Opioids guide to help this cohort implement patient safety initiatives regarding the use of opioid therapy.
In the hospital setting, a high-quality handoff between emergency medicine and hospital medicine physicians can set the groundwork for an individual’s inpatient care. For patients deemed at risk for addiction, hospitalists provide education about acute versus chronic pain management and appropriate treatment modalities, including the risk of becoming addicted to specific medications. As needed, they can help facilitate rapid follow-up with appropriate treatment centers. For those patients already on opioid medications, hospitalists assist in rapid weaning to oral formulations and, ideally, to nonopioid treatment plans. In addition, hospitalists participate in patient and family advisory councils to address issues like opioid use and abuse inside and outside of the hospital environment, so patients and their families are more prepared to manage their pain successfully.
Perioperative surgical specialists: Similar to efforts made in hospital medicine, specialty societies like the American Society of Anesthesiologists are taking note of how anesthesiologists can contribute to a solution. The society launched a national pilot, the Safer Postoperative Pain Management program, focusing on adult patients undergoing elective hip and knee arthroplasty and colectomy surgical procedures. The program includes discussing pain management expectations with patients and teaching them how to use, store and dispose of opioids safely as well as how to prevent opioid misuse and abuse after they are discharged. In both the operating room and radiology suite, anesthesiologists also can use multimodal, opioid-sparing analgesia, regional anesthesia and local field blocks before and after painful procedures.
Women’s and children’s specialists: Mirroring the epidemic seen in the general population in recent years, prescription opioid use and illicit drug use and abuse during pregnancy have risen dramatically. This environment, and the spike in neonatal abstinence syndrome, increasingly are spotlighting the role of women’s and children’s providers in helping address the opioid crisis. These specialists can do their part by performing routine screening studies to identify at-risk pregnant patients so they can receive the appropriate counseling, care and referrals for specialized treatment. They also play a key role in teaching parents how to care for babies with NAS and in encouraging parental support and presence during an affected infant’s hospital stay, as rooming-in and breastfeeding have been shown to decrease length of stay.
If we are going to be successful in combating the opioid crisis, health care providers need to work together to exchange information and expertise across specialties as well as work with their patients to control pain and treat addiction. Efforts such as white papers and collaborative gatherings can improve the delivery of care by sharing best practices and innovations for appropriate interventions, pain management plans and access to behavioral health resources. These efforts can and should be initiated by physicians from all specialties and facilities, and national multispecialty health care organizations have a unique role to play in bringing together providers to address the opioid crisis.
It’s time to stop looking at opioid abuse in specialty silos, as solely a primary care, behavioral health or emergency medicine problem. It is a national crisis, and clinicians from across specialties have to be part of the solution. As providers, we must leverage the expertise of multiple specialties to take the best care of patients, minimize the potential for opioid abuse disorders, reduce opioid addiction rates and, most important, prevent additional deaths.
Rebecca Parker, MD, is the senior vice president of advocacy and leadership for Texas-based Envision Physician Services, a national multispecialty health care organization caring for more than 30 million patients every year. Parker is a board-certified emergency medicine physician practicing in the Chicago, Illinois, metro area.