How Physicians Can Help End the Opioid Epidemic

By Toby Cosgrove, MD

Over 75 percent of opioid and heroin deaths begin with a prescription painkiller. It is clear that, as physicians, we must approach pain differently. We have a key role in turning the tide of the opioid epidemic, and we cannot wait for Washington.

Declaring the opioid crisis a National Public Health Emergency is a good first step. But as physicians, we have approaches at our disposal that can effect very real change.

Better policies have been shown to make a difference quickly. In just the past few months, we’ve:

• Hired a full-time Doctor of Pharmacy, who as a pain management specialist can improve prescribing practices and clinical care.
• Reduced the number of opioid prescriptions exceeding three days by 50 percent in our emergency departments, simply through education and communication.
• Designated every hospital unit with “pain champions,” who are conversant with alternative pain strategies.
• Reduced the number of patients receiving opioids by one-third in a group of colorectal surgery patients.

Given effective tools like these, physicians and other healthcare providers can make a lasting impact. This is one of four ways we can attack the epidemic. The others are insisting on team engagement among hospital departments; tracking prescribing data and demanding accountability; and sharing information with other hospitals in the region.

The EHR and other invaluable tools

Our EHR has been an indispensable tool. It has allowed us to connect directly to the Ohio Automated Rx Reporting System (OARRS); now, a physician can see a patient’s history of controlled substances within seconds while formulating a treatment plan. Also, our patient-provider agreements and consents are stored electronically so anyone who cares for that patient can see it, review it and update it as appropriate.

At the same time, we can use the EHR to gather data so that we truly understand current practice. What type of patients are being prescribed narcotics? Which departments prescribe opioids most often? We study these questions, find answers and then use that data to standardize care across the system.

Here are a few more approaches we’re using at Cleveland Clinic:

• Empowering physicians to “Just Say No”: Saying “no” to patients who are seeking narcotics for pain relief is difficult. That’s why we’ve instituted training courses for physicians on how to decline opioid requests from patients, with an emphasis on being compassionate. These are difficult conversations and the stakes are high. We must help our physicians navigate this by giving them the skills, strategy and practice to show empathy while managing emotion, setting boundaries and employing de-escalation tactics when needed.
• Getting Back on TREK: We are offering a different approach to first-line treatment for back pain. Back on TREK (Transform Restore Empower Knowledge) is a pilot program to help patients with chronic low back pain (with or without leg pain) restore function through nonsurgical treatment approaches and tools to manage their pain without narcotics. The program utilizes a combined treatment approach of psychologically informed physical therapy, pain neuroscience education and behavioral medicine sessions utilizing cognitive behavioral therapy, and psychological education techniques. More than 60 percent of patients showed significant improvement in pain and disability; over half demonstrated significant reduction in fatigue, pain interference and overall physical health.
• Painless mastectomy: An experimental drug, Exparel, is a local, time-released anesthetic used after a mastectomy to help patients with the worst of the pain and avoid opioids.
• Narcotic-free colorectal surgery: A program at Cleveland Clinic Akron General replaces narcotics with presurgical pain management, peripheral nerve blocks during procedure, and encouragement for the patient to get out of bed and move around within four to six hours of getting to the recovery floor. Of 80 patients in the program, one-third avoided narcotics. As a result, readmission rates and surgical costs dropped, hospital stays were shortened by 50 percent, risk of complications were reduced, and recovery improved with less pain.
• New “ERAS” of recovery: Several medical centers, including Cleveland Clinic, have been developing the concept of “fast-track” or “enhanced” recovery after surgery. Recently, comprehensive research has indicated that an ERAS (“Enhanced Recovery After Surgery”) methodology that permits patients to eat before surgery, limits opioids by prescribing alternate medications, and encourages regular walking reduces complication rates and accelerates recovery after surgery. ERAS can reduce blood clots, nausea, infection, muscle atrophy, hospital stay and more. Patients are also given a postoperative nutrition plan to accelerate recovery, and physicians are using multimodal analgesia, limiting the use of narcotics.

The good news is that the fight against the opioid epidemic is moving in the right direction. With the right tools in place, physicians can have an enormous impact on the outcomes of this epidemic.

Dr. Cosgrove is CEO and President of Cleveland Clinic.