In 2015, 90 people died each day from an opioid overdose. If you subtract deaths attributed to heroin and synthetic opioids, which is still 42 deaths daily from drugs that were prescribed by a licensed health care professional. How did we get here?
It’s complex, with many factors contributing to the changes in prescribing. But what we can all agree on is that many opioids being prescribed are not necessary. Sometimes they are abused and misused by the patients for whom they are prescribed, but often they end up in the hands of others. Data from 2012 showed that nearly 50 percent of those using opioids for non-medical purposes for more than 200 days received those medications from a friend or relative.
Health care providers need to work on reducing this oversupply of prescription opioids available in the community by improving our prescribing habits. The good news is we are already seeing a downward trend in opioid prescribing rates. The bad news is we are still prescribing far more than we have in the past. This is where the development of opioid stewardship programs comes into play.
As a pharmacist who regularly discusses this topic with members, I am often asked where to start. I have broken those recommendations down to the following key strategies that can be used to build an opioid stewardship program.
Prepare a patient provider agreement. In my opinion the patient provider agreement (PPA) is one of the most essential components of a good opioid stewardship program. This is the basis for consistent communication between the provider and the patient. The PPA should focus on the patient and provider, not the opioids. This agreement is a commitment between the provider and the patient on how pain will be managed. Using patient-centered, non-punitive language, the PPA should include required treatment goals, components of the monitoring program, risk and benefits of the prescribed therapy, and exit plans based on patient actions and efficacy. I recommend including key health care team members, patients (including patient-family councils), hospital leadership, and risk management in the development of your PPA.
Physicians obtain the right data. You need data to identify your population and to monitor your progress. Having data to monitor population- and provider-level outcomes such as the percent of patients on opioids, the percent of patients on high doses and patients receiving an opioid and benzodiazepine combination will be very important.
Physicians need an organizational policy for prescribing opioids. I recommend that opioid prescribing guidelines be a part of your organization’s larger pain management plan, and include not only guidelines and criteria for opioid use, but also non-pharmacologic and non-opioid treatment options. The CDC guidelines provide recommendations regarding considerations for non-pharmacologic and non-opioid therapy, use of immediate use versus extended release products, and initial dosing strategies.
Providers establish a risk assessment process. I get many questions about risk assessment tools and the specificity, validity and outcomes associated with using them. From a practical standpoint, these tools allow you to establish a consistent process for assessing your patients prior to initiating therapy.
These are just a few critical components to start the process of developing a comprehensive opioid stewardship program. By working together the health care industry can make a significant impact in reducing the number of opioids available and save thousands of lives.
Jim Lichauer, PharmD, BCPS, FASHP, Project Manager, PI Collaboratives and Advisory - Pharmacy, has more than 20 years of experience as a clinical pharmacy specialist and clinical pharmacy administrator in both private sector health systems and the Veterans Health Administration. He is a board certified pharmacotherapy specialist and a fellow of the American Society of Health-System Pharmacists.