RWJBarnabas Health takes multi-pronged approach to tackle opioid epidemic, enhance pain management
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RWJBarnabas Health in New Jersey provides full-time peer recovery specialists 24 hours a day at its hospitals as part of the health care system’s comprehensive efforts to address the opioid epidemic while improving how it approaches pain management. Through its Tackling Addiction Task Force, the system launched a multidisciplinary, multi-pronged initiative called Deliberate Reduction of Opioid Prescribing or DROP focused not only on reduction of opioid prescribing, but on enhancing how the system treats pain. This includes educating medical staff on appropriate opioid prescribing, increasing the use of evidence-based alternative practices in pain management, offering patients with substance use disorder support services and medication-assisted therapy, as needed, and building a network outside the system that creates seamless linkages to services once patients are discharged.
“We educated our staff, our nurses, doctors, physician assistants and nurse practitioners on changing the stigma of the disease. Here, we look at substance use disorder as a chronic disease,” Christopher F. Freer, DO, co-chair of the Tackling Addiction Task Force and the system director of emergency medicine, told Healio Orthopedics.
Freer cited the Turn the Tide Rx campaign of Vivek H. Murthy, MD, MBA, 19th Surgeon General of the United States, as a pivotal moment in the fight against the opioid epidemic, which urged clinicians to educate themselves on proper prescribing of opiates; screening of patients for opioid use disorder and connecting them with evidence-based treatment; and lessening the stigma associated with the use of opioids.
“We had every one of our providers take Surgeon General Murthy’s pledge and then, after providing extensive education, we focused on prevention,” he said.
Help from peer recovery specialists
In 2016, RWJBarnabas Health launched its Peer Recovery Program, in which trained peer recovery specialists were deployed bedside to ED patients who overdosed on opioids and were also given Narcan (ADAPT Pharma Inc.). The program expanded in 2019 to include all patients in RWJBarnabas Health hospitals, both in the ED and in all inpatient units, including orthopedic floors.
“Patients accept the support of peer recovery specialists about 90% of the time, Freer said. “We are going to measure 30-day revisits to the ED and readmission and mortality.”
“We are trying to get as many doctors waived to prescribe buprenorphine as possible and have a warm handoff from the peer recovery specialist to the navigator and outpatient program,” he said.
For patients who want to be treated for opioid use disorder, a clinical assessment is done by a patient navigator who suggests what the appropriate care plan should be. The peer recovery specialist’s role is to build trust and support the patient through the entire process.
ED tracks prescriptions
Freer noted the ED tracked opioid prescriptions going throughout the system. Prior to the implementation of peer recovery specialists and staff re-education, RWJBarnabas Health’s opioid prescription rates for patients being discharged from the ED neared 10%.
“Over 18 months, we cut that by 60%. This [took] about 6 months, but we cut our prescriptions by over 25,000 [pills],” he said.
“New Jersey put some state laws [into effect] that we can prescribe only a certain amount of medication and you have to document the patient’s risk of dependence and overdose. This all coincided with what we were doing. It changed the culture between our order sets and our staff, to prevent over-prescribing.”
Freer said the staff had to learn to set an expectation with patients that pain will not be lowered to zero, but their goal was to get them to a point when they could function.
RWJBarnabas Health changed its order sets. A multi-disciplinary team looked at the top five diagnoses in the ED — which included back pain, extremity pain, renal cholic, abdominal pain and headache — and created order sets for the conditions using non-opioid alternatives.
Freer said providers try to use ice, splints, NSAIDs and other non-opioid pain medicine first and then use low or small doses of opioids as a rescue medication. Among the non-opioid pain medication RWJBarnabas Health uses are ketamine, ibuprofen, Tylenol (Johnson & Johnson Consumer Inc.) and trigger-point injections and blocks.
Freer said patients who present with opioid use disorder or are opioid dependent due to being prescribed opioids for long periods of time need a structured plan to address their pain.
“We can expand on doing more local and regional blocks,” Freer said. “I wish I could say there was an abundance of non-opioids. People still need opioids. There are definitely times we’re going to use [them]; it’s just we are now smarter when we use them.”
Need for a medical home
Freer said the next step for RWJBarnabas Health is to develop a medical home where patients will be able to go to a family doctor for treatment and to have more involvement from pain management and addiction specialists
“I think [we need] the medical home and [getting] patients connected to a private doctor,” Freer said. “We need to do more work with regard to standardizing our OR and the prescriptions going out.”– by Monica Jaramillo
Disclosure: Freer reports no relevant financial disclosures.