Inova Reduces Opioid Prescribing in the ED

Martin Brown, MD, is board certified in Emergency Medicine and he serves as the Chief of the Department of Emergency Medicine at Inova Alexandria Hospital. Dr. Brown has served on the Inova System Opioid Task Force and on the Alexandria City Opioid Work Group. Since 2015, Dr. Brown and the Inova Alexandria Hospital Emergency Department team collaborated to eliminate the use of Dilaudid in the emergency department and decrease the use of opioids by encouraging the use of opioids alternatives to treat acute pain in the emergency department.

We’ve all seen the grim statistics. Opioids kill more than 140 people every day in the United States. They cost our country tens of billions of dollars in treatment and lost productivity each year. Here in Virginia, 1,400 people died of opioid-related drug overdoses in 2016. Despite these devastating numbers, opioids continue to be prescribed at an alarmingly high rate.

Healthcare providers must act now to change the trajectory of this crisis.

At Inova, we are leading the assault with comprehensive approaches to rethink pain management and reverse the opioid epidemic in our community. Emergency Departments (ED) across our system have implemented aggressive measures to:

• Limit the supply of opioids in circulation
• Adopt alternative treatments for acute pain
• Educate and retrain providers and clinicians
• Educate patients to reset expectations
• Identify and treat opioid-dependent patients

We’ve achieved remarkable results. Since 2014, opioid prescribing has dropped approximately 20 percent a year system-wide, and we’ve significantly reduced ED visits by the highest opioid users.

Two of our biggest success stories show a decrease in its use of Dilaudid by more than 80% with adoption of this program:

• Inova Alexandria Hospital ED. In 2016, a multidisciplinary team collaborated with admitting physicians and pain specialists to transform the culture around Dilaudid, one of the most powerful and commonly prescribed opioid analgesics. Evidence-based ordering practices and alternative pain management strategies resulted in a steep drop in Dilaudid orders and overall opioid orders. Patient safety and physician satisfaction improved.
• Inova Loudoun Hospital ED. Inova Loudoun Hospital had comparable results; they implemented the program last year. Dilaudid and opioid orders dropped significantly.

Our ED provider and pharmacy teams continue to find new ways to combat the opioid epidemic, including ongoing review and analysis of provider prescribing patterns, communicating with patients about the risks of and alternatives to opioids. Alternatives to opiates (ALTO) training for providers is offered for optional approaches to treating acute pain; these alternative therapies include:

• Ketamine
• Nitrous Oxide
• Lidocaine IV or transdermal
• Trigger point injections
• Ultrasound guided regional anesthesia
• Enhanced use of COX 1,2,3 inhibitors

In addition, we’ve established an Inova system-wide Opioid Task Force that streamlines our approach to this public health crisis. This program was initially created at Inova Alexandria Hospital and, seeing significant opioids, it was adopted across all of Inova.

The gravity of the opioid epidemic required a profound cultural shift. We believe that real change comes only as physicians, nurses, clinicians and healthcare leaders everywhere commit to a new mindset in pain management. Inova will continue to play a leadership role to make this happen.