Norton Healthcare has lowered its opioid prescriptions by more than half since 2014 through data analysis and further educating its doctors — and their patients.
Norton in 2013 created an opioid task force to monitor, analyze and decrease the number of opioids its patients were receiving. Prompted in part by state legislation, the system previously had begun providing continuing medical education about opioids to its staff.
“When we started this, you would not believe the averages of pills per script that physicians around the country and our doctors were prescribing,” said Dr. Joshua Honaker, chief medical administrative officer of Norton Medical Group.
Despite an electronic health records system, tracking information about opioid prescriptions initially was tough, Honaker said.
“It wasn’t like anybody else was giving us reports — nationally or state or local. So we developed our own set of reporting,” he said.
The task force has 10 members from across the health system, including administration, primary care physicians and pharmacy. It prompted the creation of a dashboard for each physician, tracking six metrics so that doctors could compare how many opioids they were prescribing per patient and how that compared to their peers.
If doctors saw that they were outliers, they could try to figure out why and potentially reduce how many opioids they were prescribing.
“The message to our physicians has been: ‘Please don’t use opioids if you don’t have to. Try to use alternatives. Try never to start. If you do it, do it for a few days, and don’t give everybody 120 pills,’ ” Honaker said.
Physicians at Norton also changed the way they talked to patients.
That involved telling patients “about the addiction risk; the risk of opioids in general, which have many side effects; talk to them about alternatives, talk to them about trying to just stay away (from them) if possible,” Honaker said.
“Our initiatives have gotten everybody to not just write as much but to write less of whatever they write,” he said. “So our pills per script has gone down, our pills per patient and pills per encounter has gone down.”
“Of our Schedule II opioids, we have had a 50% decrease in volume that we as Norton Healthcare have dispensed since 2014,” Honaker said.
And that’s although the number of health care providers in the system during that time has nearly tripled.
Norton’s program has been such a success that it has shared the approach with other health systems through papers and presentations.
Fear and pain
But the implementation didn’t go without any hitches.
The opioid crisis had prompted some doctors to stop prescribing altogether, Honaker said.
Doctors feared that if they prescribed significantly more opioids than their peers, they might face investigations and potentially losing their jobs.
“There’s a major fear factor,” Honaker said, “so doctors .. started naturally writing less.”
“But some patients need opioids,” he said. “Some doctors, being good doctors, had to write more, because other colleagues quit writing (prescriptions for opioids,) because of the pressure, the fear.”
Norton provided more resources for doctors and made sure that they documented their decision-making so that if questions arose, the doctors’ decisions could be validated.
Honaker said Norton wanted doctors to be in a position where they could justify that what they were doing was what was best for patients.
“We’ve tried to decrease opioids, but we’re also trying to make sure that people need opioids get opioids correctly, and with good discernment,” he said. “So this isn’t just about decreasing opioids. It’s about when you use them, make sure it’s right.”
The significant reduction in opioid prescriptions also required doctors to talk earnestly with their patients about proper storage of prescriptions — and about pain.
About half of the people who have used opioid pills without a prescription have obtained them from family and friends, Honaker said.
“The bulk of the abuse out there is people getting them free from friends and family,” he said. “Patients and families alike have to make sure they’re locked up, they’re gotten rid of, they’re used judiciously, and they’re really policed.”
Norton is helping patients get rid of unused pain pills by providing them with safe disposal bags the system provides after surgeries.
Norton docs also made sure to tell patients to lock away their prescriptions, Honaker said, and to have conversations with family and friends to stay away from the painkillers in the home.
Honaker said the effort has cost little but generated a big return, though he declined to provide details.
Honaker and Dr. James T. Jennings, a family physician and Norton’s medical director for adult primary care, also said that part of their effort has involved trying to change the culture around pain.
Many patients have become used to not feeling any pain at all, even after serious surgeries. However, Honaker said lack of pain may be undermining a patient’s recovery.
“Pain has a role. Pain can be good. Pain is actually part of healing,” Honaker said. “Pain lets us know how we’re doing. And we do not want your pain to necessarily go to zero.”
Jennings said complete lack of pain may obscure the deterioration of a patient’s condition.
“If somebody comes into my office, and their abdominal pain is a level five to them. If they go to a level eight but don’t know it, there’s something that’s changed in their body that has gotten worse, and we don’t know. And more importantly, they don’t know. So they can’t let us know.”
Jennings said that while many patients may have been used to being treated with opioids and having no pain at all, they’ve reacted well to the changes Norton has implemented.
“As long as you explain to people why, they’re much more accepting of it,” he said.
Jennings said that some patients also are offered different pain medications, and others may be encouraged to try exercising and meditation. He discussed management of chronic pain in a recent MedChat podcast, which is available on Norton’s website and through iTunes.
“Everything we do in medicine,” Jennings said, “is made better by good communication.”