The Monterey County Prescribe Safe Initiative (MCPSI) is a multi-agency collaborative conceived in February 2014 as a way to address the problem of prescription opioid misuse in Monterey County, CA. The idea for the initiative originated at Community Hospital of Monterey Peninsula (CHOMP), but the effort has now grown to include 17 organizations, including all four hospitals in the region, urgent care centers, primary care and mental health providers, advocacy groups, and law enforcement.

While the name of the initiative implies a focus on prescribing, the initiative actually includes multiple interventions that address different aspects of the opioid crisis, and emergency providers have taken a leading role in driving these interventions.

“It was just a matter of trying to figure out how to get patients the care they need in a safe way,” explains Reb Close, MD, an emergency physician at CHOMP and one of the physician leaders of MCPSI. “At the time the initiative began, the epidemic was becoming much more understood and more appreciated, and so Anthony Chavis [MD, MMM, FCCP, the vice president and chief medical officer at Montage Health, CHOMP’s parent company] and I started brainstorming about it and coming up with how to address it. And it has just spider-webbed in so many different directions because so many different people are affected by this.”

The results of MCPSI thus far are impressive. They include a 59% reduction in ED visits and a 47% reduction in variable cost avoidance in a population of recurrent visitors that are under biopsychosocial care management. Additionally, the initiative has more than halved the number of narcotic pills prescribed at primary care clinics in the region. Perhaps most notable is the reality that providers are beginning to think about both addiction and their role in treating patients who present with addiction problems in a new way.

For instance, physician leaders at CHOMP are not fans of the term “drug-seeking” to describe patients who recurrently present to the ED to fill prescriptions for narcotics.

“That is a particularly loaded and challenging term,” says Casey Grover, MD, an emergency physician at CHOMP who also has taken a leading role in MCPSI. “These patients may be looking to get a medication, but there is another reason that is bringing them to the ED.”

Such a patient may experience uncontrolled pain, suffer from an uncontrolled mental health condition, or may have an addiction, Grover notes. “It is not so much that the patients are doing something bad or wrong if they have an untreated illness ... and repeatedly going to the ED isn’t fixing it,” he says. “So [under CHOMP’s recurrent visitors program] these patients are given a plan of care, and usually what that is designed to address is the underlying issue. Is it that they need a real pain specialist? Is it that they need to see our recovery center [the hospital’s associated outpatient addiction clinic]? Is it that they need to see a psychiatrist? Those are all meant to address the underlying illness that is making them show up to the ED requesting or seeking various medications.”

Grover allows that the idea of addressing addiction in the emergency setting initially raised some eyebrows in some quarters, primarily because this just adds to emergency providers’ long to-do list.

“There has been research that we should do HIV screening in the ED and we should do domestic violence screening and depression screening,” he says. “It was one more thing that people are expecting us to do, but then as we have gone through the data, people realize that if you treat [patients] with the right medications for what is a disease, namely addiction, people have fewer ED visits and they are likely to get better faster.”

Emergency providers all went into medicine to help people get better, Grover adds.

“You present the data and people kind of put the barriers down and think that maybe they can provide better care for patients this way,” he says.

While the motivation to address addiction is there, the way emergency providers at CHOMP treat patients who present with an opioid addiction is in flux, Close notes.

“Previously, we had reasonable access in our county to the recovery center for all patients,” she explains. “If someone presented with an opioid addiction and was interested in recovery, we would start them on a single shot of buprenorphine in the ED, and then we would refer them to our recovery center where they would be seen basically the next day and [continued] on medication-assisted treatment [MAT].”

The approach seemed successful, Close observes. However, funding difficulties forced the ED to alter its approach.

“The availability for patients to see a MAT-prescribing physician in rapid fashion was non-existent, so we couldn’t use buprenorphine anymore in the ED.”

To get around this problem, emergency providers have had to adjust their addiction pathway to accommodate a longer wait time for access to MAT.

“So we give patients a prescription for a five-day course of medication with tapers [including clonidine, gabapentin, tramadol, and ondansetron], and then refer them to an addiction clinic for ongoing care. The addiction clinic can’t get them medications for treatment rapidly, but it can give them addiction services rapidly,” Close explains. “That is the model we are using right now.”

However, Close stresses that ED administrators hope to restart their earlier approach soon, involving the administration of buprenorphine while patients are still in the ED along with the referral to an appropriate outpatient setting in which patients will receive immediate chemical and dependency support services. Other hospitals in California are considering implementing a similar protocol, Close says.

“We are using expertise throughout the state to formalize how we can do these plans for patients,” she says.

Close acknowledges there still is plenty of resistance in the emergency medicine community to the idea of providing buprenorphine to patients with addictions while they are in the ED.

“We treat these patients every single day, so [it’s a matter of] reminding providers that these patients are already in their EDs and that they have a tool that can help them more safely and more effectively than any other tool they have,” she explains. “These patients are agitated, sweaty, uncomfortable, angry, and frustrated. And you give them a shot of buprenorphine and then come back in 20 minutes, and they are calm and pleasant. They thank you, and they feel so much better.”

A centerpiece of MCPSI is countywide implementation of pain management protocols for the ED, but Grover acknowledges that crafting guidelines does not guarantee adherence. Nonetheless, he notes that CHOMP has been able to achieve effective compliance with these guidelines by initiating broad educational initiatives to both providers and the public.

“We had a CME [continuing medical education] event for our providers — a big lecture on safe pain care. We also educated them about use of California’s prescription drug monitoring program [the Controlled Substance Utilization Review and Evaluation System, or CURES],” Grover explains. “Then we also educated the public that this is what the county believes is safe, and it is in all of our county EDs. In our particular hospital, every patient, no matter what they come in for, gets a copy of these guidelines at discharge, so the public knows what to expect and what we think is safe.”

There has been a general misconception that if a physician prescribes narcotics, such drugs must be safe, Grover adds.

“Between the medical side and the community side, there is a big movement to educate the whole group that these medicines can be really dangerous, so be careful, and let’s monitor them closely,” he says.

As part of this education process, providers receive advice on how to teach patients most effectively about opioids, the potential hazards associated with them, and how to minimize any negative effects, Close adds. Providers also learn about more effective responses when patients report that they need something for pain.

“The reflex is not to write a prescription for [a narcotic]; it is to talk to them about what this means,” she explains. “There are all these different treatment options, and teaching the physicians and the patients that there is not just one answer has really changed all of our practices.”

It is still up to the treating provider ultimately to make decisions about what to prescribe, but now when a decision is made that is counter to the pain management guidelines, a provider generally will approach ED physician leaders to explain why an exception was needed in this particular case. Close notes that there are valid reasons to deviate from the guidelines. For instance, the physician may report that the patient experienced a surgical emergency and he or she thought it was in the patient’s best interest to prescribe an opiate.

Close notes that the issue of opioid prescribing comes up regularly during emergency group monthly meetings, and plans are in the works to study the effect of the opioid guidelines on prescribing and provider decision-making.

Development of the guidelines for the ED at CHOMP was actually a good starting point for more communitywide participation in the overall initiative, Close says.

“Those guidelines were very well thought out and put together, and we gave them to our physicians, and then we said, ‘Hey, the clinics need them,’ and so we took the ED framework and shared it with the clinics, and then we shared [the guidelines] with the community,” she explains. “There was not one person I contacted out of the blue that questioned why we were doing this, so getting people involved ... and getting those ED guidelines, I think, for us, was a big hurdle that really made a difference.”

The original networking that took place to disseminate the guidelines created many other avenues to pursue to tackle the opioid crisis, Grover explains.

“Our contacts with the sheriff’s office turned into us being able to work with them to sponsor drug take-back events,” he explains. Such events provide an opportunity for the public to safely dispose of unused narcotics, ensuring these dangerous medications don’t fall into the hands of people who should not use them.

Similarly, contacts with the district attorney’s (DA’s) office have enabled emergency providers to take a firm stand on prescription forgery and prescription drug diversion, which already has paid dividends, Grover explains.

“The license and DEA number belonging to one of our providers were taken by a patient, and medications were fraudulently called in,” he says. “The DA investigator for healthcare fraud in Monterey County had been through the process with us, so we knew how to advise this provider, and it just all of a sudden made things so much easier to move forward.”

The physician leaders of the MCPSI discovered that much of the work they wanted to pursue was already underway in some fashion in the county — they just needed to knit all these efforts together, Grover explains.

“Doing all this work in the name of safety has been very important. It is not telling a patient that [he or she] is addicted. It is offering to treat a medical disease, and make decisions to choose medicines that are the safest,” he says. “That really inspires people that this is a good program for the community.”

Grover adds that the approach also reduces conflict when a patient presents to the ED with an addiction problem, and the provider conveys that he or she will not refill a prescription for narcotics because the provider is concerned about the patient’s safety.

“The family member will look at you and you look them in the eye and say that you are really concerned for their safety. They know you mean it and they know it is for the right reasons,” he explains.

Whereas prescribing used to be a point of considerable disagreement between patients and providers, “we have now all unified ourselves under the greater goal of safety,” Grover adds.

While MCPSI has slashed prescriptions for narcotics and strengthened the community’s response to the opioid crisis, charting the initiative’s effect on drug overdoses has been difficult. Part of the problem is that the electronic medical record (EMR) system at CHOMP does not facilitate such tracking, Grover explains.

“I am currently keeping a list of all the overdoses because we are planning, as one of the next steps in this project, to start alerting providers that are prescribing scheduled substances when one of their patients overdoses,” he says. “Anecdotally, I have not seen a fatal drug overdose in quite a while, and I can tell you that in 2013 we had around 50 fatal overdoses in Monterey County related to scheduled medications. So, anecdotally, we are seeing fewer overdoses.”

Grover stresses that he is only able to chart the overdoses that people tell him about or those of which he is personally aware, so it is hardly a perfect system. MCPSI leaders hope to devise a better way of tracking such events in the future.

Editor’s note: For more information about the MCPSI, including access to the prescribing guidelines for the ED and other resources, please visit: http://bit.ly/2ccanMw.