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Brigham and Women’s Hospital uses multidisciplinary approach to fight opioid epidemic

Scott G. Weiner

Recognizing a variation of practice patterns throughout its system, hospital leaders and clinicians at Brigham and Women’s Hospital created an organization-wide opioid stewardship program modeled after antibiotic stewardship programs implemented in other hospitals. Beginning in February 2016, the goal of the opioid stewardship program — called the Brigham Comprehensive Opioid Response and Education Program (B-CORE) — was to “leverage a multidisciplinary and multispecialty approach to looking at the opioid issue”, according to Scott G. Weiner, MD, MPH, director of the B-CORE Program at Brigham and Women’s Hospital.

“[B-CORE] covers three buckets,” Weiner said. “One, for patients who have chronic pain and how we can improve their care; the second is to improve care for patients with opioid use disorder; and then the third bucket ... is around acute pain.”

Opioid-prescribing guidelines

Weiner noted they reviewed prescribing guidelines from other hospitals in their area, as well as CDC guidelines, to help create their own guidelines with multidisciplinary input. According to the B-CORE website, some of the guidelines for prescribing opioids to patients with acute pain include:

- Consider non-opioid and non-pharmacological measures for acute pain management before prescribing opioids;

- Use a validated screening tool to determine appropriateness of opioid prescription based on diagnosis and risk for all patients;

- When necessary, prescribe opioids at the lowest effective dose and for a limited period, and opioids should not be long-acting or extended-release form;

- Patients should be counseled by providers that opioid pain medications will not resolve pain but manage pain and ideally improve function;

- Providers should also discuss side effects, addictive potential and risks for overdose with patients; and

- The primary surgeon, prescribing clinician or primary care provider should closely follow up patients prescribed opioids, and re-evaluate and re-screen patients who require opioids for longer than expected without medical cause.

Weiner also noted they are working on a protocol to taper patients already on high-dose opioids at the preoperative visit.

“If you can catch a patient earlier than that, even a couple of months earlier, and then slowly taper them down on their opioids, some other institutions have shown that it has decreased length of stay in the hospital, decreased complications and it is just better to do,” Weiner said.

Multimodal medication, patient education

In addition to the hospital-wide guidelines, Weiner noted they developed a reporting tool that allows them to track the number of opioids prescribed throughout the hospital system. He said use of this reporting tool has helped identify differences in prescription methods between colleagues on the same surgeries.

Wolfgang Fitz

In terms of opioid-sparring and multimodal options for pain management, Wolfgang Fitz, MD, associate orthopedic surgeon at Brigham and Women’s Hospital, noted the orthopedics department uses multiple medications peri-operatively, such as acetaminophen, anti-inflammatories among others in combination with pericapsular injections mixed individually for each patient by the pharmacy instead of a standard femoral nerve block.

Education of physicians and patients on the opioid epidemic and the risks surrounding opioids has also been implemented at Brigham and Women’s Hospital, Weiner noted. According to Fitz, who is also assistant professor of orthopedic surgery at Harvard Medical School, one way patient education has been implemented in the orthopedics department is through the better education through nursing before discharge. Currently, a new medication diary is implemented. Fitz added patients are provided with preoperative and postoperative education where they are directed on the multimodal pain medications they will be prescribed and about the pain they will experience after surgery.

Implementation of these educational protocols has helped change the framework of how patients understand opioids and how physicians prescribe them, according to Weiner.

“If you change the framework and say [opioids are] dangerous, this is the last medication that I want you to take on top of everything else, we are going to give you enough to make sure that you get through the acutely painful part of it and then on top of that we are going to give you instructions on how to taper off of it and then give you a bag to dispose of the medication safely, it is just a different message to a patient as opposed to here are 60 pills, do what you like,” Weiner said.

‘Review the data’

Since the implementation of these protocols and guidelines, Weiner noted they have seen a downward trend in the number of patients receiving more than 90 morphine milligram equivalents per day, as well as a drop in the prescription of long-acting opioids and in the number of patients being prescribed opioids beyond 3 months postoperatively. Fitz said they have seen a low consumption of opioids without an increase in patients going to a skilled nursing facility or rehabilitation hospital.

“We also have seen functional improvements in our patients with exercises that we predominantly do preoperatively, but not an increase in narcotic consumption,” Fitz said.

Currently, Fitz noted they are continuing research on how to optimize their multimodal protocol, while Weiner said they are working on improving patient education.

“For future steps, we will get to more of a protocolized pattern of prescribing after surgery which we have the beginning of now,” Weiner said. “If someone did not need opioids in the hospital, then they did not go home with a prescription. And if they do go home with a prescription, we use a small quantity.”

For hospitals and physicians looking to implement their own opioid-prescribing protocols and guidelines, Weiner said it is helpful to implement them in a pilot fashion to demonstrate efficacy and to share data across the hospital system.

“Do not be afraid to look at the data. You learn so much by seeing what prescriptions are after these surgeries, and comparing them in a non-punitive way with colleagues is also powerful because there will always be outliers and that is a good way to bring in the outliers,” Weiner said. – by Casey Tingle

 

References:

http://bcore.brighamandwomens.org/

Weiner SG, et al. Jt Comm J Qual Patient Saf. 2019;doi:10.1016/j.jcjq.2018.07.003.

 

Disclosures: Weiner and Fitz report no relevant financial disclosures.

Scott G. Weiner

Recognizing a variation of practice patterns throughout its system, hospital leaders and clinicians at Brigham and Women’s Hospital created an organization-wide opioid stewardship program modeled after antibiotic stewardship programs implemented in other hospitals. Beginning in February 2016, the goal of the opioid stewardship program — called the Brigham Comprehensive Opioid Response and Education Program (B-CORE) — was to “leverage a multidisciplinary and multispecialty approach to looking at the opioid issue”, according to Scott G. Weiner, MD, MPH, director of the B-CORE Program at Brigham and Women’s Hospital.

“[B-CORE] covers three buckets,” Weiner said. “One, for patients who have chronic pain and how we can improve their care; the second is to improve care for patients with opioid use disorder; and then the third bucket ... is around acute pain.”

Opioid-prescribing guidelines

Weiner noted they reviewed prescribing guidelines from other hospitals in their area, as well as CDC guidelines, to help create their own guidelines with multidisciplinary input. According to the B-CORE website, some of the guidelines for prescribing opioids to patients with acute pain include:

- Consider non-opioid and non-pharmacological measures for acute pain management before prescribing opioids;

- Use a validated screening tool to determine appropriateness of opioid prescription based on diagnosis and risk for all patients;

- When necessary, prescribe opioids at the lowest effective dose and for a limited period, and opioids should not be long-acting or extended-release form;

- Patients should be counseled by providers that opioid pain medications will not resolve pain but manage pain and ideally improve function;

- Providers should also discuss side effects, addictive potential and risks for overdose with patients; and

- The primary surgeon, prescribing clinician or primary care provider should closely follow up patients prescribed opioids, and re-evaluate and re-screen patients who require opioids for longer than expected without medical cause.

Weiner also noted they are working on a protocol to taper patients already on high-dose opioids at the preoperative visit.

“If you can catch a patient earlier than that, even a couple of months earlier, and then slowly taper them down on their opioids, some other institutions have shown that it has decreased length of stay in the hospital, decreased complications and it is just better to do,” Weiner said.

Multimodal medication, patient education

In addition to the hospital-wide guidelines, Weiner noted they developed a reporting tool that allows them to track the number of opioids prescribed throughout the hospital system. He said use of this reporting tool has helped identify differences in prescription methods between colleagues on the same surgeries.

PAGE BREAK
Wolfgang Fitz

In terms of opioid-sparring and multimodal options for pain management, Wolfgang Fitz, MD, associate orthopedic surgeon at Brigham and Women’s Hospital, noted the orthopedics department uses multiple medications peri-operatively, such as acetaminophen, anti-inflammatories among others in combination with pericapsular injections mixed individually for each patient by the pharmacy instead of a standard femoral nerve block.

Education of physicians and patients on the opioid epidemic and the risks surrounding opioids has also been implemented at Brigham and Women’s Hospital, Weiner noted. According to Fitz, who is also assistant professor of orthopedic surgery at Harvard Medical School, one way patient education has been implemented in the orthopedics department is through the better education through nursing before discharge. Currently, a new medication diary is implemented. Fitz added patients are provided with preoperative and postoperative education where they are directed on the multimodal pain medications they will be prescribed and about the pain they will experience after surgery.

Implementation of these educational protocols has helped change the framework of how patients understand opioids and how physicians prescribe them, according to Weiner.

“If you change the framework and say [opioids are] dangerous, this is the last medication that I want you to take on top of everything else, we are going to give you enough to make sure that you get through the acutely painful part of it and then on top of that we are going to give you instructions on how to taper off of it and then give you a bag to dispose of the medication safely, it is just a different message to a patient as opposed to here are 60 pills, do what you like,” Weiner said.

‘Review the data’

Since the implementation of these protocols and guidelines, Weiner noted they have seen a downward trend in the number of patients receiving more than 90 morphine milligram equivalents per day, as well as a drop in the prescription of long-acting opioids and in the number of patients being prescribed opioids beyond 3 months postoperatively. Fitz said they have seen a low consumption of opioids without an increase in patients going to a skilled nursing facility or rehabilitation hospital.

“We also have seen functional improvements in our patients with exercises that we predominantly do preoperatively, but not an increase in narcotic consumption,” Fitz said.

Currently, Fitz noted they are continuing research on how to optimize their multimodal protocol, while Weiner said they are working on improving patient education.

PAGE BREAK

“For future steps, we will get to more of a protocolized pattern of prescribing after surgery which we have the beginning of now,” Weiner said. “If someone did not need opioids in the hospital, then they did not go home with a prescription. And if they do go home with a prescription, we use a small quantity.”

For hospitals and physicians looking to implement their own opioid-prescribing protocols and guidelines, Weiner said it is helpful to implement them in a pilot fashion to demonstrate efficacy and to share data across the hospital system.

“Do not be afraid to look at the data. You learn so much by seeing what prescriptions are after these surgeries, and comparing them in a non-punitive way with colleagues is also powerful because there will always be outliers and that is a good way to bring in the outliers,” Weiner said. – by Casey Tingle

 

References:

http://bcore.brighamandwomens.org/

Weiner SG, et al. Jt Comm J Qual Patient Saf. 2019;doi:10.1016/j.jcjq.2018.07.003.

 

Disclosures: Weiner and Fitz report no relevant financial disclosures.

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