Opioid crisis: A clinical and health IT perspective
Headlines about the opioid crisis gripping the United States are inescapable. It is a complex, large-scale problem with no single or simple solution. As a general internist, I have seen its devastating impact across the care continuum.
Observations from the front lines
When I moved to Florida in 2000, the state was an epicenter of the opioid crisis. I often faced the opioid prescriber’s dilemma: Do I write the prescription and risk fueling addiction, or do I withhold the prescription and risk undertreating someone who really needs help?
As a front-line primary care physician, it was not uncommon for new patients in their 20s and 30s to see me for opioid prescriptions. The reasons given were often vague, and the medical records to substantiate their health history were frequently lacking. Given the risk of overprescribing, I was reluctant to do so, and gradually those patients stopped coming to my office.
At that time these patients would often turn to “pill mills,” where licensed physicians would inappropriately prescribe opioids after a cursory pain assessment. One such “practice” existed about one mile from my home. Each day, large numbers of desperate people lined up, seeking their opioid prescription fix; A hot dog stand was set up outside of the store front for the sizable crowd. The State of Florida subsequently enacted laws that have successfully shut down most pill mills, resulting in some reduction in opioid abuse.
On the other hand, I saw many patients in the office with legitimate chronic pain caused by conditions such as major injury, or spine- and age-related degenerative joint changes. Many of them had tried multiple non-opioid pain medications, which were ineffective. A number were not seeking a “high,” and found that opioids controlled their pain and allowed them to function. In addition, it was not always easy to find pain management specialists who could provide alternate forms of treatment.
As a hospitalist, I frequently see the consequences of opioid addition, both prescription and illicit drug use. IV drug users often develop infectious complications, such as skin abscesses, infection in and around the spine (osteomyelitis, diskitis) and on heart valves (endocarditis). One particularly sad case involved a 26-year-old woman with three heart valves infected simultaneously. She had minimal insight into her addiction and was felt to be too high risk for surgery to replace the diseased heart valves. Other similar patients in their 20s and 30s sometimes end up in hospice.
Opiate addiction is a complicated issue that cannot be solved by any single government agency, industry or group. It requires a collective effort. Health IT can play an important role in several important touch points that can influence healthcare provider prescribing behavior.
Using technology at the point of prescribing
A key workflow is at the point of prescribing, which occurs in the office, as well as at the time of discharge from the emergency department or after a hospital stay. Patients frequently receive opioids in the hospital, which can be an initiation point for later opioid addiction in predisposed individuals.
Integration of state Prescription Drug Monitoring Program (PDMP) into the EHR workflow is critical to informing prescribers about prior prescription opioid use in their patients. Review of PDMP data is a requirement in many states prior to prescribing an opioid. These systems can help identify “doctor shopping” patients or substantiate a history of legitimate opioid use.
Currently I do not have access to the Florida PDMP within my EHR, which makes review of this data extremely cumbersome and time consuming in an already very time-intensive hospitalist workflow. Anecdotally, some prescribers forgo prescribing opioids altogether due to lack of PDMP integration, which potentially harms patients for whom an opioid is appropriate for pain.
Electronic prescribing of controlled substances (EPCS) fits well into existing prescriber workflow (prescribers already often use e-Prescribing for non-opioid medication). It also enables integration of clinical decision support, such as acute pain prescribing guidelines, at the point of prescribing.
Using data to inform and predict
Analytics is another HIT tool needed to address the opioid crisis. Key data helps in understanding opioid prescribing patterns in common workflows. These include identifying individual prescribers along opioid type, prescription frequency, reason for prescribing and quantity prescribed.
This powerful data can inform individuals tasked with addressing opioid use within a healthcare system and identify prescribing patterns of concern. This data can be used to monitor opioid prescribing over time, which might be particularly useful if clinical decision support or education efforts and introduced to encourage appropriate opioid prescribing.
Prescribers may also underestimate the frequency of opioid prescribing, and data can be useful to help educate and change prescribing behavior. (See Doctors Underestimate how often they prescribe opioids)
Data can also be used to monitor suspected opioid overdose in the Emergency Department, which may serve as a “barometer” of opioid use within a community. The CDC publishes similar data regionally (Opioid Overdoses Treated in Emergency Departments). Nevada now requires its hospitals to submit this data to the state.
Finally, data can potentially be used to proactively predict patients at risk for opioid addiction or overdose, and it can inform prescribers, who might then consider a non-opioid alternative when treating pain. For a recent example, see Prediction of Future Chronic Opioid Use Among Hospitalized Patients.
As previously noted, the opioid crisis is complex and needs to be addressed as a collective effort. This will include leveraging HIT to help prescribers make more informed decisions (PDMP, decision support, predictive analytics) at the point of prescribing, and using data to understand prescribing patterns and measure the impact of interventions designed to improve opioid prescribing. The collective effort, of course, aims to ultimately reduce opioid addiction and its devastating consequences.