Christiana Care Health System is reducing its use of opioids systemwide, including in post-surgical prescribing, its emergency departments and in primary care.

New evidence of its progress included a 40 percent reduction in the number of opioids prescribed after some ob-gyn and general surgery procedures, a reduction by almost 50 percent in the rate of opioid prescriptions among discharged emergency department patients and a 37 percent reduction in primary care patients on chronic opioid therapy for pain in a pilot project.

In 2012, Delaware was the nation’s No. 1 prescriber of high-dose opioid pain relievers and 17th in opioid prescriptions overall. By 2016, Delaware saw on average a death a day from an opioid overdose.

“We’ve embarked on a multifaceted strategy to educate providers about responsible prescribing practices, promote non-opioid alternatives to control pain and spread evidence-based guidelines around opioid prescription,” said Linda Lang, chair of Christiana Care’s Safe Opioid Stewardship Steering Committee and chair of the Department of Psychiatry.

The overall goals of Christiana Care’s efforts are to reduce chronic opioid use, combat addiction and reduce overdose deaths. Because primary care offices are one of the larger sources of opioid prescriptions, it is there that much of the progress can be made.

Christiana Care is putting non-opioid alternatives front and center in patients’ electronic medical record, educating providers about alternatives to pain and identifying patients on long-term opioid use at the highest risk, said Roger Kerzner, clinical director for specialty services at the Medical Group of Christiana Care.

There is evidence that a team approach focusing on high-risk populations can pay off. A pilot project at the Rocco A. Abessinio Family Wilmington Health Center at Wilmington Hospital resulted in a 37 percent reduction in the number of patients on chronic opioid therapy.

Data analysis is one tool the pilot used to identify patients who are at higher risk of addiction and even accidental death from chronic opioid use due to their other medications, health conditions and other factors, said Ed Ewen, director of clinical data and analytics and a primary care physician at Christiana Care.

These patients’ cases were reviewed by a multidisciplinary team that came up with patient-specific recommendations to help them transition out of opioid use.

Another key focus, Kerzner said, is to try alternative approaches for patients who started using opioids in the past few months and whose use may become chronic. Many patients are first exposed to opioids after a surgical procedure and eventually become dependent on them.

Building off the work by a grant-funded effort in Michigan called the Opioid Prescribing Engagement Network, or OPEN, Christiana Care developed a set of guidelines that recommend specific medications and quantities after 21 surgical procedures.

Led by anesthesiologist Matt Powell, Delaware OPEN intends to reduce the wide variation in the number and type of opioids prescribed after surgeries. Patients who are prescribed more opioids than they need may hold onto them and use them later for ailments like pain, depression or trouble sleeping, Powell said.

Often, prescribing fewer opioids means accepting some level of pain after a procedure. Powell said doctors are now talking about pain in terms of function.

Though the guidelines are optional for prescribers, the early data showing a 40 percent reduction in opioids — which relates to many of the surgical procedures performed from July 2017 to July 2018 — shows many are taking the new advice.

Christiana Care recently hosted a team from Michigan who shared their results to a statewide audience that includes other Delaware health systems.

Christiana Care’s three emergency departments are tackling the addiction crisis from both ends by helping those with a substance use disorder access treatment and by prescribing opioids more intentionally.

Its success in cutting by nearly half the rate of opioid prescriptions among discharged patients, to 8 percent in May owes to a combination of efforts, including the implementation of new opioid prescription guidelines developed by the Delaware chapter of the American College of Emergency Physicians, or ACEP.

“Our repeated education of Delaware ACEP guidelines, along with initiatives like Middletown’s Opioid Alternative Environment and the Suboxone pilot, has helped us treat pain in an appropriate manner without prescribing needlessly,” said John T. Powell, chairman of the Department of Emergency Medicine at Christiana Care.

By tapping Project Engage’s peer counselors to meet with patients, the emergency departments are identifying those with withdrawal. When appropriate, the emergency department is piloting a program to start these patients on Suboxone, a medication that provides immediate relief from the symptoms of withdrawal, and also connecting them with an all-hours treatment center that offers medication-assisted therapy and counseling.

Meanwhile, the Middletown Emergency Department is developing alternatives to opioids in an effort called the Opioid Alternative Environment. That doesn’t mean opioids have no place there, but that other methods — including trigger point injections of anesthetic and, in some cases, IV acetaminophen — will be tried first.

Terry Horton, chief of Christiana Care's Division of Addiction Medicine, likens the battle against opioid over prescription and addiction to a raging forest fire.

“Our efforts to prescribe opioids responsibly,” said Horton, “are reducing the fuel for that fire.”

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