Md. hospitals take a hard look at their role in opioid epidemic — and solving it

It happened in front of an Anne Arundel County police station.

In front of the station, like at all Anne Arundel police stations, Dr. Barry Meisenberg saw a sign with statistics about heroin overdoses and deaths to date.

“I began to recognize what is our role here,” said Meisenberg, Anne Arundel Medical Center’s chair for quality improvement and lead on the health system’s opioid task force, recalling his “aha moment” when he realized what he needed to do.

“Our” was doctors, and Meisenberg took that moment as an impetus to look at the role physicians’ prescriptions of opioids played in Maryland’s statewide epidemic that has claimed thousands of lives.

Meisenberg has led Anne Arundel Medical Center’s efforts to reform prescription practices.

“I would say the very first part of this is to get physicians to understand that our prescriptions mutually played a huge role in creating and sustaining the opioid epidemic,” he said. “We have appealed on a scientific idea that what you do and what you prescribe really does matter.”

Over the past several years, Maryland’s hospitals have moved to change how they treat patients’ pain, reducing the amount of opioids prescribed, making a more concerted effort to educate patients about the harms and benefits of opioids and pursuing alternative pain treatments.

At Anne Arundel Medical Center, those efforts have led to a more than 50 percent reduction in opioid prescriptions.

Limiting prescriptions

Hospitals have sought to find ways to reduce the number of opioid prescriptions and the amount of opioids that are prescribed. Since 2015, most Maryland hospitals have followed guidelines that limit opioid prescriptions from the emergency department to last no more than three days.

Some hospitals have also moved to limit their use of more powerful opioids in the emergency room. For example, the University of Maryland Baltimore Washington Medical Center no longer prescribes hydromorphone, also known as Dilaudid.

Hospitals have also moved to limit prescriptions after surgeries.

Some have limited opioid prescriptions to around seven days following a surgery. At Anne Arundel Medical Center, doctors are trying to tailor their prescriptions to surgeries, using electronic medical records and patient feedback.

“To make sure we are right-sizing those prescriptions, we are following those patients,” Meisenberg said. “We’ve found that we can reduce the amount of opioids we are prescribing.”

So far, the medical center has implemented this in about one-third of its surgeries, he said.

Anne Arundel Medical Center’s focus fits in with other hospitals in Maryland that are tailoring pain management plans for patients, rather than using a one-size-fits-all approach.

“Mercy physicians endeavor to tailor pain treatment to the needs of each individual patient using a variety of interventions, and if medication is warranted, the physician and patient work together to determine what’s best to address the patient’s needs based on the individual situation,” said Daniel Collins, a spokesman for Mercy Medical Center.

But even as hospitals look for ways to manage opioid prescriptions, they don’t want to go so far as to stop managing patients’ pain, said Dr. Elias K. Shaya, MedStar’s north regional medical director and senior associate executive director for behavioral health services.

“Your ultimate goal is to relieve suffering and to help people feel better and to help them heal,” he said. “You don’t ever want to be in a position where someone is in pain and you (cannot help) because you are going too far in the other direction and you are afraid of giving proper medication.”

Educating doctors

To help find the right balance, physician education on opioids has become an important part of the process for hospitals. Many set up programs to help keep them updated.

Electronic medical records have become a valuable tool for hospitals in figuring out how and where to draw the line for pain treatments. The records can track a doctor’s prescriptions without accessing identifiable patient information, allowing doctors to track how their prescription levels match what other physicians are prescribing.

“I think physicians are very concerned about harming their patients,” Meisenberg said. “They were very interested in knowing where they compare to their peers.”

They can also use the records to see a connection between their patients and any long-term users.

“We need better understanding about the appropriate use of opioids and either avoid them or reduce them,” he said. “That would avoid people becoming long-term opioid users.”

The education has also involved medical students.

Prescribing opioids is something that professors focus on when teaching students at the Johns Hopkins University School of Medicine, said Dr. Peter Hill, senior vice president of medical affairs for the Johns Hopkins Health System and an associate professor of emergency medicine at the school of medicine.

“Our school of medicine faculty is teaching the next generation of providers a more nuanced approach to pain management that includes prescribing opioids as a last resort and alternative options,” he said in a statement.

Educating patients

Extending education to patients is also necessary. Making sure patients know what they are taking and the strength of those drugs has become another priority for hospitals.

Many hospitals have implemented patient education programs to help keep them informed about opioids and proper disposal of medication.

At the University of Maryland Baltimore Washington Medical Center, every patient receives a handout with his or her discharge paperwork. And during morning rounds, the pharmacist will educate every patient who has an opioid ordered about the risks and benefits of using opioids for pain.

Another concern for physicians is what happens to opioids when a patient returns home but may not need to use the entire prescription. They worry another family member may be vulnerable to opioid misuse.

“(That family member) all of a sudden is trapped into this readily available bottle and could end up in trouble with it,” said Shaya. “Educating the patient on the proper storage and disposal of these pills (is important).”

He suggests improving awareness of drug takeback programs and other disposal methods to help reduce the amount of unused opioids in patients’ medicine cabinets.

Offering alternatives

The general awareness of the opioid epidemic has helped hospitals’ patient education efforts. They know more about the risks and even ask about alternatives.

“It makes it easier to say we’re going to take a non-opioid approach to your ankle pain, Meisenberg said. “Patients actually appreciate your concern about your long-term risk.”

The University of Maryland Medical Center has increased its use of an integrative medicine service, which brings alternatives to medication to help patients with pain.

Some of those alternatives include mindfulness practices, acupuncture and music therapy.

Psychiatrists, physical therapists, occupational therapists, health psychologists and other health care professionals have worked at LifeBridge Health’s Center for Pain Treatment and Regenerative Medicine to create individualized diagnostic and treatment plans for patients, which can include alternatives to opioids.

For patients with chronic pain, opioids are often not an appropriate treatment, Shaya said. Preferences include Tylenol and ibuprofen.

Doctors should set expectations for patients, including treatment goals and plans on incorporating chronic pain into life without allowing it to take over, Shaya said.

“All of that is a corollary, is a necessary coupling to actual pharmacological pain management,” he said. “You have to set the right expectation. You have to give the patient coping skills.”

Correction: A previous version of this story misspelled Dr. Elias K. Shaya’s name.