Massachusetts ranks among the top 10 states with the highest rates of drug overdose deaths involving opioids. In 2016, the number of opioid-related deaths in Massachusetts was rising rapidly and would peak at nearly 2100 that year (30.5/100,000 residents and a 21% increase from 2015).1 In response, Beth Israel Deaconess Medical Center (BIDMC), a Harvard Medical School teaching hospital, created an Opioid Task Force. The task force identified several needs: a bridge clinic for patients initiating medication-assisted treatment (MAT) for opioid use disorder (OUD), an addiction consultation service, patient management and therapeutic support for office based MAT (OBOT), physicians waivered by the Drug Enforcement Administration to prescribe buprenorphine (“X-waivering”), assorted guidelines and policies, established relationships with community providers of OUD care, and alternatives to opioids for pain management. Finally, they recommended establishing a committee to lead systemwide efforts related to opioids and OUD. This was the origin of the Opioid Care Committee (OCC), part of BIDMC’s Annual Operating Plan in 2017.
Several of the chapters included in this volume of International Anesthesiology Clinics were authored by members of the committee and showcase the breadth and depth of expertise that was, and is, available to the OCC and its mission. However, it also points to the complexity of the issues surrounding opioid use and misuse. We know that overprescribing of opioid medications may lead to misuse by the patient or diversion to others, but we still need to treat pain. Treatment of OUD is subject to provider bias, lack of resources, and substantial relapse risk. MAT is evidence-based, but remains underutilized.
The OCC is multidisciplinary and multispecialty, and reports directly to the Chief Medical Officer and the Medical Executive Committee. Members run the gamut of specialties and roles including pain management, surgery, primary care, hospital medicine, psychiatry, social work, nursing and patients, among others, and a project manager. This breadth is meant to ensure a comprehensive approach for prescribing of opioids, treatment of OUD, and multimodal pain management. The initial OCC objectives, as defined by the committee charter, were to: (1) implement an Addiction Treatment Team model and comprehensive approach to OUD; (2) meet recommendations for established best practices for opioid use; and (3) comply with Federal and State regulatory requirements.
The initial activity of the team included a gap analysis and a great deal of brainstorming. Workgroups were formed, covering assessment, prescribing, treatment, communication, education of patients and providers, monitoring, and reporting. A Possible, Implement, Challenge and Kill chart exercise (Fig. 1) was used to prioritize where best to begin and create tangible goals. Members were asked to volunteer to work in the group where they had the most interest and/or impact; these groups have shifted as various goals are completed and new ones arise (Fig. 2). Each group has a volunteer lead, and meets outside of the monthly OCC meetings to work, providing reports back to the committee as a whole and getting support and feedback from the larger membership. Enthusiasm has not been lacking, as each committee member also has a personal or a professional stake in some aspect of the group’s mission.
Information technology has been both a source of early gains and some frustrations. Our electronic medical record now has a single sign-on to the Massachusetts prescription monitoring program and the ability to indicate the option for partial filling of opioid prescriptions. An online internet portal was created to act as a repository of information for providers within our system. An opioid patient fact sheet authored by OCC members prints upon discharge of a patient with an opioid prescription; the patient’s primary care provider is also notified through the electronic medical record. However, collating, distributing, and utilizing prescriber data, so important for changing practice, have proven more challenging and continues to appear on our annual to-do list.
An addiction psychiatrist and nurse practitioner were hired to add to existing social work and advanced practice nurse resources, and an addiction psychiatry clinic opened for business. A virtual pager directs addiction consults through the psychiatry consult service, although questions still remain amongst providers about when this consult should be activated versus care being initiated by a hospitalist or other engaged team member. The addiction psychiatry service provides a bridge clinic, and our primary care group, Healthcare Associates, offers a steadily growing OBOT service as well. However, access for patients outside of our network can be more difficult to navigate.
Some goals were created or accelerated by legislation. For example, Massachusetts now requires emergency department access to MAT. This resulted in a rapid deployment of resources targeted to X-waivering of all emergency medicine physicians and creation of pharmacy pathways for dispensing buprenorphine “starter kits.” The letter of the law was met, and yet, uptake by patients has thus far been limited, suggesting that a different or an additional approach may be needed.
Perhaps the most significant challenge is culture change. Opioid prescribing practices and patient expectations regarding pain management have been embedded in US medical practice for decades. Education on appropriate prescribing has been shown to reduce the quantity of opioids prescribed without increasing the rate of patient refill requests in the postoperative period. Right-sizing opioid prescriptions will avoid creating an excess supply for patient use and possible diversion to the community, while still treating pain appropriately. We have mandated online education for trainees, which we plan to extend to our advanced practice providers and faculty at a later date. Patients must also be educated—nurses play a key role here, reinforcing instruction with printed materials available in a variety of languages.
What has been gained from the creation of the OCC is the ability to collate resources, eliminate redundant efforts in a system without much time or bandwidth for redundancy, and connect providers across silos to provide better care for patients. The care of the patient with OUD, while improving, is not yet easy or seamless. Also, complications of opioid therapy continue to occur. However, the OCC, and like-minded groups elsewhere, must continue to work and share successes to achieve the best possible outcomes for our patients. I hope that this issue of International Anesthesiology Clinics might contribute to that effort.
Conflict of interest disclosure
The authors declare that they have nothing to disclose.
The authors would like to acknowledge the contributions of the late Donna Martin, RN, in her role as first project manager of the OCC.