The Institute for Healthcare Improvement (IHI) has collaborated with the Boston Medical Center (BMC) to provide a set of best practices for reducing morbidity and mortality related to opioid use disorder, focusing on practical steps that can be taken immediately.1
Simply reducing the number of opioid prescriptions is not enough, the report authors wrote. Hospitals must be much more proactive in identifying patients with opioid use disorder and initiating treatment wherever those patients are encountered within the treatment process.
The Agency for Healthcare Research and Quality (AHRQ) reports that in 2016 the rate of opioid-related inpatient stays in U.S. hospitals was 300 per 100,000 population. That is twice the rate in 2008.2 In addition, the number of opioid-related ED visits more than doubled from 2008 to 2017.
The report from IHI and BMC encourages hospitals and health systems to focus on five areas:
- Identify and treat individuals with opioid use disorder at key clinical touchpoints;
- Modify opioid prescribing practices to minimize harm and maximize benefit;
- Train stakeholders on the risks of opioid use disorder and how to reduce stigma;
- Identify and screen individuals at high risk of developing opioid use disorder;
- Reduce the harms of substance use disorder.
The suggestions in the report should help hospital leaders who want to do more to address the opioid problem, says Michael Botticelli, co-author of the report and executive director of the Grayken Center for Addiction at Boston Medical Center in Massachusetts.
It has been known for some time that hospitals are key touchpoints for people with substance use disorder, and they are underused in addressing these patients’ needs, adds Botticelli, who served as the director of the White House Office of National Drug Control Policy under President Obama.
“There are significant opportunities for hospitals and health systems to not only prevent opioid use disorders but also to implement what have been proven to be good evidence-based strategies to identify people and initiate treatment,” he says. “There has been wide variation in hospital responses to the opioid epidemic ... if hospitals have been doing anything, it’s largely centered on their opioid prescribing. That’s a good first start, but clearly there are lots of great examples of hospitals going way beyond their prescribing.”
The first tactic emphasizes initiating treatment at key clinical touchpoints, Botticelli says, because AHRQ data indicate a significant increase in ED visits related to opioids.2
Those visits are not seen routinely as opportunities to intervene and address the patient’s substance use disorder in a meaningful way, he says.
“This is where emerging evidence meets clinical practice. A study from Yale New Haven showed that initiating treatment within the emergency department has significantly better engagement rates for people with opioid use disorder than the current common practice of giving people a list of referrals for treatment, or sometimes doing nothing else,” Botticelli says. “There is good evidence to show that initiation of treatment within the emergency department, particularly the use of buprenorphine, is a key opportunity.”3
Significant Effects Possible
Initiating such treatment in the ED improves patient engagement with treatment but also significantly reduces the chance of overdose, Botticelli says.
Also, there is a unique opportunity for hospitals to pursue treatment with patients who are hospitalized for the effects of their substance use disorder, he says. For instance, patients with endocarditis can be offered ongoing treatment that not only reduces mortality but also subsequent admissions and hospital stays, which introduces a cost saving element.
The report includes case examples to illustrate how hospitals can implement practical improvements, rather than providing theoretical guidance. One example comes from the Johns Hopkins Bayview Medical Center Inpatient Addiction Consult Service, which provides information for inpatients with substance use disorder.4
Available throughout the facility, the service offers “brief behavioral interventions and counseling, guidance on clinical management, brief buprenorphine/naloxone bridges, education, and facilitates linkages.”
Early data from the service suggest that it made patients less likely to have more than three ED episodes and more likely to have more than one ambulatory care visit, according to the IHI/BMC report.
“We hope that institutions will look at this as sort of a road map on programs that can address opioid use disorder and use these examples as a yardstick against their own actions to date,” Botticelli says. “There have been so many guidance documents out there ... but we tried to synthesize the guidance into one document that provides some practical options that can be implemented now.”
Systems Problem, Not Prescriptions
The report also indicated that healthcare leaders should think of the opioid and pain crisis as a systems problem, says Mara Laderman, MSPH, report co-author and senior research associate at the IHI in Boston. It is not sufficient to reduce the number of opioid prescriptions, she says.
“They need to be thinking about the different points at which patients will be interacting with the health system, whether they have an opioid use disorder or might be developing one,” Laderman explains. “One theory on why there hasn’t been enough progress toward reducing overdose deaths, given the financial and human resources that have been going into addressing this problem, is that current approaches have been focused on isolated parts of the system and not necessarily in a coordinated way.” One of the most important things that hospitals can do is to enhance the capacity of clinicians to provide medication-assisted treatment, Laderman says. Currently, clinicians must apply for an X waiver to treat opioid use disorder with buprenorphine, and many clinicians do not have the waiver, she says. (Learn more at: .)
“Hospitals can assist [clinicians] in getting the waiver and encourage them to get it. This may mean making it a requirement that residents have an X waiver, for instance,” she says. “The next step is to ensure that those clinicians are actually using those waivers where appropriate in the ED or elsewhere. You have to make sure the clinicians have the capacity to provide the buprenorphine, and then make sure they are actually providing that care at those points where they interact with those patients.”
- Botticelli M, Gottlieb M, Laderman M. Effective strategies for hospitals responding to the opioid crisis. Boston: Institute for Healthcare Improvement and The Grayken Center for Addiction at Boston Medical Center; 2019. Available at: . Accessed Dec. 2, 2019.
- Healthcare Cost and Utilization Project. Opioid-related hospital use. Available at: . Accessed Dec. 2, 2019.
- D’Onofrio G, Edelman EJ, Hawk KF, et al. Implementation facilitation to promote emergency department-initiated buprenorphine for opioid use disorder: Protocol for a hybrid type III effectiveness-implementation study (Project ED HEALTH). Implement Sci 2019;14:48.
- Johns Hopkins Bayview Medical Center. Addiction medicine. Available at: . Accessed Dec. 2, 2019.
- Michael Botticelli, Executive Director, Grayken Center for Addiction, Boston Medical Center. Phone: (617) 414-6926.
- Mara Laderman, MSPH, Senior Research Associate, Institute for Healthcare Improvement, Boston. Phone: (617) 301-4800.