No more leftovers: Tackling the opioid crisis one pill at a time

By Chelsea Rice and Laura Longsworth | September 21, 2016

The opioid crisis had long been simmering in York County, Pennsylvania, but by 2014, it had reached a boiling point. Overdose deaths more than doubled that year, to 110 — most of them men between the ages of 30 and 49, cut down by a combination of prescription pills, heroin, and cocaine.

Mark Bentzel, chief of the Northern York County Regional Police, said his officers had shifted from arresting users to “collecting bodies." And in the course of that grim work, police were also collecting pills.

Officers emptied 30 pounds of prescription drugs per month out of the department's drug take-back boxes: leftover medication, legitimately prescribed and appropriately discarded. But it begged the question: How much more was lingering in medical cabinets?

Leaders of OSS Health, a thriving local orthopedic practice, wanted to help their community turn the tide. But to be part of the solution, they had to recognize a difficult truth that applies to many medical organizations: Their own prescribing rates, based on professional guidelines and concern for patient pain, were probably feeding the problem on the streets.

"We understood that this was where we step into this story," says Suzette Song, M.D., an orthopedic surgeon and partner at OSS Health.

So practice leaders undertook a bold project: Enlisting the community to help educate and train clinicians, cutting their own prescriptions for top surgeries in half, and taking control of the crisis, before any laws or mandates took hold.

"If we can help other physicians and practices really take that lead," Song says, "we could decrease the volume of medications that are out there that could eventually cause trouble. Big trouble."

With four offices and 250,000 patient visits per year, OSS Health was likely one of the largest opioid prescribers in the York County region. That in itself is no surprise: Nationwide,orthopedists are the fourth-leading prescribers of opioids, after primary care providers, internists, and dentists.

In 2014, OSS Health's 20 providers, who perform 6,000 surgeries and 8,000 pain procedures per year, had prescribing rates consistent with most practices nationwide when it came to treating short-term, acute pain after injuries and surgery.

But after Meghan McNelly, OSS Health's director of pharmacy, attended a meeting of the York County Heroin Task Force, she and Song studied internal data and were stunned at what they found. In 2015, their patients went home with 18,000 prescriptions a year for opioid painkillers, adding up to approximately 800,000 pills.

"This number, when we looked at that, just seemed staggering to us. And we recognized then — wow, we can really do better," says Song.

Song and other practice leaders had watched other states tackle the issue through legislation and mandates. They realized that, if they didn't want clinical decisions dictated to them, they would need to take control of prescribing practices on their own.

"If it adds bureaucracy and inefficiencies to our practice, [a solution is] not going to be received nearly as well," Song says. "These concepts need to be received with complete open arms to really make a big impact."

Step by step, surgery by surgery

So in February 2016, Song and McNelly launched a comprehensive, multi-step plan approach to decrease the number of pills their practice prescribed. The highest volume surgeries would have the most impact, so they focused on the top 10: total knee and hip replacements, rotator cuff, carpal tunnel, ACL reconstructions, unicompartmental knee replacement, herniated or degenerative disc surgery (ACDF), lumbar laminectomy, lumbar fusion, and knee arthroscopy.

Song and McNelly worked with surgical teams to establish baseline information: the typical discharge prescription, including the quantity and type of medication. But they found nothing typical about their prescribers — who, like physicians across the healthcare landscape, had a wide range of opioid prescribing patterns and approaches.

Gracia Etienne, M.D., an orthopedic surgeon who performs the practice's highest number of total knee replacements, was the first "guinea pig" in the initiative. On day one, the practice instructed Etienne's surgical staff to ask patients how many pills remained in their bottles during follow-up appointments, or to call patients recently out of surgery to ask how many pills they had left over.

The team collected data on 20 patients in two weeks. All of them had a lot of pills left over, Song says. That quickly convinced Etienne to start prescribing fewer pills.

 

The president and CEO of OSS Health, Joseph Alhadeff, M.D., conducts the second-highest rate of total knee replacement surgeries. He was told of Etienne's new prescribing rates and asked to launch his own trial. Once Alhadeff was on board, says Song, all 20 surgeons who did total knee replacements followed suit.

First, surgeons dropped prescriptions from 120 pills — typical for a knee replacement — down to 90. After patient feedback revealed this was still too many, the team dropped the target number to 60.

With a rhythm soon established, practice leaders moved on to hip replacement surgeries, then hand procedures, and so on, picking a surgeon ready for the challenge for each of the top 10 surgeries. The team decreased the initial number of pills prescribed after surgery by 5 percent, assessed patient reactions and call volumes for refills, then lowered the baseline by 10 percent. The process continued until the surgeons felt their prescribing rates had reached a manageable standard.

"We're always going to have some people that need to call in for refills," says McNelly, “and that handle pain a little bit differently. But the majority of our patients were having both adequate pain control and not needing anything more at home."

Six months later, OSS Health has reduced its total volume of opioid prescriptions by 11 percent — or an average of 20 percent fewer pills prescribed, all while patient visits are up by 5 percent and surgeries by 6 percent.

For the top 10 surgeries, the change has been even more dramatic: a 50 percent reduction in pills prescribed after total hip replacements and, depending on the surgeon, up to a 50 percent reduction in pills after total knee replacements.

Practice leaders are pleased by what those percentages could mean in the long term. Even shaving 7 pills from every hydrocodone prescription could have a cumulative effect: Since providers write about 5,600 prescriptions for the drug annually, the practice is on track to reduce the total number of pills prescribed this year by 38,000.

Changing expectations

The most difficult part of the process, Song says, was convincing surgeons that the high-quality work they'd been doing for years — which earned high patient satisfaction rates — needed changing.

"I think the biggest challenge for a lot of physicians, especially the ones that have had great track records of success with their surgeries and their patients' satisfaction, has been for them to take that first leap of faith," she says.

A key way to reassure surgeons, it turned out, was to systematically educate patients and discuss their expectations for post-surgery pain. Etienne's physician assistant, Austin Merges, established talking points to help convince patients that reducing the quantity of pills they received was in their best interest.

"We have a very serious conversation about how there's no such thing as a pain-free surgery. And I can help make them comfortable, but I can't totally eliminate all pain. And they kind of expect that they're going to have some pain once the day of surgery comes around," says Merges.

 

The pharmacy made follow-up calls to patients' homes after surgeries, offering information that may have been forgotten in the haze of anesthesia.

"Sometimes their pain is actually better than what they were anticipating," Merges says. "So sometimes they're even happier in the hospital than I ever expected them to be."

Once OSS Health had established its new protocols, it rolled out a patient education plan for the entire operation, from pre-surgery clinics to post-operative care, to ensure that all patients were having the same conversation around opioids and managing pain.

Then they reached out to local politicians and legislators, as well as the Heroin Task Force and the state Department of Drug and Alcohol, in the hope that others could learn from their success.

"We weren't just making our patients better, we were making our York County community better as well," says McNelly.

So far, the effort has resonated.

"I think this is a very bold and brave move on their part," Bentzel says. "I don't know how long it will take for us to see results in a positive way. But hopefully, we'll be able to start seeing something within the next 12 to 18 months."

York County Coroner Pam Gay has even broader hopes.

“If other providers would adopt that model throughout the county, throughout the state, throughout the country," Gay says, “we would have a big handle on this opioid epidemic."

Chelsea Rice, staff writer for athenaInsight, reported and wrote this piece. Laura Longsworth, video producer for athenaInsight, produced and edited the videos.

If you’re doing innovative work to address the opioid crisis or have suggestions for further research, comment below, tweet us @athena_insight, or email us at athenainsight@athenahealth.com.

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    Good to limit to sensible quantities and kudos for that! However, the idea that this will solve the epidemic of widespread is naive. Is the practice screening for addictive disorders and using opiate risk tools? What’s needed is adequate screening for addiction, prevention and referral to and availability of treatment. Ortho surgeries are not the primary drivers of this epidemic so the article covers an important and laudable intervention but grossly overstates its impact.
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    No more leftovers: Tackling the opioid crisis one pill at a time