Misuse of opioid prescriptions has become an issue in the United States which is causing untold harm to families, significantly increasing the cost of healthcare, and keeping women in our community from living a fulfilling life. In this country the most common class of prescribed medications are opioid analgesics. In 2014, pharmacies filled 245,000,000 prescriptions for this class of medication (Volkow & McLellan, 2016). Furthermore, provider prescriptions are the major source of misused opioids (Volkow & McLellan, 2016). Thirty percent of Americans suffer from some type of acute chronic pain. Among the elderly this percentage increases to 40% (Substance Abuse and Mental Health Services Administration, 2012). Persons suffering from acute chronic pain are the most common users of opioid analgesics. While chronic pain causes opioid misuse among all stratifications and divisions in our society, there are certain populations who have additional challenges (Nahin, 2015). As a result of these and other statistics, the National Institutes of Health have recommended a greater recognition of pain as a significant health concern in our country.
According to the Department of Health and Human Services’ Office on Women’s Health (2016), women are more susceptible to the misuse of opioid analgesics than men. They are more likely to report pain and more likely to suffer from more severe pain. In addition, women need less medication across a shorter period of time to become dependent while providers are more likely to prescribe opioids at a higher dose to women for a longer period of time. Women are more likely to self-medicate to cope with life stress, negative emotions, anxiety, stress, and have an increased co-morbidity of substance and mental abuse disorders. In their white paper, the Department of Health and Human Services’ Office on Women’s Health (2016) states that from 2008 through 2012 a quarter of women who had private insurance filled a prescription for opioids. The same is true for 33% of women who had Medicaid.
Local Problem
Our hospital, Sentara RMH Medical Center (SRMH), serves residents of north central Virginia including portions of the Virginia Health Districts of Central Shenandoah and Lord Fairfax. Eighty-eight percent of our patients reside in the counties of Rockingham, Page, Shenandoah, and Augusta or in the cities of Harrisonburg and Staunton. As in the rest of Virginia, the effects of Opioid misuse and abuse in our service region are evident. Of the 35 health districts in Virginia only 4 districts have both a higher number of prescription opioid deaths and a higher rate of death per 100,000 for women, 2 of which are in our area, namely Central Shenandoah and Lord Fairfax health districts (Virginia Department of Health, 2016).
Individual providers within the SRMH Medical Group report that the Virginia Prescription Management Program (PMP) is very cumbersome to use. The process of exiting the EMR, logging into the PMP, and entering the patient’s information is time-prohibitive, taking up to 1/3 of the time traditionally allotted to patients. In addition, over 27% percent of all women over the age of 34 seen by any SRMH medical provider between July 1 and December 31 of 2016 had an active opioid prescription. This compares to only 23% of men. This disparity increases with age. Between April 15th and December 31st of last year, 23,377 opioid analgesic prescriptions were written by SRMH providers for people of all ages in our community. Over 67% of those were written by primary care providers. During this time frame, women comprised 82.41% of all patients’ whose chief complaint was chronic pain.
Women Rise
The main goal of Women Rise is to lower prescription opioid misuse in women across the lifespan in SRMH service region through a 5% reduction in the number of opioid prescriptions provided to women in our community by June 30, 2020. In concordance with the Center for Disease Control and Prevention guidelines (Dowell, Haegerich & Chou, 2016) our initiatives to achieve this goal include:
- limiting inappropriate access by developing an alert for providers when patients have received over 7 days of opioid analgesics for acute pain or 14 days for surgical procedures and streamlining provider access to Virginia’s PMP
- limiting misuse by increasing providers’ knowledge about issues involving opioid misuse in women across the lifespan, providing primary and secondary prevention to women in the community through Chronic Pain Self-Management Program (CPSMP) and peer support specialist services
-removing 76,000 unneeded pills; 29,000 mL liquid; or 10,000 patches that may be misused by women of any age.
Ethical Considerations
The Women Rise program was approved by the Institutional Review Board of record and all participants were provided with informed consent prior to enrollment. Refusing to participate in the evaluation did not disqualify patients from enrolment in the program.
Initiatives
The CPSMP was developed for people who have a primary or secondary diagnosis of chronic pain. Pain is defined as being chronic or long term when it lasts for longer than 3 to 6 months, or beyond the normal healing time of an injury. Examples of chronic pain conditions are: chronic musculo-skeletal pain, fibromyalgia, whiplash injuries, chronic regional pain syndromes, repetitive strain injury, chronic pelvic pain, post-surgical pain that lasts beyond 6 months, neuropathic pain, or neuralgias, and post stroke or central pain.
Strength in Peers is responsible for hiring, training, and supervising a peer support specialist; providing women in the community who are in danger of becoming addicted to opioids one-on-one peer support; providing support groups if critical mass is achieved; collecting and reporting data; and participating in partnership meetings.
An alert was to be developed to notify any prescribing provider through the electronic health record prior to prescribing an opioid analgesic for more than 7 days for acute pain or more than 14 days for post-surgical pain.
Preliminary Program Evaluation Results
From January through March 2018 (Q1 of data collection) a total of 5,014 opioid prescriptions for were written by SRMG physicians across all specialties; compared to 4,674 prescriptions in from April through June (Q2); and 5,014 prescriptions from July through September 2018 (Q3). Q4 results are not yet available however we expect the reduction to continue. There were 752 fewer opioid prescriptions written in Q3, which resulted in a 15% reduction in opioid prescriptions across SRMG from Q1 to Q3.
The Opioid alert has been created. The IT team decided that an alert that triggered when certain diagnosis codes were used, instead of a patient just having an open opioid prescription, would better help physicians screen and monitor patients. The alert provides tools including links to the VA and NC state Prescription Monitoring sites, a MEDD (Morphine Equivalent Daily Dose) calculator, a link to the Discussion Points and Controlled Substance Agreement (which both physician and patient need to sign), Naloxone (Narcan) orders and patient instructions, and Urine Drug Screen orders.
Valley Program for Aging Services (VPAS) has finished one CPSMP training with 6 women completing the program. Two trainings were started with a total of 14 women starting the program. Two additional trainings are scheduled to start in October. Scheduling and recruitment efforts have begun for CPSMP classes in Spring 2019. Preparation for classes has started, including finding classroom space, recruiting participants, and advertising dates. VPAS is currently also planning a class for the Spring of 2019 that will be held entirely in Spanish.
Next Steps
Based on the favorable preliminary program evaluation results, we aim to continue our initiatives with one recommendation for change. Namely, the peer support specialist recruitment. There has been significant shift in primary care in the last 9 months away from prescribing chronic opioids in primary care. Instead it is being treated as a specialty practice and primary care providers are referring patients to one of three pain management clinics in town. Inpatient providers still prescribe a significant portion of the Opioids provided in the community with women who are not yet addicted. As a result Women Rise is looking to inpatient and beginning conversations with one of the pain clinics as well as the inpatient social workers. We will move to a more flexible model that places the peer in the inpatient setting in the morning and seeing patients throughout the community in the afternoon. They may see patients in any primary care setting at the request of the providers and/or in the community at the request of the patients. In addition, marketing efforts are being planned to increase community awareness of peer support specialists availability to women for secondary prevention. The Peer Support Specialist will provide women one-on-one assistance, including education, help with monitoring signs and symptoms of opiate dependence, and modeling effective coping techniques and self-help strategies based on the specialist’s own experience.
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