Got pain? Toothache, lower back discomfort?
There was a time not too long ago when narcotics were prescribed for just about everything — from a twinge in the back to post-surgical pain.
A surfeit of opioid prescriptions led to widespread misuse, from patient addiction to black market resale to those addicted to opioids.
According to the Centers for Disease Control and Prevention, sales of prescription opioids in the U.S. nearly quadrupled from 1999 to 2014. As a result, misuse of the medications, addiction and overdoses soared.
Initiatives on the part of the medical community, nationally and locally, however, are greatly reducing the number of prescriptions being written for opioids, and positive results are being seen.
In 2018, the American College of Emergency Physicians created the Opioid Initiative to help emergency departments throughout the country work on opioid focused interventions.
Froedtert South was one of 180 hospitals recruited to take part in the American College of Emergency Physicians’ Wave I Initiative administered through its Emergency Quality Network, known as E-QUAL.
“The E-QUAL initiative is focused on reducing the amount of narcotics prescribed to patients in the ED (emergency department) setting,” said Terri Harold, director of emergency services at Froedtert South. “These initiatives utilize best practices and evidence-based interventions set forth by the American College of Emergency Physicians.”
Aurora Health Care has also made sweeping changes in its ER opioid prescription protocols, according to Dr. Michael McNett, co-chairman of the Wisconsin Medical Society Opioid Task Force and system lead for Aurora’s department of non-interventional pain management.
“In 2014 Aurora adopted the ‘Oxy-Free ED (emergency department)’ because we were seeing a large number of patients claiming they were out of oxycodone/Percocet and needed more to avoid withdrawals,” McNett said. “They would say they couldn’t get in to (see) their doctors and were asking the ER to give them prescriptions.”
For Froedtert South, participation in Wave I was an outgrowth of initiatives its Kenosha medical centers had been working on since 2016, Harold said. To combat the prescription opioid problem, emergency departments began tracking opioid prescriptions, offering non-narcotic pain control alternatives and educating patients about their pain medications.
Froedtert South began participating in the E-QUAL Wave I Initiative after Harold was approached to see if there was interest in the program. “As a member of the Kenosha County Opioid Task Force, I was all for it,” Harold said.
Nalani Tarrant, spokesman for the American College of Emergency Physicians, explained that E-QUAL was created to engage emergency clinicians to improve clinical outcomes, coordinate care and reduce costs. “EDs participate in an E-QUAL initiative by joining a learning collaborative offered annually, focusing on a single clinical topic,” he said.
The Wave I initiative gave participating hospitals a choice between investigating back pain, dental pain or chronic pain.
“We picked dental pain because especially at this campus there are many patients who don’t have access to dental care who come to us when they have dental pain,” Harold said.
Emergency physicians at Kenosha Medical Center and St. Catherine’s began tracking patient prescriptions and offering non-narcotic pain relievers like nerve blocks with antibiotics for an abscessed tooth. “We would then refer the patient to Kenosha Community Health Care for follow-up dental care,” Harold said.
Aurora’s prescribing changes also began in the emergency department. “We looked at three conditions — headaches, low back pain and kidney stones — and began developing protocols,” McNett said. “The concept of the new initiative was that patients had to get (narcotic medications) from their regular doctor and not the ED.”
More changes have developed since Aurora Health Care merged with Advocate Health of Illinois last April.
“We are in the process of developing new guidelines for prescribing,” McNett said. “If a patient is on opioids for longer than two weeks, we’re asking the prescribing doctor to do a formal risk assessment (for opioid misuse).”
Physician alerts are also being incorporated into AdvocateAurora Health’s Epic computer system, he said. “If a doctor writes a prescription higher than those of recommended opioid guidelines, we have an alert that lets him or her know and to reduce the dose.”
Patient education is also critical, say physicians.
“The objective is to educate our patients regarding the safe use of opiates as well as alternatives to opiate treatment,” notes Dr. James Kambol, emergency department medical director at Froedtert South, St. Catherine’s Medical Center and department of emergency medicine chairman.
“(The Wave I Initiative) took a look at how many (narcotic) prescriptions were currently prescribed and established benchmarks and set up education for nursing staff, physicians and other staff and educated everybody that opioid use for dental pain is not best,” Kambol said.
The program then tracked usage and practices and blended this information with the Froedtert & Medical College of Wisconsin system.
McNett notes that the new protocols at Aurora “emphasize the use of non-narcotic pain treatments but do not prohibit narcotics if needed. We also looked to try limiting the prescribed number of pills given for patients with a wide variety of conditions.”
Before these changes, ER and regular physicians were challenged by addicted patients who pushed hard to convince physicians to prescribe them narcotics, Harold said.
“We want to effectively treat patients and at the same time keep them safe with the treatments we provide,” McNett said. “It might mean a little more pain but lower risk of addiction.”
Some patients might come in with pain conditions that are hard to prove, like dental or back pain, Harold said. “Or they might pretend to have kidney stones by pricking their fingers and adding a drop of blood to their urine.”
Others have tried to bypass the system by pretending to be allergic to every non-narcotic prescription suggested by the doctor, Harold said. “They would say something like, ‘I’m allergic to every pain med except the one that starts with a D.’”
For its work with Wave I initiative, E-QUAL representatives noted in a letter of recognition: “Froedtert South Kenosha Medical Center has been identified as a top performer or major improver in opioid prescribing or overdose care during the 2018 Opioid Learning Collaborative.”
“ER docs now ask patients if they want alternatives like traction rather than narcotics,” Harold said. “The first six months it was rough, but after that word got out that (our emergency departments) aren’t going to give out narcotics so don’t go there.”
In addition to following new prescription guidelines, ER staff are also on the lookout for incoming patients who may present with narcotic addictions, Harold said. She cited a case of a patient with chronic back pain who began talking with an ER nurse, who helped the woman develop a new pain management plan. “Eventually she was able to quit (narcotic) medications,” Harold said.
“From a health care perspective, we are doing a much better job, especially compared to five years ago,” Harold said, “It a night-and-day difference. Five years ago people would say, ‘Oh, you’re in pain; go to the emergency department.’”
“(Aurora) has reduced the number of (opioid) pills prescribed by 50 percent,” McNett said. “This means that there are fewer actual pills piling up in medicine cabinets that can be pilfered and sold.”
“We’re trying to change the notion that if you have pain you always get narcotics,” Kambol said. “We’re not trying to be mean; we’re just trying to be safe.”
“Once we stopped (giving out narcotics), patients starting coming in when they truly needed them,” added Harold.
Harold reports that over the past three years the number of patients coming to Froedtert South’s emergency departments seeking narcotics for pain management has drastically decreased and alternative therapies have been successful.
“The community is aware of our concern about the dangers of opioid addiction, and the expectation for dental pain patients no longer includes a prescription for a narcotic pain medication,” Harold said. “I’m just really proud of being part of what the community is doing (to reduce opioid use).”
And for patients who do need relief from pain, Harold said, “We’ll take care of them; they won’t necessarily get a narcotic, but there are other medicines out there.”