Though rates of illicit drug use are on the rise across the United States, opioid addiction leading to death by overdose often begins with a doctor’s well-meaning prescription for pain medicine.
Ohio, where two of us (A.M. and J.T.) work as physicians, has been particularly devastated by opioids. In 2016, Ohio reported more than 4,000 deaths from unintentional drug overdose (a 33 percent increase from the previous year), one of the highest totals in the country for this preventable cause of death. As a country, approximately 140 Americans are lost to opioids every day — a death toll equal to one Sept. 11 attack every three weeks. There appears to be no downturn in sight.
In Cleveland, an epicenter of Ohio’s opioid problems, an innovative program established by the Veterans Affairs health system has helped reduce opioid prescribing by nearly 25 percent since 2010, compared to a less than 10 percent reduction elsewhere in the region and approximately 12 percent reduction nationally.
And among the most potent prescription opioids, such as hydrocodone and oxycodone — the ones most likely to lead to death or disability from abuse — there was a 50 percent reduction in prescribing from 2008 to 2015. Among all VA hospitals in the continental United States, the Cleveland VA health system ranked best for the fewest opioid prescriptions dispensed per patient at the height of the prescription opioid epidemic in 2012.
How the Cleveland VA system did that at a time when opioid overdose deaths are rising in the country overall may offer lessons for others as we come to grips with this preventable epidemic.
The Cleveland VA created a culture of low-opioid reliance through four guiding principles:
- A unified message of adherence to evidence-based pain-management practices
- Safe pain medication prescribing
- Use of innovative technologies
- System-wide sharing of best practices
These four principles were the foundation on which a flagship program to reduce opioid use was created in 2011: the VA Specialty Care Access Network — Extension for Community Health Care Outcomes (VA SCAN-ECHO) project. It uses video teleconferencing technology to link a multidisciplinary pain management specialist team, located at Cleveland’s main VA hospital, with primary care providers at community-based VA outpatient clinics throughout northeast Ohio.
Weekly 90-minute training sessions make it possible for pain specialists to share their expertise with primary care providers using a lecture format as well as real-time consultation on actual patient cases.
SCAN-ECHO team members aim to reduce opioid prescribing across the Cleveland VA system. They do this in various ways. One is to work with providers to help them taper their patients off opioid pain relievers and transition them to non-opioid pain medications such as gabapentin and pregabalin. They also help providers identify noninvasive and invasive interventions that provide pain relief and restore function. Because opioid prescribing varies widely across physicians, sometimes by as much as threefold among providers practicing in the same hospital, the SCAN-ECHO team also aims to provide guidance on appropriate opioid prescribing for patients who are legitimate candidates for these medications.
At these teleconferences, primary care providers share their opinions on how specific patients’ pain might be managed, with the discussion facilitated by the Cleveland VA pain management team. The pain management recommendations for each patient reflect a best practice model of care.
The one-year curriculum trains primary care providers to care for patients with various common pain management issues and develops working relationships between these providers and pain management specialists. In the wake of the program’s rollout, wisdom and expertise in evidence-based pain management have spread throughout the entire Cleveland VA primary care network, resulting in markedly diminished utilization of opioids to treat chronic pain.
Creating a culture of safe opioid prescribing requires knowledge, institutional investment, and a technological platform that facilitates interactions between health care workers who are involved in treating patients with acute and chronic pain. The outcomes of the Cleveland VA approach to pain management demonstrates that it is possible to improve physicians’ opioid prescribing patterns. An approach like this could easily be replicated — and should be robustly evaluated — in other health care systems to help stem the tide of the opioid epidemic.
Ali Mchaourab, M.D., is chief of the Pain Medicine Service at the Louis Stokes Cleveland VA Medical Center, associate professor of anesthesiology at Case Western Reserve University, and director of the Cleveland VA SCAN-ECHO Center in Cleveland. Jason Tuckerman, M.D., is a physician and research fellow at the Louis Stokes Cleveland VA Medical Center. Anupam B. Jena, M.D., is associate professor of health care policy and medicine at Harvard Medical School and a research fellow at the National Bureau of Economic Research. Drs. Mchaourab and Tuckerman have nothing to disclose. Dr. Jena has received consulting fees from Pfizer, Inc., Hill Rom Services, Inc., Bristol Myers Squibb, Novartis Pharmaceuticals, Vertex Pharmaceuticals, and Precision Health Economics, a company providing consulting services to the life sciences industry.