Pain reframed: UTMB's Opioid Stewardship team focuses on safe prescribing, alternative treatments for pain

Apr 19, 2018, 19:40 PM by KirstiAnn Clifford
Dr. Erin Hommel goes over a pain contract with all patients who are taking or are considering taking opioids for chronic pain.
When it comes to opioid addiction, many people don’t see it coming. It can happen to anyone, anywhere—and quickly spiral out of control.

“I’ve had patients who had a surgical procedure and three weeks later were addicted to heroin,” said Dr. Edythe Harvey, an addiction psychiatrist at UTMB.

According to the Centers for Disease Control and Prevention, more than 2 million Americans are dependent on or abuse prescription opioids. It’s a nationwide trend that continues to grow. Opioids—including prescription opioids, heroin and fentanyl—killed more than 42,000 people in 2016, more than any other year on record.

In response to the widespread and growing problem, hospitals and health systems across the country, including UTMB, have begun implementing physician-led opioid stewardship programs with a simple mission: to help save lives. While there are many different factors contributing to addiction and abuse, these programs specifically look to lower rates of overprescribing among health care providers and curb patient addiction risks.

“We have always known opioids to be dangerous—that’s not new news,” said Dr. Erin Hommel, a clinical geriatrician and assistant professor in the Department of Internal Medicine, who serves on the opioid stewardship team along with Harvey and others. “But the degree at which the opioid epidemic has grown in our country is a relatively new problem over the last decade—it’s really ramped up. Health care providers are saying, ‘We have to do things differently.’”

Hommel, who has spent the last two years tracking prescription opioid use in the geriatric patient population at UTMB, says that doesn’t mean physicians should stop prescribing opioids altogether.

“We know there are people who need these medications, but we have the responsibility to prescribe appropriately and safely, and to educate patients about the risks. As a health system, we want to provide people with the tools to do the right thing and take better care of patients. We’ve seen a lot of motivation to do that, which is good,” Hommel said.

Making improvements will require collaboration. As a first step, UTMB’s opioid stewardship program is currently looking into providing continuing education programs for physicians and others who prescribe or administer opiates.

“Our hope is to implement some kind of online course as part of annual training,” said Harvey. “People need to know safe prescribing habits, how to identify someone at risk for overusing pain meds, what treatment resources are available, and be reminded of core competencies on a regular basis. I’ve already been on the circuit giving drug talks to departments around the institution, including orthopedics, anesthesiology, geriatrics and others.”

Hommel says the education piece also needs to include information on alternative methods for pain management, such as acupuncture, physical therapy or injection options such as steroids. She points to research showing that while prescriptions for opioids have quadrupled since 1999, there hasn’t been a corresponding drop in reported pain.

“A lot of data shows that using opiates for chronic pain over a long period of time doesn’t help patients manage their pain better—they actually become tolerant to the medications and their awareness of pain is heightened,” said Hommel. “So it’s not always best to start with opioids as the first line of defense.”

For those who need opioids for chronic pain, the stewardship program is exploring ways to help physicians and patients proceed in a safe, responsible manner. That may include implementing standard “pain contracts,” in which the patient and provider agree to various conditions under which opioids will be prescribed or discontinued, as well as regular urine drug screening tests.

Technology will also play a role in opioid stewardship. Based on recent recommendations, UTMB’s Epic electronic medical record now includes a direct link to Texas’ Prescription Monitoring Program (PMP), allowing physicians easy access to the state’s electronic database that tracks controlled substance prescriptions. Clinical guidelines encourage physicians to use the PMP prior to prescribing in order to identify patients who may be misusing prescription opioids or who may be at risk for overdose. In addition, information about naloxone, an opioid antidote used to reverse overdoses, may soon be included on patient handouts when an opioid is prescribed.

Addressing the opioid epidemic head-on and discussing the risks with patients may be uncomfortable, but Harvey and Hommel agree: It’s a critical responsibility for all physicians, who took the Hippocratic oath to first “Do no harm.”

“We need to be really careful and have a discussion with all patients who may be prescribed an opioid,” said Harvey. “It only takes a few minutes and it’s the right thing to do.”

Other members of UTMB’s Opioid Stewardship team include Dr. Dwight Wolf, Dr. Loretta Grumbles, Dr. Evan Ross, Dr. Khannah Smith, Dr. Kuo Yong-Fang, Morgan McClure and Mary Feldhusen. For more information about UTMB’s efforts to become a high-value practicing organization, visit intranet.utmb.edu/best-care.