Fighting an Epidemic: How Einstein Is Reducing the Use of Opioids
First in a series
For the last two years, as Einstein Healthcare Network and other hospitals nationwide focused on combating COVID-19, another epidemic didn’t go away. In fact, the opioid crisis – especially deaths by overdose – got worse.
But the network has been taking steps the last several years to reduce the use of opioids in medical care, from surgery to treatment of chronic (long-term) pain.
Located just north and west of ZIP Codes with some of the city’s highest overdose rates, Einstein Medical Center Philadelphia continues to confront the opioid epidemic every day.
The result has been a swing away from the approach of the previous two decades, when pharmaceutical companies heavily marketed drugs such as Oxycontin and national organizations evaluated doctors and hospitals in part based on how well they provided pain relief for patients.
“The change here began with the recognition of the magnitude of the opioid problem that is affecting our patients in our community,” says Steven L. Sivak, MD, President of Einstein Physicians Philadelphia. “Now the focus is to really look for alternative ways to treat patients.”
Einstein officials, like hospital and physician leaders nationwide, acknowledge that medical treatment of pain, with prescription opioids such as oxycodone, has played a significant role in causing the opioid epidemic.
Pain Management and Addiction Treatment
This is the first of a series of articles that will look at steps Einstein has taken to:
- Manage short-term pain – for example, during and after surgery – with less use of opioids
- Move toward a variety of other approaches to relieve chronic pain
- Help patients overcome addiction to these drugs
Philadelphia has the highest overdose rate among the nation’s 25 most populated counties, at 63 per 100,000 people, according to the University of Wisconsin Population Health Center.
Unintentional drug overdose deaths increased 6% in 2020 compared with the year before, according to the Philadelphia Department of Public Health. The increases were even steeper among African Americans. More than 86% of the deaths involved some type of opioid drug, mostly illegal ones such as fentanyl.
According to the National Institute on Drug Abuse, about 80% of people who use heroin first misused prescription opioids.
The initiatives to diminish opioid use at Einstein began with grassroots efforts by several doctors and evolved into the Opioid Network Committee, established in 2017, which led to multiple steps that have reduced opioid use both inside and outside the hospital.
“The main mission is to help protect people who are not yet depending on opioids from becoming dependent. And the key way to do that is not exposing them to opioids,” says David Greenspan, MD, Chair of the Department of Psychiatry and Co-Chair of Einstein’s Opioid Network Committee.
“And if you’re going to use opioids,” he adds, “have the dose as low as possible but – more important than low – as short as possible. Most of the research says that anything from three to five days is probably safe. But beyond five days, the risk of developing dependence starts to go up.”
A large study published by the Centers for Disease Control and Prevention (CDC) in 2017 found that about 6% of people prescribed opioids were still taking them a year later. But the rate was 14% for those whose first prescription was for longer than a week.
‘Start Low, Go Slow’
In 2017, Einstein adopted new guidelines for pain management. The guidelines encourage doctors to minimize opioid prescriptions for treatment of pain from injuries, back problems and other causes.
“Start low, go slow should be the motto,” says Christopher Scaven, DO, Medical Director of Einstein Community Health Associates and head of the opioid subcommittee for outpatients.
However, Dr. Greenspan cautioned that people who have been taking opioids for years require a different approach than those who are taking them for the first time. Reducing the use of opioids in this group needs to be accomplished gradually if at all, he says.
Besides the changes that have taken place in outpatient prescribing, the Medication Safety Committee pushed to reduce opioid use for inpatients at Einstein Medical Center Philadelphia.
Horacio Hares, MD, vice chair of the Department of Medicine, said doctors were concerned about dosages and side effects of opioids for hospital patients. Besides the risk of addiction, overdose and even death, prescription opioids can cause cause constipation, nausea, dizziness, drowsiness and breathing problems.
“We realized that we needed to spread information and knowledge about a multi-model approach to deal with pain,” Dr. Hares says. “So we created a guideline on how to give the best treatment for pain that we can with the least amount of narcotics.”
The multi-modal approach includes non-opioid medications, use of heating pads and cold packs, and other treatments.
Primary care doctors at Einstein Philadelphia also developed guidelines, which were expanded to other specialties, Dr. Scaven says. All are based on CDC recommendations published in 2016.
“For short-term treatment, we recommended no more than five days of opioid medication,” Dr. Scaven says. “And if it’s going to be longer than 30 days, there have to be set criteria to substantiate why the patient is taking the medication.”
For example, before prescribing longer-term opioids, doctors would order certain tests, try muscle relaxers or anti-inflammatory medicines such as ibuprofen, and possibly send the patient for physical therapy or treatments such as nerve-block injections that are offered by the Einstein Pain Center.
Primary Care Guidelines
All guidelines are built into the electronic medical record system where doctors order prescriptions. The system also links to a state database that lists whether patients are getting opioids from other providers. This tool allows doctors to look for potentially dangerous opioid use before writing prescriptions.
When patients do need long-term opioid treatment, the network has required for many years that they receive the medication from only one doctor and one pharmacy. They agree to random testing to guard against dangerous interactions with other drugs.
Doctors have had a positive reaction to the guidelines, Dr. Scaven says. Patients’ reaction has been mixed. But they also have received the message from news media as well as doctors that opioids can be addictive and dangerous, he says, and many are open to treatment with little or no opioids.
For such longer-term use, Einstein wants to strike a balance to make sure people receive the most appropriate care, Dr. Greenspan says. “We don’t want to undertreat people. And on the other hand, we don’t want to give them enough that they become dependent.”