Inova is taking steps to protect patients and reduce opioid use

Prescription for Safety

The statistics are staggering. According to the Centers for Disease Control and Prevention, every day 91 Americans die from an opioid overdose.

In response to the growing problem of opioid addiction in the community, Inova emergency personnel are working closely with all of the hospital departments and across the system to adopt a highly effective standardized approach to treating pain.

To deter opioid addiction locally, the emergency rooms at Inova Loudoun Hospital and Inova Fair Oaks Hospital are taking actions to reduce opioid use, both in the emergency setting and after a patient is discharged.

“We recognize that there is a national and local crisis with opioid overdoses,” says Edward Puccio, MD, FACEP, Medical Director of the Emergency Room at Inova Loudoun. “In some cases, evidence has shown that first exposure to opiates occurs at a hospital or during an ER visit. In 2016, we decided to try to decrease exposure whenever possible while still being mindful to adequately meet our patients’ needs.”

The efforts are working. Thanks to the initiative, the Inova Loudoun ERs (Lansdowne, Leesburg and Ashburn) have reduced physician orders for hydromorphone (Dilaudid) by an average of 83 percent. And efforts are being translated to the inpatient side of the hospital as well.

Inova’s opioid reduction initiative

The opioid reduction initiative involves:

1. Educating hospital personnel about alternative medications that may be used in the place of narcotics,
2. Monitoring opioid prescriptions through a state database,
3. Educating patients and families about their options, and
4. Providing a continuum of care to resolve each patient’s pain issues.

“Education is a large component of the program,” says Dr. Alexander-Nicholas Sutingco, Director of the Emergency Department at Inova Fair Oaks. “We want our providers to know that a lot of painful conditions can be managed with non-opioid treatments.”

“Our goal has always been to treat pain safely, effectively, compassionately and also judiciously without putting patients at an increased risk for abuse or addiction,” says board-certified emergency physician Sameer Mehta, MD. “The initiative was launched in response to the crisis we saw locally. We still remain committed to the excellent care of our patients and managing their pain appropriately.”

Dealing with pain: Narcotic alternatives

As part of its protocol, Inova hospitals are exploring the use of non-narcotic alternatives in the acute ER setting. These include ketorolac (Toradol), intravenous lidocaine, lidocaine patches (Lidoderm) and nitrous oxide. “We’re moving away from highly potent, fast-acting, long-lasting medications that have a euphoric effect to other medications that are shorter-acting — just to control the painful episode for the patient,” explains Dr. Puccio. “We’ve seen a dramatic reduction in the use of particular opioid medications that have been found to lean more toward potential addiction in vulnerable patients.”

Despite the shift away from opioids as a first-line therapy, patients will continue to receive individualized care at emergency rooms and, when appropriate, will be treated with opioids such as morphine and hydromorphone. “There are times where it’s appropriate to use opioid medications, such as if someone has a broken leg or a major trauma,” says Dr. Mehta. In instances where opioids are necessary, patients are given a lower dose for a shorter period of time.

Understanding patients’ medication history

Inova’s initiative meets new regulations regarding opioid use approved in 2017 by Virginia’s Board of Medicine. In compliance with the regulations, when a patient is admitted to the ER with painful symptoms, the staff accesses the National Prescription Drug Monitoring Program to determine whether the patient is already being treated with narcotic medications.

“This information is taken into consideration when we devise our plan to relieve a patient’s painful episode,” says Dr. Puccio. “If we feel the patient may be at risk for addiction — or may benefit from alternative options — we have a frank discussion with the individual about their use of opiates. Our goal is to develop a strategy together to relieve the patient’s pain without continuing down the path for potential addiction.”

Dr. Sutingco notes that community resources are part of the plan as well: “We are more knowledgeable about the resources in our community, so we’re able to make sure that patients have adequate follow-up and are guided toward the specialist who can ultimately provide definitive care if the patient’s condition does not improve in a few days,” he says. “We want to be part of a solution, not part of the problem.”

Pain control after the ER

To ensure pain continues to be well-controlled, Inova connects chronic pain ER patients with a variety of medical specialists. “We have a very robust program with on-call medical specialists who can help us manage a patient’s painful condition or injury. This includes developing a plan for pain control moving forward,” says Dr. Puccio.

Once a patient is discharged from the ER, emergency personnel prescribe non-narcotic medications as a first-line treatment when appropriate. The new protocol is designed to limit the number of prescriptions for powerful opioids such as hydrocodone (Vicodin) or oxycodone (OxyContin, Percocet).

Dr. Puccio is pleased with the initiative so far: “We have more to do, but we are making a difference, and that’s what matters.”

Opioid overdose rates in Northern Virginia

In 2016, there were more than 100 drug overdose deaths in Fairfax County, the highest of any jurisdiction in Virginia; 80 were opioid-related (compared to 60 in the previous year). The same year, in Loudoun County, at least 17 of nearly 80 opioid overdoses were fatal. That represented an increase from 2015, when 10 out of 49 overdoses were fatal.

“Deaths due to opioid addiction have increased over the last several years, and we are responding to the crisis,” says Dr. Mehta. “We are looking critically at what we can do as physicians day-to-day in the emergency department that will have an impact.”

Drug addiction by the numbers

Source: Centers for Disease Control and Prevention
91 The number of Americans who die every day from opioid overdoses (which includes prescription opioids and heroin).

>6/10 The number of drug overdose deaths that involve an opioid.

>500,000 The number of people who died from drug overdoses from 2000 to 2015.

> x4 The amount that deaths from prescription opioids, such as oxycodone, has grown by since 1999.

Opioid Addiction in Virginia

To learn more about opioid addiction in the state of Virginia, visit the Virginia Department of Health website at www.vdh.virginia.gov/commissioner/opioid-addiction-in-virginia.