National opioid crisis heightens during pandemic; Rewrite the Script team holds true to its promise
Paul Hilliard, M.D., was a recent guest on The Wrap employee podcast. Check out his discussion of Rewrite the Script above!
Just when the health care industry was working together to reverse the effects of the national opioid crisis, the COVID-19 pandemic erupted, causing a spike in opioid overdoses. Opioid-related deaths have intensified in more than 40 states, according to the American Medical Association, and in Michigan alone, overdoses have risen by 26 percent. (State of Michigan, April-June data, 2020 vs. 2019)
The Rewrite the Script Team refused to be knocked down by this one-two punch. This group of dedicated physicians, nurses, therapists and other volunteers first came together back in November 2018 to fight the opioid crisis here at Michigan Medicine and despite time constraints and resource reductions caused by COVID-19, have carried on with their aggressive goals. And their efforts have allowed them to hit many critical milestones while remaining committed to their promise to better manage pain, improve function and reduce harm for patients.
“The assumption that we can solve pain with a pill is an oversimplification of a complex problem and has led us down a dangerous path,” said Paul Hilliard, Associate Professor of Anesthesiology and Medical Director for Institutional Opioid and Pain Management Strategy. “We are striving to manage pain by listening to each patient, and helping them to tell their story so we can understand what will best meet their needs. We want to meet them were they are, and offer more proactive and positive approaches to pain. We also need to do a better job understanding that when patients do develop an opioid use disorder, this is a medical condition just like any other and we need to remove the stigma and unconscious biases that go along with caring for these patients.”
A three-pronged approach
While the team has made so much progress in many ways, their work can be highlighted in three key areas:
- The creation of pain profiles, which capture the patients “pain story” and key information to facilitate pain treatment across the care continuum.
- Expanding non-pharmacologic options for pain including acupuncture, healing touch, aromatherapy, art/music, guided imagery, mindfulness and greater incorporation of movement.
- Increased access to Substance Use Disorder (SUD) treatment and recovery support.
Their first step, the pain profile, was well received by both patients and physicians, according to Hilliard.
“The adult pain profile is now available within MiChart across the system, and we are working with targeted clinics to incorporate it thoughtfully into their already time-stressed workflows,” Hilliard said. “The tool allows the patient and care team to work together to understand what works best for the patient in managing pain, and I have experienced first-hand how much richer a conversation I can have with my patients as a result of this information being readily accessible. The team is also excited to be finalizing a pediatric version of the profile, which will be piloted in the coming months.”
Offering a menu of pain management options
The non-pharma team laid out a full menu of options for pain management which continues to evolve as the team pilots various modalities at clinics and inpatient settings throughout the system. Although they have not moved as fast as originally planned due to the pandemic, each month they have experienced new exciting results.
For instance, an aromatherapy policy has recently been approved within nursing; the Burlington Back and Pain Clinic now has acupuncture, healing touch and an integrative medicine specialist present several days a month; and an interprofessional group has been working on finalizing a toolkit that will bring more specific non-pharma interventions to the bedside.
One of the key interventions relates to movement: “We are having a different kind of conversation with our inpatient teams about how to use movement to assess function and reduce patients’ pain, involving frontline nurses, techs, physical therapists and physicians,” said Katie Barwig, the nursing lead for Rewrite the Script. “Pulling these groups together to build a shared language and approach to movement is not only going to enhance our pain management, but also have positive impacts on many other priorities for Michigan Medicine, like pressure injuries and falls.”
While the team’s efforts are focused on minimizing opioid-related harm, the reality is that many patients in our system and community have developed an opioid dependence or opioid or other substance use disorder (SUD). After reading the research on the complexity and stigma attached to SUD, the team recognized that Michigan Medicine had a long way to go to ensure it could adequately treat SUD patients or patients suffering from pain who were potentially susceptible to SUD.
Research shows that 15-20 percent of hospital patients nationally have at least one SUD, and that patients who engage with an inpatient SUD consult service while in the hospital are twice as likely to engage in outpatient treatment. Further, those patients with opioid use disorder (OUD) who engage in outpatient medication-based treatment are 2.5 times less likely to return to hospital. As a result, the team approached this problem through a systems lens, and assembled many experts to launch a multi-pronged approach.
“We have been building a stronger base within primary care providers who can prescribe medications for OUD, and our primary care teams have stepped up in a big way,” said Hae Mi Choe, chief quality officer for the U-M Medical Group. “In the past 12 months, we have gone from having five primary care clinics with a physician who could actively manage patients with OUD, to now having 12 out of 15 of our primary care clinics able to support these patients.”
“On the inpatient side, the team works alongside our ED and inpatient care teams to bring an expert and compassionate lens to patients suffering from SUD in our acute care setting, and provide robust handoffs to outpatient follow-up,” said Fiona Linn, strategic advisor to the chief medical officer and project lead for the SUD implementation. “Most critically, the team will prompt a new conversation and work toward normalizing care for this chronic disease – so that one day, managing SUD will become as routine as managing diabetes.”
The work continues…
While the COVID-19 pandemic presents pragmatic challenges to implementing this work, the team is far from deterred – in fact, their resolve has never been stronger.
“This pandemic has exacerbated the opioid crisis, SUD and mental illness. People are more isolated, less able to access already-stretched support resources and non-pharmacologic therapies, and under unprecedented financial pressures,” said Hilliard. “But it has also highlighted how critical it is for us to continue this work. We have made a promise to our patients – to manage their pain, to listen to them and to most of all – do no harm.”