Health Advisory Council December 2019 Member Meeting: Keynote speaker summary
On December 6, NCL hosted its winter Health Advisory Council (HAC) meeting of 2019.
The winter HAC meeting featured a presentation by Rachel Uzlik CPHQ, Vice President of Clinical Services at Twin Cities Orthopedics (TCO), on TCO’s efforts in reducing opioid reliance by revising opioid prescription guidelines.
Rachel Uzlik CPHQ, Vice President of Clinical Services Twin Cities Orthopedics Golden Valley, MN
Rachel led a presentation titled “A Community Approach to Combating the Opioid Crisis”, which discussed the history of the opioid crisis and the results of Twin Cities Orthopedics’ clinical study to reduce patient opioid use. Twin Cities Orthopedics is a Minnesota and Wisconsin based private orthopedic practice that is one of the three largest orthopedic practices in the United States. TCO partnered with REVO Health for the opioid prescribing study, a company that assists specialty practices with designing and building value-based care solutions.
Uzlik gave an overview of the progression of the opioid crisis, focusing on the creation of opioid prescription guidelines and efforts to curtail the opioid crisis. She then turned to sharing the work of TCO in addressing the over-prescribing issue. TCO conducted a study to determine guidelines for providers for the prescribing of opioids for specific procedures and patient types. The study had three main goals:
(1) to determine how prescribing patterns vary among surgeons,
(2) to maintain patient pain control and satisfaction when reducing opioid scripts, and
(3) to improve the practice’s opioid disposal practices.
TCO standardized opioid prescription practices by creating prescription reference cards for their common orthopedic procedures and creating quarterly routine open reports of individual physician prescribing practices for reference. TCO distributed patient education flyers that included positive patient testimonials about alternative forms of pain management. Patients were required to sign a patient contract acknowledging opioid risks upon receiving an opioid. TCO improved its opioid disposal practices through distributing narcotic disposal bags, specifically Deterra bags, with every opioid script. These bags prompted physician-patient conversations about why patients may not need to use the entire prescription and how to properly dispose of any leftover opioids to avoid misuse.
The TCO study found promising results with a reduction in prescribing of opioids, maintenance of patient pain management satisfaction, and safe disposal of opioids. At the end of the four-phase study, patients reduced the consumption of opioids at a rate faster than providers reduced prescribing them. Prescribers were more consistent in their prescribing patterns as, on average, patients were prescribed 16 pills compared to 41 pills before the program. Even when patients took less or no opioids, 89 percent of them still reported pain satisfaction. Because TCO provided neutralizer bags to patients with every opioid script, they estimated that they reduced approximately $1.5 billion in wasted narcotics in TCO’s practice over the study’s period and were able to increase safe opioid disposal practices by patients by 23.7 percent.
TCO plans to share its findings: TCO will release four research papers to accompany the survey findings and is working with private practices in other states to implement TCO’s provider guidelines. TCO hopes to further reduce the over-prescription of opioids, expand its distribution of neutralizer bag resources for all types of medicines, and improve patient opiate tracking.
Q&A and Discussion
Efforts of other organizations and CDC
TCO is working with private practices outside of Minnesota and Wisconsin and national organizations to create prescriber guidelines. TCO believes some of the CDC guidelines for prescribing narcotics are too broad or difficult to apply for chronic pain patients. The three-day limit recommended by the CDC may not be appropriate for some surgeries. TCO emphasized the importance of creating guidelines for specific procedures and believes the CDC’s recommendations are a good benchmark to start from and encourages consideration of alternative medications for chronic pain.
Demographic differences in need for opioids to counter pain
TCO considered if patient age and gender differences generated different pain responses. Patients over the age of 75 took fewer opioids than patients 25 and younger. For patients older than 75, there was no gender difference in the number of opioids taken. For patients 25 and younger, TCO found a strong gender difference in opioid use, with women taking fewer opioids and reporting less pain. It is important to note that TCO’s data is different than what is traditionally published in part because TCO initially experienced a greater response rate from women. TCO has since improved its data collection techniques to collect more representative data.
Alternatives to opioids
Uzlik reported that the majority of patients were aware of the opioid crisis, and 86 percent of patients were happy to avoid opioids because of fear of opioid addiction. She noted that many patients have trouble identifying drugs as narcotics and do not think to ask their provider about opioid alternatives. To help patients identify narcotics, TCO distributed narcotic education sheets and disposal bags when prescribing opiates. TCO was interested in looking at the prescribing patterns of opioids to see if there is a pattern to time of discussions about post-surgery medications and the subsequent prescribing of opioids. Patients sometimes do not retain much information about alternatives after their surgery because of the high-stress post-op.
HAC members emphasized the importance of creating educational resources for patients regarding what questions patients should be asking their providers about taking opioids. Representatives of Allied Against Opioid Abuse highlighted a video produced by Johns Hopkins University that discussed that pain is a normal part of the healing process, and it is ok for patients to be in pain.
Decreasing quantity of opioids prescribed
Uzlik stated that reducing narcotic use of long-acting narcotics and short-acting narcotics both effectively managed pain and recommended eliminating long-acting narcotics. 13 percent of TCO’s patients were able to manage their pain with over the counter medicine like Tylenol or Advil.
Patient-provider dialogue about using alternatives to opioids
TCO found that some providers were resistant to follow the medication guidelines because they were worried about adverse patient reactions. TCO remedied these fears by creating a guide of what type of pain is reasonable and when patients should reach out to providers because of pain.
TCO prioritized implementing opioid disposal practices to motivate patients to get rid of their leftover medications. TCO found that patients were most likely to keep their extra medicine because of fear of pain from physical therapy. TCO hopes to work to dispel this belief and hope to provide disposal bags at physical therapy centers.