The rise of opioid addiction has brought pain, suffering and death to families and communities across the United States. According to the U.S. Centers for Disease Control and Prevention, more than 28,000 people have died from overdoses in this country in 2014—quadruple the rate in 2000. Massachusetts has one of the fastest-growing overdose death rates, increasing 18.8 percent between 2013 and 2014.
Scott Weiner, MD, MPH, FAAEM, FACEP, a physician in the Department of Emergency Medicine, founded the Brigham Comprehensive Opioid Response and Education (B-CORE) program at the hospital earlier this year. The group is working to standardize a multidisciplinary response to the opioid epidemic.
BWH Clinical & Research News asked Weiner, the director of B-CORE, about how BWH is tackling this complex and urgent public health crisis.
What led you to organize BCORE?
SW: Over the last two decades, I have seen a significant increase in the number of opioid prescriptions given to patients, including in the Emergency Department (ED). As this was going on, I saw more and more overdose patients coming in to the ED on nearly every shift, almost to the point that it became normal. We typically provide patients who had overdosed with naloxone—an antidote for opioid overdoses—and observe them for a short time before discharging them. It does not feel like a long-term solution.
I began doing research on Massachusetts’ Prescription Drug Monitoring Program (PDMP), the state database of prescribed opioids or similar medications. I was involved in trying to get that system up and running because it is so valuable for practitioners. When I came to the Brigham in 2014, I noticed various groups were working on ways to tackle this devastating epidemic, but these efforts were siloed. It became clear that the Brigham needed to adopt an institution-wide response. I was awarded a Nesson Fellowship, which recognizes health professionals interested in health policy, based on my passion for this cause. The grant associated with the fellowship helped us get B-CORE off the ground.
What are B-CORE’s goals and who oversees this effort?
SW: Our goal is to develop a comprehensive program that measurably demonstrates the implementation of guidelines for addiction prevention, opiate prescribing, management of chronic pain, management of opioid addiction through technology and outreach data for clinicians and clinical training. We have an executive committee that represents leadership from the whole hospital, including executives from the departments of Nursing, Medicine and Information Systems, among others. BWFH, Dana-Farber and multiple affiliated community sites are represented. In addition, we have champions from various clinical areas, including Addiction Psychiatry, Pain Management and Orthopaedics. These groups are developing projects for their own constituents, and our role is also to help foster those efforts. B-CORE is an umbrella and belongs to the whole hospital and community to provide support for all opioid-related projects.
Addiction is a complex disease. From an organizational perspective, how is B-CORE approaching it?
SW: There are two task forces: the prescribing task force and the addiction task force. The prescribing task force is working on the guidelines for the patients who are not yet addicted and figuring out how we can safely prescribe painkillers to them. The addiction task force is working to increase access to medication-assisted treatment, such as suboxone—a medication that treats opioid dependency—and establishing a bridge clinic that would temporarily take care of patients while they look for long-term treatment programs.
What changes has the program instituted so far?
SW: We facilitated the distribution of naloxone in the form of a kit provided to at-risk patients in the ED. If a patient has suffered an overdose and comes into the ED, physicians can give the kit to the patient at discharge. Patients have the ability to ask over-the-counter pharmacies for naloxone, but the stigma associated with the antidote is often a barrier. As health professionals, it is in our best practice to be administrators of naloxone in the ED. Our security guards are now also beginning to carry this antidote, since they are often among the first to respond to these events in the outpatient setting.
In addition, we have started a drug “take-back” option through the outpatient pharmacy. Patients can now bring leftover medication to our pharmacy, where it will be disposed of properly.
We are also working with the Partners eCare team to prepare for new legislation going into effect in October that will mandate that every patient must be looked up in the PDMP before an opioid can be prescribed. We are actively working to simplify how prescribers access the database by creating a single login, with the goal that every time a prescription for an opioid is written, the PDMP record for that patient will automatically appear in eCare.
Based on your experience, what is the best answer to the opioid crisis?
SW: I think it is helpful to view this complex issue as affecting two groups of patients: the “opiate-naïve” and those with an existing addiction. The opiate-naïve patients have not been exposed to these strong pain management medicines before. We need to do a better job of educating, screening and cautioning these patients about the risks associated with the medications before prescribing. We must educate this group on taking the medication as prescribed and, when done, to return it to the drop box at the pharmacy. Prescribers have to do a better job of limiting the number of pills we give—for example, most patients will not require 90 tablets even after a major surgery, and leftover pills are sometimes abused or diverted. So education of prescribers is also fundamental. I like to think about these medications like antibiotics—that is, we don’t give the strongest antibiotic to every patient with a strep throat. We need to be better stewards of opioids and tailor the type, strength and pills prescribed to the specific patient.
On the flipside, patients with existing opioid dependency need to be treated in a more sophisticated manner. We need to co-prescribe naloxone for patients on high doses of opioid pain medicine. For patients with substance use disorder, we need to expand access to medication-assisted treatment, such as suboxone. We need to treat this like other chronic diseases and eliminate any stigma associated with it. In sum, we can—and will—do a better job for our patients.