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Four Effective Opioid
Interventions for
Healthcare Leaders
̶ Heather Schoonover

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The Opioid Crisis
At one time, pain was undertreated, even among
patients dying from cancer, and opioids were
reserved to treat only the most severe pain.
Pharmaceutical companies began aggressively
developing and selling different configurations
of opioids (long acting, different routes, etc.),
deeming them safe for patients.
Regulatory boards and professional
organizations, such as the American Pain
Society, began pushing against the
undertreatment of pain.

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The Opioid Crisis
Social attitudes toward opioids changed, as
did clinician prescribing patterns, as they
attempted to relieve their patients’ pain.
Now, the U.S. is facing an opioid epidemic.
The increase in prescribing patterns has
led to the increased availability of opioids
and the potential to overuse them by the
patient it was prescribed for.
In many cases misuse by others who beg,
borrow, or steal the opioids from the
intended patient, the so-called “non-
medical use of opioids”.

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The Opioid Crisis
The facts from the CDC about this public health
problem are sobering:
Since 1999, overdose deaths involving opioids
have quadrupled, and sales of opioids have
almost quadrupled.
More than six out of every ten drug overdose
deaths involve an opioid.
On an average day, 3,900 people initiate
nonmedical use of prescription opioids and 78
people die from an opioid-related overdose.
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The Opioid Crisis
Figure 1: CDC map outlining variability in opioid prescriptions state to state

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The Opioid Crisis
Because misuse is a multifactorial problem,
multiple opioid interventions are required to
combat the epidemic.
But there are steps healthcare organizations
and prescribers can take—both process and
data driven—to decrease the risk of harm
from opioids.

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The Call for Opioid Intervention
While we healthcare providers absolutely need
to do our best to alleviate pain and suffering,
there is evidence that suggests non-medical
opioid use is associated with heroin abuse, and
that even appropriate medical use increases
the risk of chronic opioid use.

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The Call for Opioid Intervention
A recent publication from the CDC evaluated the
impact of early opioid prescribing patterns on
opioid-naïve patients.
The findings reveal the risks:
A second opioid prescription doubles the risk for
opioid use one year later
Risk increases with each additional day of opioids
supplied, starting on day three
The sharpest increase after the fifth and 31st day
of therapy, a second prescription refill, 700
morphine equivalent cumulative dose, and an
initial 10- or 30-day supply.
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Four Approaches to Confront the Opioid Epidemic
Data, analytics, and best practices can be used to
identify opportunities for improvement and drive the
prevention of opioid misuse and overdose:
1. Use Data and Analytics to Inform Strategies that
Reduce Opioid Availability
2. Adopt Prescription Drug Monitoring Programs to
Prevent Misuse
3. Adopt Evidence-Based Guidelines
4. Consider Promising State Strategies for Dealing
with Prescription Opioid Overdose

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Four Approaches to Confront the Opioid Epidemic
Use Data and Analytics to Inform Strategies that
Reduce Opioid Availability
Healthcare systems, payers, and prescribers can use
data and evidence to change practices and reduce
the opioid availability within the community.
Payers have access to rich data they can
use for improvement.
This data can be evaluated and provider-
specific data shared with individual
prescribers.
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Four Approaches to Confront the Opioid Epidemic
Use Data and Analytics to Inform Strategies that
Reduce Opioid Availability
For example, Aetna actively analyzes its claims database
and intervenes if there is evidence of abuse.
It notifies physicians if patients are taking more than
three opioids, or if they have multiple prescriptions.
This opioid oversight program reduced opioid
prescriptions by 14 percent between 2010
and 2012 among 4.3 million members.
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Four Approaches to Confront the Opioid Epidemic
Use Data and Analytics to Inform Strategies that
Reduce Opioid Availability
In 2016, Aetna evaluated prescribing patterns and the CMO
sent personal letters to nearly 1,000 prescribers—the top one
percent—who refill prescriptions at a much higher
rate than their peers.
At times higher amounts of opioids are
clinically appropriate and should be prescribed.
Sharing data creates the opportunity for prescribers
to evaluate their prescribing patterns relative to
their peers and adjust where appropriate.
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Four Approaches to Confront the Opioid Epidemic
Adopt Prescription Drug Monitoring Programs to Prevent Misuse
States can increase the availability of Prescription Drug Monitoring
Programs (PDMPs) and availability of data from other state PDMPs.
Vendors need to integrate all available state
data into EHRs, improving the workflow
and ease of use for prescribers.
State regulatory boards can help
communicate evidence-based
dosing guidelines, increase
education opportunities and
ongoing education requirements
for prescribers.
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Four Approaches to Confront the Opioid Epidemic
Adopt Prescription Drug Monitoring Programs to Prevent Misuse
PDMPs help providers identify patients who
might be misusing their prescription drugs.
Following the implementation of statewide
PDMP programs and requiring prescribers
to check the PDMP prior to prescribing,
New York saw a 75 percent decrease,
and Tennessee a 36 percent decrease,
in patients who were seeing multiple
prescribers to obtain the same drugs.
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Four Approaches to Confront the Opioid Epidemic
Adopt Evidence-Based Guidelines
Washington state implemented evidence-based dosing guidelines
which includes:
Dosing threshold trigger for consultation with
pain specialists, criteria to be considered
a pain specialist.
Elements for patient evaluation.
Periodic review of the patient’s
treatment plan.
Exemptions for special circumstances.
Continuing education requirements.
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Four Approaches to Confront the Opioid Epidemic
Adopt Evidence-Based Guidelines
The state also obtained additional funding for the PDMP.
These changes are believed to have contributed to
a 27 percent reduction in opioid deaths between
2008 and 2012.
Primary care providers account for approximately
50 percent of all dispensed prescription opioids.
Individual prescribers, particularly those within
primary care, should be familiar with, and use,
the most recent evidence when making decisions
regarding the treatment of chronic pain.
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Four Approaches to Confront the Opioid Epidemic
Adopt Evidence-Based Guidelines
The CDC Guideline for Prescribing Opioids for
Chronic Pain can help providers make informed
decisions about pain treatment for patients 18 and
older in the primary care setting.
The ED is the largest ambulatory source for opioids.
Prescribers within the ED can make use of the
opioid prescribing resources made available by the
American College of Emergency Physicians, and
should limit prescribing opioids for chronic pain to
only the immediate treatment of an acute
exacerbation of uncontrolled pain.
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Four Approaches to Confront the Opioid Epidemic
Adopt Evidence-Based Guidelines
When prescribing opioids, prescribers
need to check the PDMP, use the
lowest possible effective dose, and
start with immediate release opioids
rather than long-acting opioids.
The quantity prescribed should align
with the expected duration of the pain.
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Four Approaches to Confront the Opioid Epidemic
Consider Promising State Strategies for Dealing with
Prescription Opioid Overdose
States can use data from PDMPs, Medicaid,
workers’ compensation programs, and state-
run health plans to identify pain clinics that
may be prescribing opioids in ways that are
risky to patients, so they can address
inappropriate prescribing.
Many states also need to increase access to
substance abuse treatment services and
medication-assisted treatment services.
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Four Approaches to Confront the Opioid Epidemic
Consider Promising State Strategies for Dealing with
Prescription Opioid Overdose
Increases in the availability of naloxone,
Good Samaritan laws, and education
for the public regarding the safety and
utility of naloxone can reduce the
number of overdoses.
Between 1996, when naloxone was first
made available to laypersons, and June
of 2014, more than 150,000 naloxone
kits were distributed, and 26,463
overdoses were reversed.
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How Allina Health Reduced Opioid Prescriptions
by One Million Pills in One Year
Using data from the enterprise data warehouse, Allina
Health obtained data on prescribing patterns, shared it
with providers, and identified several opportunities to
reduce the number of opioids prescribed.
The Allina Health team evaluated prescribing patterns in
relation to national guidelines and evidence, and
instituted guidelines for primary care providers, including:
Avoiding long-acting opioids.
Prescribing less than 20 opioid pills per prescription.
Limiting the duration to less than five days, unless it is
assessed that the injury or medical condition will last longer.
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ONEYEAR
ONEMILLION
Allina Health prescribed nearly one million fewer opioid pills in the
outpatient setting in just one year.

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The Opioid Epidemic is a Public Health Problem
with a Treatment
It is critical that healthcare providers continue to work to alleviate
pain and suffering.
At the same time, it is increasingly important that
each of us involved in the delivery of healthcare,
use data, analytics, and evidence-based
practices to inform prescribing patterns,
identify potential misuse, and change
practices to minimize opioid misuse
and overdose.
Patients are relying on us to relieve
their pain without inadvertently
increasing the risk that they will be harmed.

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For more information:
“This book is a fantastic piece of work”
– Robert Lindeman MD, FAAP, Chief Physician Quality Officer

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More about this topic
Link to original article for a more in-depth discussion.
Four Effective Opioid Interventions for Healthcare Leaders
Combatting Opioid Abuse with Data-Driven Prescription Reduction – Executive Summary
How to Use Data to Improve Patient Safety
Stan Pestotnik, MS, RPh, VVP, Patient Safety Products
Valere Lemon, MBA, RN, Senior Subject Matter Expert
The Best Way to Use Data to Determine Clinical Interventions
Cherbon VanEtten, Director of Education
The Top Five Essentials for Outcomes Improvement
Ann Tinker, Engagement Executive, VP; Leslie Hough Falk , Senior VP
Improving Patient Safety and Quality through Culture, Clinical Analytics, Evidence-Based
Practices, and Adoption – Leslie Hough Falk , Senior VP

25.
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Heather Schoonover has more than 20 years’ experience in nursing and healthcare. Prior to joining
Health Catalyst, she was a director of professional practice at PeaceHealth and was responsible for
improving patient safety and outcomes, organizational outcomes, leader and staff competency, and
the nurse practice environment. Heather developed and implemented best practice and evidence-
based nursing care standards, facilitated practice changes throughout the organization, and ensured
appropriate integration of nursing standards and workflow into the EHR. Heather has
served as adjunct faculty teaching entry level nursing students, and has held pro tem appointments with the
Washington State Nursing Care Quality Assurance Commission (the state regulatory board for nursing) as a
member of the advanced practice sub-committee, and as a reviewing commission member, reviewing cases of
alleged misconduct and participating in disciplinary hearings. Heather has a Master of Nursing degree from
Washington State University, and is board certified by the American Nurses Credentialing Center as a clinical nurse
specialist in public and community health. Heather has been the recipient of leadership awards from both Sigma
Theta Tau, the International Honor Society for Nursing, and the Northwest Organization of Nurse Executives.
Other Clinical Quality Improvement Resources
Click to read additional information at www.healthcatalyst.com
Heather Schoonover