NORMAN — Emergency room doctors know first hand the effects of the opioid crisis.
At Norman Regional, Dr. J.T. Ball, a third-year ER resident, is passionate about making changes that will prevent emergency rooms from unwittingly contributing to addiction.
“It’s a huge problem,” Ball said. “I’m actually doing my research for the residency program over ways to reduce the number of prescriptions that come out of the emergency department.”
In 2015, more than 52,000 Americans died of drug overdoses. Nearly two-thirds of those deaths were linked to opioids such as OxyContin, Vicodin, heroin, and fentanyl, according to the U.S. Department of Health and Human Services.
“The number of overdose deaths has eclipsed the number of people in our country who die from trauma,” Ball said. “That’s happened in the last couple of years, but it’s been growing over the last 15 years.”
Ball said Oregon, Ohio and Maryland have developed guidelines for their ER physicians to avoid inappropriate prescriptions.
He’s drawing on those examples to develop guidelines for Norman.
“What I’ve been trying to do is develop a set of recommendations to use in the emergency department to decrease the number of prescriptions that we write,” he said.
Ball said people come in who present chronic pain and exacerbation of chronic pain. With a policy in place, ER doctors can explain they don’t write prescriptions for this type of pain out of the emergency room. Those people need to work with private doctors and pain specialists.
Ball said a recent study looked at people who had not taken opioids six months prior to an ER visit where they were prescribed medication.
“People who were prescribed one day of pain medicine in the ER, 6 percent of those people at one year were still taking opioid pain medication,” he said. “If those people received eight days worth of medication, it was 13 percent at one year who were still taking them. Thirty days and the number goes up over 30 percent.”
Ball said research indicates a single prescription can lead to addiction.
“If we can reduce the initial prescribing pattern, then we can prevent all those people becoming addicted,” Ball said. “It’s something I’m passionate about.”
Local efforts to reduce reliance on opioids
The opioid crisis affects hospitals on several levels, said Norman Regional Health System Pharmacy Director Brad Foster, who along with Ball and others serve on the multidisciplinary Norman Regional Health System Pain Committee.
As part of its mission, the NRHS Pain Committee is evaluating all aspects of opiate use in the hospital system.
Nationally, there has been an increase in emergency room visits and hospitalizations due to opioids, Foster said. Another trend is an increase in babies born addicted, most of whom end up in a Neonatal Intensive Care Unit (NICU). Consistent with the national trend, the HealthPlex NICU has experienced an increase in babies born addicted to opioids, said Interim CNO Brittni McGill, who also serves on the committee.
In 2016, the Centers for Disease Control and Prevention (CDC) released guidelines for prescribing opioids for chronic pain. In March 2017, the President Donald Trump declared the opioid crisis a national public health emergency and created “The President’s Commission on Combatting Drug Addiction and the Opioid Crisis.”
That commission recommended including that questions on pain management be removed from patient surveys used by the Centers for Medicare and Medicaid Services (CMS) to measure hospital performance. Those measurements are directly linked to financial incentives and penalties, meaning if patients answered that they were in pain during their stay, hospitals were potentially penalized for low patient satisfaction, meaning they were literally incentivized to administer more pain medication.
Additionally, the commission believes post surgical pain is a key contributing factor to the opioid crisis. To combat that, the commission is asking CMS to review reimbursement policies that discourage non-opioid alternatives.
“Drugs that are used to treat post-surgical pain are bundled into the payment that addresses surgical supplies, so if we use a non-opioid that costs significantly more our payment doesn’t go up,” Foster said.
Still, Foster said patient safety is worth the cost.
“We’ve added a lot of non-opioid alternatives,” Foster said.
Norman Regional also has a multidisciplinary, system-wide drug monitoring program to prevent drug thefts. Foster said program is “very robust” in tracking and accounting for drugs administered at NRHS hospitals and facilities. That includes checking drugs at every step along the way, even checking drugs turned in for disposal to make sure they are what they are supposed to be.
Working to enhance patient safety
The NRHS Pain Committee’s review revealed areas for improvement to increase patient safety.
“What we quickly realized when reviewing our systemwide pain policy is it was really heavily geared toward medication intervention and not so much toward those non-pharmalogical interventions such as imagery or massage or breathing techniques,” McGill said. “We really need to change our focus to what we want it to be.”
The pain committee also researched using a screening tool to determine patient tolerance to pain medications.
“The treatment really should be individualized and tailored to that patient,” McGill said.
Another tool is the state’s Health Information Exchange, which allows health organizations to look at information on patient care at other facilities and make sure they aren’t double prescribing.
Under consideration at the state legislature, House Bill 2931 promotes electronic prescribing of scheduled drugs such as opioids.
“Not all pharmacies are set up for this, but the majority of them are, and that’s another safety measure,” McGill said. “We’re not doing hard-script writing.”
That measure would help reduce prescription forgeries and medication errors.
McGill said the Norman Regional Health System has worked to stay ahead of the curve in initiating safety factors even prior to recent federal mandates, but it has been a system-wide, team effort.
How we got here
Key factors identified as contributing to the opioid crisis include illegal importation of opioids, inappropriate marketing by pharmaceutical companies, over prescribing and using pain as the fifth vital sign.
Illegal importation is certainly a problem. On Feb. 9, 33 pounds of fentanyl was seized in Boston from the Mexican Sinaloa Cartel. In its raw form, that’s enough fentanyl to kill 7 million people, Foster told the Norman Regional Hospital Authority on Monday.
To combat the marketing issue, lawsuits have been filed across the nation, like the one Oklahoma Attorney General Mike Hunter filed against Purdue Pharma and other pharmaceutical companies, alleging that marketing played down or denied the addictive nature of opioids, presenting them as the cure to human suffering through pain elimination.
Marketing opioids
In 1996, time-released oxycodone (OxyContin) was touted as having a low risk for addiction by its maker, Purdue Pharma. Purdue Pharma was founded in 1892, but in the 1950s three brothers, Arthur, Mortimer and Raymond Sackler, bought the company, according to multiple sources.
In response to this article as originally published, Purdue Pharma has clarified that, “Recent news coverage has wrongly characterized the relationship between Dr. Arthur M. Sackler and Purdue Pharma L.P., the company founded four years after his death by his brothers, Drs. Mortimer and Raymond Sackler. OxyContin was brought to market nine years after Arthur’s death and neither he nor any of his descendants have ever had any involvement or financial stake in its success. Dr. Arthur M. Sackler was never involved in any way in the invention, research, development, business or marketing or any other activities of Purdue Pharma L.P. or of OxyContin.”
Mortimer and Raymond Sackler and their heirs have become billionaires in the pharmaceutical industry through developing and marketing drugs, turning Purdue Pharma from a small company to an industry leader.
In 1987, Arthur Sackler died and was inducted into the Medical Advertising Hall of Fame for his promotional work helping Valium become the United States’ first $100 million drug.
Believed to be less dangerous than barbiturates, Valium became the most prescribed drug in the United States, peaking in 1978 before falling into disfavor due to withdrawal symptoms.
That same type of marketing genius was used to promote Purdue Pharma’s OxyContin which was approved by the government in 1995 and released for use by Americans in 1996, according to the Federal Drug Administration. OxyContin was the first formulation of oxycodone that allowed dosing every 12 hours instead of every four to six hours because of its time-release formula.
Purdue conducted an OxyContin marketing campaign from 1996 to 2001, hosting more than 40 national pain-management and speaker-training conferences at resorts across the nation.
“At the time of OxyContin’s approval, FDA product labeling warned of the danger of abuse of the drug and that crushing a controlled-release tablet followed by intravenous injection could result in a lethal overdose,” the FDA states. “There was no evidence to suggest at the time that crushing the controlled-release capsule followed by oral ingestion or snorting would become widespread and lead to a high level of abuse.”
In July 2001, the FDA added stronger warnings to the OxyContin label about the potential for misuse and abuse.
Over prescribing and pain as a vital sign
Oklahoma is ranked as one of the worst states nationally for over prescribing painkillers. While marketing is believed to have contributed to this problem, another contributor is using pain as a vital sign.
“In the late 90s there was a push to using pain as the fifth vital sign and today that is considered a contributing factor to the current state of the opioid crisis,” McGill said.
To improve pain management, the “Pain as the 5th Vital Sign” initiative required a pain intensity rating (0 to 10) at clinical encounters, measuring and tracking pain along with blood pressure, heart rate, respiratory rate and temperature as vital signs within a patient’s record based on patient feedback, according to the National Institutes of Health.
Pain as the fifth vital sign was easier said than done
“In clinical practice, pain as the fifth vital sign has proven to be more complex to assess, evaluate, and manage than originally anticipated. It has also had some serious consequences which were never intended. Associated with the national push to adequately manage patients in pain has been a rise in prescription opioids as well as a rise in opioid related death,” Dr. Natalia E. Morone and Dr. Debra K. Weiner wrote in their study, “Pain as the 5th Vital Sign: Exposing the Vital Need for Pain Education.”