November 19, 2019

For Hospitals, A Blueprint for Fighting the Opioid Epidemic

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A new report from the Grayken Center for Addiction and the Institute for Healthcare Improvement collects evidence-based strategies to help hospitals fight the opioid epidemic.

Hospitals are on the front lines of the opioid epidemic. Nearly 500,000 people with an opioid use disorder (OUD) are discharged from the hospital each year. Rates of opioid-related emergency department visits and inpatient stays have risen dramatically, as have rates of serious infections, such as endocarditis and hepatitis C, stemming from opioid use. Total hospital costs related to opioid overdoses have been estimated at $2 billion annually.

These stark statistics show the mounting pressure on hospital capacity and resources. But the numbers also reveal the tremendous opportunity hospitals have to influence the opioid epidemic. No other setting provides as many touchpoints to engage people with OUD and connect them with effective treatment.

For any hospital, transforming OUD treatment is a challenge. Fortunately, hospitals have more access than ever before to a wide array of evidence-based tools and strategies, ranging from effective medications for opioid use disorder to detailed guidelines for opioid prescribing. As the evidence for these and other best practices increases by the day, the urgency increases as well. With so many best practices available to us, hospitals cannot delay in creating a systems-level approach for addressing the opioid epidemic.

To help hospitals meet the need and overcome challenges, the Institute for Healthcare Improvement (IHI) and the Grayken Center for Addiction at Boston Medical Center teamed up to document effective strategies that hospitals can put in place to respond to the opioid crisis and support their patients. The resulting report, a synthesis of evidence-based guidelines and lessons learned from around the country, serves as a blueprint for hospitals.

The blueprint: key strategies

Many hospitals across the United States are already responding to the opioid epidemic in strategic and innovative ways. The full IHI/Grayken Center report contains dozens of these examples, along with specific actions hospitals can take. Below are three broad areas in which hospitals can have an immediate impact.

Identifying and treating individuals with OUD at key clinical touchpoints

The emergency department (ED) remains an underused touchpoint for treating acute withdrawal and initiating treatment. EDs everywhere should be equipped to provide this frontline care. (In some states, including Massachusetts, this standard of care is already required by law.) Medication initiation in the ED works. When patients are given buprenorphine in the ED and referred to ongoing treatment (versus screening or referrals alone), they are more likely to remain in treatment and reduce their use of illicit opioids after 30 days, research from the Yale School of Medicine has shown.

Given the rise of opioid-related inpatient stays, addiction consult services are another key opportunity to reach patients and connect them to ongoing care. These services, which engage patients during acute hospitalizations and often provide key harm reduction, have the capacity to improve care quality and reduce readmissions. 

Hospitals often cite the lack of community-based referral capacity as a barrier to implementing substance use disorder services. However, successful models exist for growing ongoing care capacity internally. For instance, office-based addiction treatment, developed first at Boston Medical Center, centers around a nurse care manager model of primary care in which nurses oversee patient care and offer medications for OUD such as buprenorphine when appropriate. This model keeps patients engaged, destigmatizes the experience, and minimizes disruption to patients’ employment and other responsibilities. Research from Marc Larochelle, MD, at Boston Medical Center, and others found that medication for opioid use disorder (specifically buprenorphine and methadone maintenance treatment) was associated with reduced opioid-related mortality and all-cause mortality over several months. The office-based addiction treatment model has already spread throughout the country, and the “Massachusetts Model” treats hundreds of patients, with dozens of community health centers adopting the model.

Changing the way that hospitals treat pain

Many hospitals have already responded to the opioid epidemic by rethinking how they prescribe opioid medications—often reducing the number of pills prescribed—and the settings in which they’re prescribed. The Michigan Opioid Prescribing Engagement Network, affiliated with the University of Michigan, has been a leader in the field, bringing together hospital systems and clinicians to develop evidence-based prescribing guidelines, encourage safe opioid disposal, and develop patient education materials. 

However, in some cases the increased attention has led providers to be overly wary of prescribing opioids, to the point that the Centers for Disease Control and Prevention (CDC) decided to clarify that there are many situations where opioids are indeed appropriate. Providers are also learning to emphasize alternative medications and treatments for acute pain management and newly identified chronic pain. For patients already on high-dose chronic opioids, providers should cautiously manage those prescriptions; abruptly tapering patients is not clinically advised. Prescription drug monitoring programs are now regularly required by state governments, and pharmacies have become crucial partners in using existing data to identify patients, providers, and prescribers who may need additional attention. While this requires oversight to be effective, it represents true progress. Clinicians are being more thoughtful about how to prescribe opioids effectively and safely, and hospitals are beginning to incorporate this thinking across specialties—from primary care to dentistry to post-surgical care. In Massachusetts (as well as a few other states) there’s a phone line that clinicians can call with prescribing questions.  

Training stakeholders on the risks of OUD and how to reduce stigma

The prevalence of substance use means that many more individuals than ever before need to learn about opioid use, opioid use disorder, and substance use disorder more generally. This includes not only people working in addiction medicine, but health care professionals outside of the addiction sphere, patients, and the public at large. Widespread stigma around opioid use disorder and the medications to treat it persists, even among medical professionals. A survey from RIZE Massachusetts found that only one in four providers had received training on addiction during medical education. Startlingly, less than half of providers in emergency medicine, family medicine, and internal medicine believed OUD is treatable. 

The stigmatizing attitudes about patients with substance use disorder among medical providers are well documented, and the consequences are severe, leading to the undertreatment of patients with substance use disorders. This stigma leads them to hesitate before sharing important information about their substance use with providers for fear of judgment and retribution. It may also cause patients to use drugs in secret, which could lead to a fatal overdose or cause people with an OUD to forgo potentially lifesaving drugs, such as methadone or buprenorphine, because of the negative stories they may have heard. 

Hospitals, given their direct line to patients, families, and employees, can dismantle this stigma. One way to do this is to teach all faculty and staff the facts about substance use disorder. Another is to encourage a hospitalwide commitment to using clinically appropriate terminology—for example, referring to “people with a substance use disorder” rather than “addicts.” Hospitals can also be incubators for positive community change. As employees unlearn the stigma they’ve been taught, they’ll share this view with family and friends, helping the community at large to reframe the way they think about addiction.

Hospitals working together

Some hospitals—including those we highlight in the report—have done all this and more; others are just beginning to take a systematic approach to taking on the opioid epidemic. In either case, the efforts to date have largely been independent and disconnected. To achieve the size, scale, and sense of urgency needed to turn the tide of the epidemic, hospitals must work together to accelerate learning and secure buy-in from their organizations.

To turn the tide of the epidemic, hospitals must work together to accelerate learning and secure buy-in from their organizations.

In the next phase of our partnership with the IHI, we will be using the IHI’s Leadership Alliance to formalize a learning network among a group of hospitals that will voluntarily commit to expanding their response to the opioid epidemic and sharing their experience with the network.

Invariably, as hospitals band together, we will encounter policy and payment barriers. The learning networks we develop to scale effective strategies can also be used to advocate for policy and practice change. The willingness to work together collaboratively will continue to be essential as hospitals collectively heed the call and assume a leadership position in fighting the opioid epidemic. 

Authors’ Note   As noted in the piece, the Institute for Healthcare Improvement and the Grayken Center collaborated on a report outlining effective strategies for hospitals to address the opioid epidemic. Neither party received financial compensation for their input on this report.

This article originally appeared on the Health Affairs Blog (12/20/19), 10.1377/hblog20191217.727229. Copyright © 2019 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

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Michael Botticelli, Donald M. Berwick, Maia Gottlieb, Mara Lederman

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