Overthrowing Opioids

​"We need to help people view addiction as a chronic medical disease rather than a character flaw or poor choice," says Krisanna Deppen, MD, a family medicine physician at OhioHealth Family Medicine Grant and medical director at Maryhaven, a treatment center in central Ohio. "This is a real need and we have a responsibility to address it."

She continues to double down on this sentiment as a growing chorus of voices and change-makers across OhioHealth join the fight against the opioid epidemic. What is emerging are new and thoughtful ways to better address pain management, and ultimately, avoid the unintended consequences of opioid addiction.

The Naloxone Pilot, Addiction Fellowship and Project ECHO

Dr. Deppen is using her experience to drive change — both in perception and programming — to combat opioid addiction.

"The Naloxone pilot we established in the Grant emergency department is working, but we still need data for clinical validation," said Dr. Deppen. "It's saving the lives of people who have accidentally overdosed."

The pilot, which also is established at OhioHealth Marion General Hospital, OhioHealth Pickerington Medical Campus and OhioHealth Westerville Medical Campus, provides lifesaving Naloxone to reverse the effects of an opioid overdose. It has also opened a pathway for real change, particularly the Addiction Fellowship at Grant. The fellowship is not about opiates, it's about treating addiction as a whole. Every year, two fellows will receive an additional year of training that's specific to substance use disorder.

"There is momentum in the hospital setting that we can no longer view addiction and mental health as someone else's problem, that it will get solved in a different silo of care," said Dr. Deppen. "We need to address it as we would any other chronic disease. With the right treatment, people get better."

Another initiative, Project ECHO, virtually connects patients with primary care doctors in areas where there aren't enough resources or expertise. Dr. Deppen said OhioHealth is leveraging the Project ECHO approach to bring primary care doctors together with pharmacists, pain management specialists and addiction experts to create a virtual team that can collaborate and learn from one another with regard to opioids, pain management and addiction.

"We are at a tipping point and there have been disconnects when it comes to addiction, medicine and treatment," said Dr. Deppen. "Communities are watching to see how we're handling this."

Grant Substance Use Disorder Education Program

Fueled by the epidemic, her involvement in the Franklin County Opioid Action Plan, and the Naloxone ED pilot, Paula Kobelt, DNP, RN-BC, clinical outcomes manager in Quality and Patient Safety at OhioHealth Grant Medical Center, was tasked as part of a process improvement initiative to lead her team to develop substance use disorder (SUD) education for the hospital.

"We learned a lot of healthcare professionals don't fully understand substance use disorder because it isn't part of their training or education," said Kobelt. "We want to improve knowledge and reduce stigma around this medical condition."

Kobelt and her team surveyed hospital staff in late 2017 to identify knowledge and attitude gaps and what people wanted to know. They learned there was an appetite for greater understanding and a need for clinical resources on substance use disorder and treatment.

They developed a three-pronged approach to address these gaps including:

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• An online learning series "Understanding Addiction" produced by Harvard Medical School Global Academy, which provides eight, free CME credits.
• Monthly "Lunch and CME" sessions featuring presentations and group discussion on a topic covered in the online series.
• A dedicated Addiction/Substance Use Disorder for associates with educational resources, like training videos and more.

"We received feedback that the series helped our healthcare team view addiction as a medical condition that is treatable, with recovery as an outcome," said Kobelt.

"The language we use matters," said Kobelt. "Replacing the terms drug addict or drug abuse that labels people and is demeaning with a person with a substance use disorder is an example of person-first language. People with heart disease or diabetes don't feel shame or judgment about their medical condition and individuals with substance use disorder shouldn't either. More importantly, stigma prevents people with SUD from seeking treatment. We want them to seek treatment just as anyone else would."

It Takes a Village: The Dreamland Effect

In and around Athens, Ohio, the opioid epidemic has taken its toll.

"We were seeing a lot of work happening, but really didn't know how to bring people together as a community in a way that shared best practices and didn't duplicate efforts," said Brittany Jarvis, MHA, BSN, RN, nurse manager, cardiac catheterization lab, pain management program and cancer services at OhioHealth O'Bleness Hospital.

Jarvis met with her co-founding member of Athens HOPE, Rebecca Robison-Miller, who serves as senior director of community relations for Ohio University's College of Health Science and Professions, and learned of college dean's desire to do something about the opioid epidemic. Jarvis and Robison-Miller decided to reach out to Sam Quinones, author of Dreamland: The True Tale of America's Opiate Epidemic, inviting him to speak on how the community could work together.

When the author agreed, a three-day series of talks was scheduled, including community events with opioid awareness and discussion for medical staff and forums in Nelsonville and Athens for frontline professionals. The events, co-sponsored by OhioHealth O'Bleness Hospital, Ohio University's College of Health Science and Professions, and the OhioHealth Foundation, reached more than 1,500 individuals and was recently named the Prism System Award Winner for Stewardship in the team category.

"We were dreaming big, but this was bigger than we imagined," said Jarvis. "These events brought medical professionals, educators, police, firefighters, family members affected by opioids, social workers and counselors together. It's been really positive."

"This was a spark for our physician group to take deliberate action," said Brett Kim, vice president of OhioHealth Physician Group's south region. "There is a greater understanding now and our providers think deliberately about pain, addiction and patients who could be prescribed opioids."

Kim said physicians in his region helped initiate four key actions:

• Identifying and sharing best practices for weaning patients from opioids across all practices.
• Securing support for PastRx, a prescription drug monitoring program to help providers understand a patient's history with controlled substances.
• Stocking Naloxone in all clinical offices in the southeast Ohio region and providing training on how to use it.
• Securing grant funding for the first-ever substance and addiction patient navigator.

"For people wanting to know more or who are in a crisis, the navigator will work with providers and help patients get on the right path," said Jarvis. "They also will do important follow-up and step in earlier to help prevent substance issues before they begin."

A New Era for Postsurgical Recovery

For decades, the protocol for patients before and after surgery has been clear — no eating in advance of surgery, ask for pain medication as needed and stay in bed during recovery. But recent research and concern about opioid addiction has paved the way for an Enhanced Recovery After Surgery (ERAS) program.

"Dreamland was an eye-opening read and it motivated me to think about how we use narcotics in our pre-operation, in-hospital and post-operation phases," says Anand Satyapriya, MD, quality medical director of anesthesia at OhioHealth Riverside Methodist Hospital. "I believed we could cherry-pick the best of what was out there in practice and customize it for OhioHealth. I also believed it would reduce the length of stay, provide cost-savings and dramatically reduce narcotic use."

This became Dr. Satyapriya's process improvement project, although it took significant time to present evidence and educate a team on how to employ an ERAS program. He admits it was challenging.

"It goes against what everyone has been taught and trained to do," said Dr. Satyapriya. "The ERAS approach advocates that a carbohydrate-loaded drink before surgery helps with wound healing and insulin resistance after surgery, and that getting up and walking speeds up recovery."

Dr. Satyapriya also said that specific anesthesia techniques are affecting postsurgical need for narcotics.

"Asking, 'What is your pain level?' meant that pain was viewed as a vital sign and treated with narcotics," said Dr. Satyapriya. "Previously, doctors wouldn't want to see you again for six weeks and would prescribe medication to last as long. We need to ask how they feel and exhaust all alternatives to opioids first."

Preparing for ERAS took six to nine months. A group of 30 to 40 colorectal surgery patients without chronic pain were selected during the program's first three months in 2017.

The results were convincing and worth the effort.

"We saw length of stay drop from 3.3 days to 2.9 days with a financial analysis suggesting a quarter million dollar savings across 150 patients," said Dr. Satyapriya. "And among our first 40 patients, only two took an IV of narcotics."

ERAS has already been used with more than 250 colorectal, orthopedic and gynecology patients, and Dr. Satyapriya looks to share the approach across the OhioHealth system.

"We are trying to innovate and use everything in our toolbox to avoid narcotics," said Dr. Satyapriya. "The risk is real. ERAS is making a difference."

This story was originally published in an internal OhioHealth associate publication.