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This Expert Panel is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.
In preparation for this week's discussion, I wanted to share some resources that might be of interest. We encourage you to share additional resources on this important topic, as well as any questions you'd like to see our panel address over the course of the week. Looking forward to a great discussion!All resources for this Expert Panel can be found at ghdonline.org/opioid-epidemic/resources
Link leads to: http://www.ihi.org/resources/Pages/AudioandVideo/WIHI-The-Opioid-Crisis-What-Health-Care-and-the-Community-Can-Act.aspx
Link leads to: https://hms.harvard.edu/videos/local-efforts-combat-opioid-epidemic
Link leads to: http://www.jhsph.edu/research/centers-and-institutes/center-for-drug-safety-and-effectiveness/opioid-epidemic-town-hall-2015/2015-prescription-opioid-epidemic-report.pdf
Link leads to: http://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2015/12/08/15/11/prevention-and-intervention-strategies-to-decrease-misuse-of-prescription-pain-medication
Please see attached article on the role of the family
Link leads to: http://www.tandfonline.com/doi/full/10.1080/08897077.2015.1124479
Good morning! I'm excited to join you for this week's expert panel on the opioid crisis. I am a senior researcher with the innovation team at Institute for Healthcare Improvement (IHI), where I lead IHI's work in behavioral health. Over the past year, our team has been developing and testing a systems approach to addressing the opioid crisis in a community, with the theory that a coordinated, collaborative approach will be more effective than point in time interventions that focus on only one part of a complex system. This theory is based on our study of over 30 efforts around the country, many of which have some good results, but have yet to make a widespread impact. Part of the reason is a lack of coordination and communication between efforts and slow uptake of promising practices; because the opioid crisis affects different populations and involves multiple actors across a community (which could be a city, a state, or a region), there is a real opportunity for stakeholders to work together and design a systems approach that is tailored to how the opioid crisis is unfolding in their particular geographic area. Looking forward to the discussion!
Link leads to: http://healthaffairs.org/blog/2016/06/13/a-systems-approach-is-the-only-way-to-address-the-opioid-crisis/
Link leads to: http://www.ihi.org/resources/Pages/Publications/Addressing-Opioid-Crisis-US.aspx
Colerain Township, OH, a community of 60,000 residents and the 14th largest community in the State of Ohio initiated a unique response to the heroin/opioid epidemic. The response plan was facilitated through the creation of a "Community Health Collaborative" group that includes local police, Fire/EMS, and HR personnel. The group also includes the local public health organization, the local school district, area business members, the faith based community, media and people serving in the treatment and recovery business. This group worked to ask questions, listen to answers and then identify the needs of our community. This group facilitated two community meetings; one in early 2015 to learn from a larger scope of community members, the significance of the problem. A second forum was conducted in 2016 to let the community know that the problems raised in 2015 were investigated and steps were initiated to make an impact. The group also identified a lack of information available to families/addicts about the disease of addiction and reputable treatment resources. The Police and Fire Departments partnered with a local organization, "Community Recovery Project" to distribute "Resource Recovery Packets" at all overdose responses by police and fire. Since August 2014, the Township distributed almost 500 packets to our community. Several patients/families returned to thank the departments and its officers/firefighters for their help to find help. The Township also created a tri-fold brochure that is used an education tool for our residents. The brochure is provided during "Door to Door" canvassing efforts in our most affected neighborhoods. In our first neighborhood, five families called and asked for help, when only receiving the brochure. The brochure contains 24-hour help telephone numbers and the "signs of an overdose" along with our "Drug Drop Box" hours. This brochure is also provided at any public event to reach as many of our 60,000 residents as possible. In July 2015, the work done to that point was not enough and more was necessary. At that time, the Police and Fire Departments partnered with the Cincinnati Addiction Services Council professionals to provide "on-site triage and assessments" for persons who experienced an overdose within a three-five period. The team reviews police incident reports and conducts follow up to any resident who overdoses and enrolls that person in the Medicaid system, if necessary. The team has also purchased birth certificates to assist in the obtaining of a state identification card as well as meals, when the need arises. Since July 2015, the team conducted more than 200 follow up investigations, with an 80% success rate of getting the addicts to treatment. The team also provides Narcan to family members to help them save a life, if/when a relapse occurs within their ability to respond.
Daniel - thanks for sharing! This is exciting work that shows how multiple stakeholders in a community can come together, identify priority areas, and use the different assets and resources of different actors to put programs into place. It sounds like a lot of your work has been around preventing diversion of unused medication, educating the public about overdoses and local options for addiction treatment, and intervening with individuals and their families during the critical period after a nonfatal overdose, all of which are key parts of the system of opioid misuse, dependence, and addiction. Two questions for you:1) What role do health care organizations and providers play in your collaborative?2) What advice would you give to a community who is just getting started in building these collaborative efforts to address the opioid crisis? What worked well, and what do you wish you had known when you were starting out? Thanks again!
MaraThank you for reading my post. I am glad it can provide assistance. We have been speaking throughout the region and in North Carolina, just last week on this effort to spirit engagement and hope. I will answer your questions.Two questions for you:1) What role do health care organizations and providers play in your collaborative? Our community is served by five hospitals and while not all are partners in the larger county wide "Heroin Coalition," a group of hospitals provided funds to ensure our Addictions Services experts could continue their services as the initiative expands to other County communities. The hospitals funded for expenses for the creation of a second community effort. This was a huge gap filled by the providers. Without their financial support, I was not sure our addiction professionals would be able to continue serving my community.2) What advice would you give to a community who is just getting started in building these collaborative efforts to address the opioid crisis? Just do it. Time passes while "experts" work to create the "perfect" response model. In the meantime, people are dying, families are being destroyed and communities are lost as to how and survive the epidemic.What worked well, and what do you wish you had known when you were starting out? The collaboration of outside entities was absolutely necessary. The differing perspectives was and continues to be important in understanding and maintaining an appropriate perspective on the problem. Actually, the step toward making these efforts happen was the implementation of a "Problem Solving" operating philosophy. That clarified our response from a lot of police and fire perspective. The hardest issue to date has been the lack of commitment from other communities to "just so something." It saddens me that so many have many reasons to not do anything and in turn, have no answers for the residents of their communities. It seems that many seem to just hope this problem goes away, on its own.Thank you again for reaching out. If there is anything else that I can do to help, just let me know.Dan
I believe creating awareness in the community about the absolute indication of opioids for treatment and consequences of overdose may play a pivotal role.This issue can be addtessed by following strategies.A) The message can be dessimenated via leaflets and posters in primary care settings. The health talk organised at community level may also strengthen the message.B) Opioids can be classified as controlled drugs and it's dispension must be carried out under strict regulations.It is usually considered as first line pain killers in hospital settings.It may only be dispensed in community as patient controlled analgesia driven by programmed syringe pump to prevent overdose.
I agree, Saad - raising the public's awareness of the risks of prescription opioids is a key driver to changing the trajectory of the opioid epidemic. There are a few different strategies that can be used to educate individuals and raise this awareness. First, as you note, providing information within health care settings. This should include dental/oral surgery practices in addition to primary care, women's health, and other outpatient settings in which a patient may be prescribed opioids. Another strategy is to work with state and local public health departments to create educational campaigns. Many people are unaware that prescription opioids are chemically similar to heroin, and are surprised when they learn that they have such a potentially dangerous substance in their medicine cabinets. Numerous communities have started such campaigns, encouraging individuals to dispose of unused prescription opioids to prevent diversion during drug take back days and by having safe drug disposal in certain areas such as in police stations. Finally, educating youth and adolescents, particularly in high schools, about the risks of opioids is critical.
Hello everyone! I am reading through your discussion posts, and I was initially intrigued by the title, "those who may not traditionally have a role to play" in tackling the opioid crisis. My personal experiences have largely encompassed young adults in the age range of 18-30 who are becoming addicted to these drugs. I absolutely agree that raising public awareness such as described by Saad and Mara is critical to addressing the knowledge deficits. Mara, you made an excellent point that many people are unaware of the risks of prescriptions opioids, perhaps because they believe them to be "safe" if prescribed from a medical professional. Providers must be held accountable for educating patients on the risks of prescription opioid therapy, and should be required to document alternative pain therapies attempted in an effort to decrease any unnecessary use of opioids. I also appreciate that you mention the various specialities who have the capacity to prescribe these medications, as the topic of opioids was discussed at the NYS Board of Midwifery meeting today, and its important to consider all pathways of prescription. My other thought was to expand on what Dan had mentioned within his community, and extend these preventative practices to peer advocates. I love the idea of a hotline and informational brochure being distributed within the community! I was also initially thinking of the importance of establishing a help line, and its great to see that you have done this. I do feel that the message may receive some pushback from young adults though. Defiance motivates much of a young adult's actions during this time, and I question how well received the message would be coming from community leaders, firefighters, EMTs and even teachers. I wonder if initiation of advocacy and opioid educational programs specifically designed for young adults would attract peer leaders who may have the capacity to target those facing addiction within their community/social circles sooner? Has anyone experienced implementation of a program such as this within their community, and if so, what were the outcomes?
Hello Mara and everyone else interested in this aspect of the Opioid Epidemic.Thanks for the comments and the work of IHI on this and other important aspects of health and medical care. As part of a project I plan to make public shortly, I am creating a county platform that contains information, resources and strategies to make an impact on the community level...Although not public yet and needs more work, here is a link to that county platform section..http://shimonwaldfogel.wixsite.com/the-opioid-epidemic/county-oneHere is link to the project http://shimonwaldfogel.wixsite.com/the-opioid-epidemic/about-I was not able to access relevant resources on the IHI site...any help getting access? Would greatly benefit from your insights..With gratitude,Shimon
In Washington we (Washington State Health Alliance) we are working on a consumer facing brochure but the draft version looks like a doctor and an attorney drafted it (see attached). I am also a volunteer advisor to one of the Way to Wellville cities (5 cities of under 100k people - that are codesigning health from the community level upward) and one of their priorities is the opioid crisis in their area - so I really appreciate the brochure and real world experience that Daniel shared above/below.
Sherry, I thought your document looks great. I'm putting a problem for the public here on Denver in March. Would you mind if I use your document? Thanks
Sherry,Do you or any of the other contributors know of any trials in the use of a community wide, standardized Narcotic Prescription Contract organized to be updated on a scheduled basis by a "collective action" process? My state, Nebraska, is currently implementing a real time data base for narcotic prescriptions filled by our State's pharmacies. It seems natural to now take the next step. Paul Nelson, M.D.
I keep asking for the ability to edit our PMP here in Maine. Right now all I can do is see what was filled. But when someone has violated narcotic contracts I should be able to put that in the system to alert others.Now that Maine has the strictest laws in the country I thought we would get some changes but alas no - we are given excuses
I have used narcotics contracts since residency = they have evolved through the years. I am more than happy to share mine if anyone wants
Dr. London,Please post-it. Would you be so kind to discuss, a bit, what is it about its use and content that makes it useful?Paul
Sure. A controlled substance contract (as I use one not just for narcotics) is between the clinician and the patient. It explicitly states up front that there are goals, risks and responsibilities with the use of the medication. I treat everyone the same as diversion of medication has occurred from all walks of society as does addiction.Attached is the contract I use please feel free to adapt and use
I look forward to the day when we have nationwide access to Prescription Monitoring Programs - I argued when I was in NYC all they did was fill in NJ or NYC. Here in Maine they can go to NH we have patients who go south and elsewhere I would really like to see more nationwide data sharing if diversion is to be stopped
Cathleen,I like the contract, it bears the marks of several edits based on experience, especially the barn-yard language on the phone! Have you ever tried to limit the Contractee to the use of only one Hospital Emergency Department? Have you ever set an automatic cancellation date? And, how often have you done urine screening? Finally, I have always thought that students participating in a school sponsored school activity should be subjected to random urine testing? One positive means more testing until out of school and a brief Chemical Dependency Eval; the second positive needs counseling and no further school activity participation for one month; a third positive means no further school activity participation, a psychiatric consultation, and no further testing. I proposed this to a school principal once while my two daughters were in high school, a church sponsored all-women school. The idea didn't take hold. My impression was that if implemented, it might be too threatening to prospective parents...very sad concern. I didn't think it would change hard-core use very much. But, if it reduced the experimentation slowly over several years, it might make it easier for most of the students to maintain their sobriety. Your thoughts about all of this? Paul
I do witnessed UDS EVERY time until I trust someone and then randoms on top of it (called in for count and UDS) after that randomly when they come in. If they are in recovery - ie on suboxone EVERY time. and those are sent out to Ameritox - I do not fool around.I am VERY rural so no cannot limit to one ER - I draw from 2 counties. People travel far distances to see me. But we all share and talk. I have no problems calling an ER and saying do not prescribe etc.And if a patient breaks contract they are done. I follow through
Clearly, a kindred spirit; easily the best strategy to help avoiding co-dependent health care. We have had an office policy to never prescribe a narcotic for a first visit. The folks who do that all know each other. It only becomes a problem when a new provider joins the practice. The first visit policy helps to shield our group desire to be caring, as in non-critical acceptance. The road to beneficence has many detours.
One of my clients has created software to reduce/eliminate drug diversion in hospitals. In many communities, drug diversion can be a major source
Hi, Joe, what kind of software did you client creat? is that helpful for medical institutions to reduce false drug diversion? would you mind providing more detailed information regarding this software?Thank youLeo
I think that a big trunk of the problem of opioid crisis is due to doctors who are prescribing to much sometimes. I have witness situations where doctors are reluctant to really dig deeper and try to understand what is really happening with their patients. Instead they choose the easy way of prescribing to take care of symptoms just to satisfy the patients' need in that particular time. When that is done over and over it becomes easy to understand how addictions can develop which can be followed by overdoses and hence an opioid crisis.I believe that solutions to this problems should heavily involved doctors, nurse practitioners, registered nurses and patients. All those stakeholders should be given the opportunity to really understand the problem at stake and what a burden the opioid crisis is for society in general. In the hospital or even in private clinics there should be better way of monitoring opioid prescription. There should also be a better way of tracing patients who are on opioids.Best,Bazile
On a similar note, I have often been dismayed by the post-op joint replacement orders for pain control that have been used in hospitals. I understand that the "chief complaint" of most persons who see an orthopedic specialist is "It hurts." In the long run, this is driven by our nation's inadequate Primary Healthcare traditions. Too often, the orthopedic physicians are forced into chronic pain problems by the inadequacy of a person's Primary Healthcare. Remember, the decision processes of an orthopedist are substantially based on imaging. A usually, very precise quick decision process. Chronic pain control cannot be adequately managed by a a "quick" prescription or post-op order set. Currently, this is made worse by the use of hospitalists for post-op care who have no knowledge or relationship with the patient. For the last three years (unable to make hospital rounds because of the 50% decrease in work efficiency of an EMR), I have not received even one phone call from a hospitalist about an admitted patient of mine. No one from within the hospital "silos" seems to understand the value of a long-standing "caring relationship" between a person and a Primary Physician. So then, it seems that an investment in the Social Capital, community by community, will be necessary as the underlying, "rallying cry" for solving the "opiate misuse epidemic." Collective Action initiatives, very important, are still unlikely to be effective without it. And, the best strategy for ultimate healthcare reform should be promoted with this model. The Design Principles for Managing a Common-Pool resource (as in healthcare's portion of the national economy) are known, and they are well supported by the evidence available from the political science economists. We only lack the will to make it happen. Unfortunately, our nation's healthcare industry is gripped with an unrelenting Paradigm Paralysis.
"It hurts" is an important chief complaint, and please don't take my comments out of context. Pain is real, and needs to be addressed. Full stop. However, a person's ability to cope with pain is affected by stress, fear, and tension. Yet we do not have a systematic way of addressing a person's ability to cope with pain. In Scandinavia, pregnant women are assessed for fear during prenatal visits, and they can be referred to fear clinics in an effort to reduce the need for pain control during childbirth. Would a similar approach work for surgical patients? As part of the pre-op visit, a patient could be assessed for fear, and then referred for "fear management" as a means of reducing the one-size-fits-all of opioids. http://www.tandfonline.com/doi/abs/10.1080/02646830802408498http://www.hus.fi/en/medical-care/medical-services/maternity-services/babyjou...
Leo - Attached is some information about the Drug Diversion software product. The company is looking for a partner site for an initial launch.