opioid panel report - envision physician services · 4 | envision physician services 2018 overview...

APRIL 2018OPIOID PANEL REPORT

2 | ENVISION PHYSICIAN SERVICES 2018

TABLE OF CONTENTSAuthors ..................................................................................................................................................................................... 3

Overview ..................................................................................................................................................................................4

Envision Physician Services .............................................................................................................................................. 5

Management of Acute Pain ..............................................................................................................................................6

Specialty-Specific Strategies ........................................................................................................................................... 7

Emergency Medicine ..................................................................................................................................................... 7

Hospital Medicine ............................................................................................................................................................8

Perioperative Surgical ...................................................................................................................................................8

Algiatry (Pain Management) and Addictionology .............................................................................................9

Trauma and Acute Surgical ....................................................................................................................................... 10

Women’s and Children’s ...............................................................................................................................................11

Advocacy ................................................................................................................................................................................12

Future .......................................................................................................................................................................................13

References ........................................................................................................................................................................ 14-15

OPIOID PANEL REPORT | 3

AUTHORSWritten by Rebecca Parker, M.D., FACEP (Emergency Medicine)

Contributors:Joshua Bloomstone, M.D., M.S., FASA (Perioperative Medicine)

Srinivas Bollimpalli, M.D. (Algiatry (Pain Management))Matthew Carrick, M.D., FACS (Trauma and Acute Surgery)

Megan Prado, M.D. (Women’s and Children’s)Gina Puglisi, M.D. (Hospital Medicine)


OVERVIEWOn October 26, 2017, the White House declared the opioid epidemic in the United States a public health emergency.¹ Drug overdoses are now the leading cause of unintentional death in the U.S. with over two-thirds of the deaths due to opioids. According to the Centers for Disease Control and Prevention (CDC), 140 Americans die daily from an opioid overdose. Deaths are up among both men and women, across all races and nearly all age groups.² Additionally, according to the American Society of Addiction Medicine, more than 20 million Americans ages 12 and above suffered from a substance use disorder in 2015. Of these, 2 million involved prescription opioids and 591,000 involved heroin.³

Opioid overdose deaths, including prescription opioids and heroin, had quadrupled since 1999 to more than 28,000 deaths in 2014, with more than half from prescription opioids. However, starting in 2013, the U.S. experienced a sharp increase in opioid overdose deaths and saw more than 45,000 deaths in 2016. Illicit fentanyl and fentanyl analogues to the heroin supply, added with and without the user’s knowledge, appear to be the cause. In fact, a recently published CDC review of 2016 data in 10 states shows fentanyl and fentanyl analogues caused 56.3 percent of all opioid deaths, with the vast majority being fentanyl at 97.1 percent. The increased potency of these synthetic opioids is striking. Fentanyl is five to 10 times more potent than morphine. The fentanyl analogue carfentanil is 10,000 times more potent than morphine.4,5 Unfortunately, the reduction of prescription opioids may also drive first-time illicit opioid use, addiction, overdose and death. In addition to opioid-related deaths, increases in neonatal abstinence syndrome, HIV and hepatitis C have also been reported.⁶ It is also crucial that other aspects of the addiction crisis, such as the concomitantly significant escalation of cocaine-related deaths, are not overlooked.7

Drug overdoses are now the leading cause of unintentional death in the U.S. with over two-thirds of the deaths due to opioids.


ENVISION PHYSICIAN SERVICES During the last 20 years, clinicians employed and engaged with Envision Physician Services’ affiliated medical practices have treated millions of patients with acute and chronic pain. In fact, in emergency medicine, pain is the most common presenting sign/symptom of patients accessing emergency care. Additionally, as hospital-based clinicians, beyond direct bedside care, physicians affiliated with Envision Physician Services provide departmental and hospital leadership in the creation and implementation of evidence-based hospital policies, clinical practice and quality and patient safety initiatives with care coordination inside and outside of the hospital.

Envision Physician Services and its affiliated medical practices (the medical practices are collectively referred to as Envision Physician Services throughout this report) has a large national footprint, and its more than 25,000 affiliated physicians and advanced practitioners respond daily to this public health emergency through the organization’s multispecialty infrastructure. Of our 22 specialties, key front-line responders include emergency medicine, hospital medicine, perioperative medicine, algiatry (pain management) and addictionology, and acute surgical specialists. Specialists within our women’s and children’s service line also play a special role in the crisis by treating opioid addiction during pregnancy and the resultant effects, such as neonatal abstinence syndrome (NAS).

Our opioid crisis strategies include approaches to the management of acute and chronic pain and specialty-specific departmental strategies supported through resources from specialty societies such as the American College of Emergency Physicians, Society for Hospitalist Medicine, American Society of Anesthesiology, American Society of Addiction Medicine, American Pain Society, American College of Surgeons, American Academy of Pediatrics, Substance Abuse and Mental Health Services Administration and the CDC. It is important to note that the patient populations discussed here do not include patients in palliative and end-of-life care programs.

MANAGEMENT OF ACUTE PAINEnvision Physician Services’ front-line specialists are experts in acute and chronic pain management. Throughout the opioid crisis, our physicians have adopted evolving evidence-based literature demonstrating the value and efficacy of multimodal, opioid-sparing prescription pain management. Continuing education includes knowledge for caregivers on the effectiveness and usage of various medications in pain relief. During the last two years, these specialties have refocused on alternatives to medications along with emerging non-opioid medications. As an example, for emergency medicine specialists, simple approaches to treating musculoskeletal injuries such as stabilization of injuries, local compression and ice pack application as primary interventions are effective.

These specialists are adopting guidelines like St. Joseph’s Regional Medical Center’s Alternative to Opiates (ALTO®) program. These guidelines promote local trigger point injections for muscle spasms and regional blocks, such as femoral blocks for femoral fractures, and are proven methods of non-opioid pain relief. ALTO®’s non-opioid medication guidelines include intravenous lidocaine for kidney stones, subdissociative doses of ketamine, haloperidol, nitrous oxide gas, transdermal lidocaine, oral and transdermal non-steroidal medications and acetaminophen, and provide effective analgesia.8 Researchers are studying these new methods currently for efficacy and evidence-based affirmation. For our specialists engaged in the surgical realm, both multimodal opioid-sparing analgesics and regional blocks are actively being used with success in reducing postoperative opioid administration. If the patient requires opioid analgesia at discharge, physicians in all of our specialties strive to prescribe a short course of opioids, as recommended by the CDC and specialty societies.



SPECIALTY-SPECIFIC STRATEGIESEmergency MedicineFor many years, our emergency medicine physician leaders have created and implemented pain management policies and guidelines. By our physician leaders standardizing the commitment of the department approach to acute and chronic pain management, day-to-day expectations are set for care providers, and clinicians are empowered to address the growing opioid crisis in their clinical practice. Our departmental policies typically include a standard approach to pain assessment, treatment guidelines, care coordination expectations – including pain contracts, chronic pain patient medication limitations – and follow-up processes. Additionally, these policies usually include patient and family education, before, during and after Emergency Department (E.D.) treatment, and include educational handouts. These departmental pain policies have expanded in the last few years to include the use of state-sponsored prescription drug monitoring programs, alternatives to opioid treatment guidelines, as above, more specifics regarding “no refill” policies and limitations on outpatient opioid prescriptions.

At our individual practice level, many medical directors approached physician education and behavior by simply providing information to individual providers on their number of written opioid prescriptions compared to their peers. Coupled with education and departmental implementation of alternative treatment programs, Envision Physician Services physicians and their partner hospitals have seen success in decreasing the number of opioid prescriptions. Other approaches include removing commonly abused opioids from ready availability in the department (e.g., “Demerol-free” and “Dilaudid-free” E.D.s – although still available for case exception) and instituting E.D. team-based rounding, treatment planning and bedside patient education with nursing and other clinical support staff. A final effective method for patients includes a systematic, real-time identification of patients at risk of addiction, with thoughtful choosing of appropriate pain control methods while assuring referrals programs to agencies for follow-up and treatment.

In the U.S., E.D.s provide the safety net for the healthcare system, and our practices are no exception. As such, our emergency medicine specialists, with their partner hospitals, frequently participate in social strategies for all patients, including pain patients. Key social strategies include assuring and supporting the maintenance of appropriate evaluation and treatment facilities for those patients at risk for addiction and providing safe and timely follow-up for acute pain conditions with medical staffs and hospitals. Additionally, identifying and addressing unforeseen issues, such as effective disposal methods for unused opioid medications, advocating for more outpatient treatment options, including medication-assisted treatment programs and advocating for opioid reversal agents for first responders, are examples of social strategies our emergency medicine physicians advocate for on behalf of their patients.


Hospital MedicineThe role of our hospital medicine specialists has many similarities to that of our emergency medicine specialists. A high-quality handoff between emergency medicine and hospital medicine physicians sets the groundwork for the patient’s inpatient care. Our hospitalists identify patients at risk of oversedation and take precautionary measures to avoid complications. Additionally, for those patients on opioid medications, hospitalists assist in rapid weaning to oral formulations and, ideally, to non-opioid treatment plans. Envision Physician Services hospitalists help identify those patients at risk for addiction and facilitate rapid follow-up with appropriate treatment centers. Finally, our hospitalists play a crucial role in patient education on acute versus chronic pain and the appropriate treatment modalities, which includes the risk of opioid addiction.

The Society of Hospital Medicine has aggressively embarked on hospital medicine-specific programs for Reducing Adverse Drug Events related to Opioids (RADEO) to improve patient safety and has been recognized by the Centers for Medicare and Medicaid Services (CMS) for maintaining ongoing collaborative partnerships with CMS. In addition, hospitalists have developed Patient and Family Advisory Councils (PFAC) through which patients and families can partner with the members of the hospital healthcare team to address issues like opioid use and abuse inside and outside of the hospital environment.

Perioperative SurgicalThe use of multimodal, opioid-sparing analgesia, regional anesthesia and local field blocks prior to and following painful procedures, either in the Operating Room or within the radiology suite are now being implemented across our specialties. Efforts follow with Enhanced Recovery After Surgery guidelines closely and have reduced overall opioid administration.9 Additionally, Envision perioperatists have developed best practice approaches to care for surgical patients who are opioid-tolerant as well as those receiving chronic medical treatment with methadone and buprenorphine-naloxone. The American Society of Anesthesiologists has launched a national pilot called the Safer Postoperative Pain Management program focusing on adult patients undergoing elective hip and knee arthroplasty and colectomy surgical procedures. Our specialists are adopting these strategies, which include discussions about pain management expectations with patients and families and education on safe opioid use, storage and disposal as well as opioid misuse and abuse prevention following hospital discharge.10 Finally, with the recognition that certain opioid analgesics, such as remifentanil, may increase pain after exposure (opioid-induced hyperalgesia), our perioperatists are implementing best practices that limit its administration.11


Algiatry (Pain Management) and AddictionologyIt is estimated that more than 100 million Americans suffer from chronic pain with estimated costs exceeding $600 billion. These patients may often be referred to an algiatrist for diagnosis and treatment options. Often, they may already be on high-dose, long-term opioids from their referring physicians before being seen by an algiatrist.

As fellowship-trained and board-certified physicians with expertise in pain management, our algiatrists will often utilize interventional procedures and non-opioid medications with the goal of maximizing pain relief and minimizing or avoiding opioid utilization. Opioid medications, however, will be a necessary and effective part of the treatment plan for some patients.

Many patients have been started and maintained on opioid medications by physicians across multiple specialties with the well-intentioned goal of alleviating patient suffering. A number of these patients may develop opioid use disorder (OUD). The management of these patients is very challenging. Management strategies for OUD patients include the utilization of a team approach with addictionology and behavioral health and the incorporation of weaning or medication-assisted treatments. As referenced by the Substance Abuse and Mental Health Services Administration, a “whole person” approach is needed for the OUD patient.

Envision Physician Services algiatrists have been actively involved at the state and national levels seeking to help legislative colleagues draft rules that promote safer opioid prescribing practices while minimizing the undertreatment of patients who legitimately benefit from opioid medications – which may paradoxically drive patients to engage in dangerous, illicit drug use behavior to better control their pain. We, and others, need to continue working with legislators to create a safe and financially viable environment that encourages a broader availability of clinical resources to treat the OUD patient.

100 MILLION

Americans suffer from chronic pain with estimated costs

exceeding $600 billion.


Trauma and Acute SurgicalOur acute surgical specialists also work with patients in acute pain settings and employ opioid-sparing analgesic techniques. In some settings, local or regional blocks are requested by our acute surgeons. In almost all cases, multimodal pain management is employed. When opioids are required, surgeons work to wean the patient as quickly as possible to non-opioid treatments. Typical acute abdominal general surgeries have self-limited pain courses that last no more than two weeks. As a result, opioid prescriptions, if necessary, are limited to this timeframe and generally bridge the patient to the first follow-up appointment. Refills of opioid pain medications are generally discouraged. The complicated trauma patient, who endures numerous surgeries, interventions, orthopedic reconstruction with prolonged, complicated hospital courses, often receives high doses of opioid medications. In spite of aggressive early weaning, these patients represent a high-risk population once they depart the acute care setting. Our trauma and acute care surgeons can often be caught in the unenviable position of doing the right thing to prevent addiction and risking a dissatisfied patient and family members who are frustrated by the pain caused by the injuries. These complicated trauma cases require a multispecialty approach, which includes follow-up with skilled primary care and chronic pain specialists to support the patient during post-acute care rehabilitation.

Women’s and Children’s Unfortunately, the opioid epidemic is also affecting increasing numbers of adolescents, pregnant women and, the most vulnerable in our society, newborns and infants. Prescription opioid use, as well as illicit drug use and abuse, during pregnancy, has risen dramatically in recent years, mirroring the epidemic seen in the general population. In 2007, 22.8 percent of women who were enrolled in Medicaid programs in 46 states filled an opioid prescription during pregnancy.12 In a study looking at hospital discharge diagnostic codes, antepartum maternal opioid use increased nearly fivefold from 2000 to 2009.13 The rising prevalence of opioid use during pregnancy has led to a sharp increase in neonatal abstinence syndrome from 1.5 cases per 1,000 hospital births in 1999 to 6.0 per 1,000 hospital births in 2013, with an associated $1.5 billion in related annual hospital charges. States with the highest opioid prescribing rates also have the highest rates of neonatal abstinence syndrome.14

Whether in the office-based women’s setting, the labor and delivery floor, the newborn nursery or the neonatal intensive care unit, our physicians and clinicians are dedicated to developing and implementing best practices for pregnant women, fetuses and newborns under our medical supervision. For instance, our office-based and hospital-based obstetricians (in conjunction with the facilities) perform routine screening studies to identify at-risk pregnant patients so they can be counseled, managed and referred, when appropriate, for specialized treatment.

Neonatal abstinence syndrome is a drug withdrawal syndrome that may result from chronic maternal opioid use during pregnancy and is an expected and treatable condition seen in 30–80 percent of infants born to women taking opioid agonist therapies. Education by our clinicians begins during pregnancy so parents can be better informed and prepared to care for an infant affected by NAS. These specialists encourage parental support and presence (if the social situation allows) during an infant’s hospital stay, as rooming-in and breastfeeding have been shown to decrease the length of stay. All of our pediatric and neonatal providers have developed best practice bundles for use in their hospitals so infants can be readily identified and either preventive strategies or treatment with opioids can be safely administered when indicated. One of our latest neonatal quality initiatives has been developed to specifically address shortening the time of medication use by 10 percent from the baseline average of 14 days for infants hospitalized with NAS.



ADVOCACYIn the spring of 2017, the White House formed the President’s Commission on Combating Drug Addiction and the Opioid Crisis. This year, more than a billion dollars in federal funding was authorized to address the epidemic and allocated to prevention and treatment efforts, first responders, prescription drug monitoring programs (PDMP), recovery programs and other care. Declaration of the opioid crisis as a public health emergency allows assignment of new resources and federal support such as access to telemedicine pilots and resources from the Department of Health and Human Services and the Department of Labor. Additionally, the U.S. surgeon general (current and previous) prioritized the crisis. The CDC also serves a crucial role in monitoring and educating the public and healthcare providers, and has done so since the start of the crisis years ago.

At the state level, legislators continue to pass and consider passing legislation related to the opioid crisis. Approaches are variable but include mandatory PDMP participation and look-up, often with an exemption for short course opioid treatment under anywhere from three to seven days. Other approaches include mandatory continuing medical education requirements regarding opioids, the addition of a mandatory referral from primary care physicians to algiatrists for the consultation of patients on higher dose opioid medications, expansion of treatment programs, informed consent requirements, increased regulation and requirements for pain clinics, and ready availability of opioid-reversing agents with or without liability protections.

The key for our physicians is that any laws, regulations and resources should augment and support physicians’ ability to care for patients. This will require close monitoring and support of clinicians’ advocacy efforts, where appropriate, to guide legislators to practical and effective advocacy efforts in partnership with specialty and state medical societies.


FUTUREAs a multispecialty, primarily hospital-based, physician group with a large footprint across the U.S., Envision Physician Services has a unique opportunity to describe and distribute its numerous best practices and innovations and to innovate even further. Initial collaborative gatherings, such as the recent gathering of our multispecialty practices in Arizona, hold promising exchanges of information between experts and can directly impact patient care. Efforts to exchange multispecialty expertise through papers such as this are important to building the Envision Physician Services network of the future. These efforts directly impact the daily delivery of care to our patients and, potentially, to the nation at large.


REFERENCES¹ President Donald J. Trump is Taking Action on Drug Addiction and the Opioid Crisis.

The White House. https://www.whitehouse.gov/briefings-statements/president-donald-j-trump-taking-action-drug-addiction-opioid-crisis/. Accessed 2018 March 12.

² Kuehn B. Opioid Emergency Declared. Jama. 2017;318(24):2418. doi:10.1001/jama.2017.19014.

³ Opioid Overdose. Centers for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/index.html. Accessed 2018 March 12.

⁴ American Society of Addiction Medicine.Opioid Addiction Facts & Figures 2016. https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf. Accessed 2018 March 12.

⁵ O’Donnell JK, Halpin J, Mattson CL, Goldberger BA, Gladden RM. Deaths Involving Fentanyl, Fentanyl Analogs, and U-47700 — 10 States, July–December 2016. MMWR Morbidity and Mortality Weekly Report. 2017;66(43):1197-1202. DOI: http://dx.doi.org/10.15585/mmwr.mm6643e1.

⁶ Ohio Department of Health. 2016 Ohio Drug Overdose Data: General Findings. https://www.odh.ohio.gov/-/media/ODH/ASSETS/Files/health/injury-prevention/2016-Ohio-Drug-Overdose-Report-FINAL.pdf. Accessed 2018 March 12.

⁷ Frakt A. Overshadowed by the Opioid Crisis: A Comeback by Cocaine. The New York Times. https://www.nytimes.com/2018/03/05/upshot/overshadowed-by-the-opioid-crisis-a-comeback-by-cocaine.html?_sm_au_=it6qQ4tM552ZPfMM. Accessed 2018 March 12.

⁸ LaPietra AM, Rosenberg MS. Alternatives to Opioids ALTO®. Copyright St. Joseph’s Healthcare Center. 2015. Available at: https://smhs.gwu.edu/urgentmatters/sites/urgentmatters/files/ALTO%20program%20ED%20protocols%2C%20Innovation%20Award_0.docx. Accessed 2018 March 12. ALTO® is a registered trademark of St. Joseph’s Regional Medical Center.

⁹ Kirkner RM. ERAS pathway can cut postdischarge opioid use. ACS Surgery News. American College of Surgeons https://www.mdedge.com/acssurgerynews/article/158109/pain/eras-pathway-can-cut-postdischarge-opioid-use. Accessed 2018 March 6.

10 American Society of Anesthesiologists (ASA). American Society of Anesthesiologists. https://www.asahq.org/about-asa/newsroom/news-releases/2017/07/premier-inc. Accessed 2018 March 12.

11 Fletcher, Martinez. Opioid-induced hyperalgesia in patients after surgery: a systematic review and a meta-analysis | BJA: British Journal of Anaesthesia | Oxford Academic. OUP Academic. https://academic.oup.com/bja/article/112/6/991/243753. Accessed 2018 March 6.


12 Desai RJ, Hernandez-Diaz S, Bateman BT, Huybrechts KF. Increase in prescription opioid use during pregnancy among Medicaid-enrolled women. Obstet Gynecol 2014;123:997–1002.

13 Patrick SW, Schumacher RE, Benneyworth BD, Krans EE, McAllister JM, Davis MM. Neonatal abstinence syndrome and associated health care expenditures: United States, 2000–2009. JAMA 2012;307:1934–40.

14 Patrick SW, Davis MM, Lehmann CU, Cooper WO. Increasing incidence and geographic distribution of neonatal abstinence syndrome: United States 2009 to 2012 [published erratum appears in J Perinatol 2015;35:667]. J Perinatol 2015;35:650–5.

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opioid panel report - envision physician services · 4 | envision physician services 2018 overview...

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