Dr. Phillip Chang’s emergency room epiphany started with a wreck.
A patient admitted to the trauma unit of the University of Kentucky Albert B. Chandler Hospital was prescribed opioid painkillers for injuries he sustained in a nasty car crash. Within days, the patient returned for more pills, the first of many trips to multiple doctors.“This guy was not a substance abuser before,” Chang said. “Because of the pain medicine, he became one. We asked ourselves: Were we responsible for it?”
The incident prompted the emergency department to issue new guidelines that opioids be prescribed only as a last resort. It has worked so well in the past two years that Chang, now UK HealthCare’s chief medical officer, is hoping to roll out the same protocols in 10 health systems across the state, which could change practices in dozens of hospitals.
Similar changes are sweeping the nation. With heroin deaths now surpassing gun homicides, hospitals have been rewriting protocols and retraining staff to minimize prescriptions of narcotic painkillers.
Emergency departments, in particular, feel a heavy responsibility to take action: Collectively, they’re one of the top prescribers of opioids nationwide, behind family and internal medicine practices.
And so, this month in eastern Mississippi, Baptist Memorial Hospital-Golden Triangle began limiting opioid pain medication only to patients in the most acute pain. St. Joseph’s Regional Medical Center in New Jersey, which has one of the nation’s biggest emergency departments, is pushing to replace opioids whenever possible with less addictive treatments, like nerve blocks to dull pain. The center has even hired a harpist to fill the noisy halls with calmer notes.
It’s all part of a push “to stem the tide of the opioid epidemic,” said Dr. Jay Bhatt, chief medical officer of the American Hospital Association.
But it’s not always easy.
“Patients say, ‘Doc, I want the strongest thing you’ve got,’” said Dr. Daniel del Portal, an assistant professor of clinical emergency medicine at Temple University in Philadelphia. “But patients don’t always understand the risk the strongest pain medicine can create. Patients don’t appreciate that until it’s too late.”
At the UK hospital in Lexington, Ky., Chang said the philosophy used to be to give an opioid painkiller right off the bat. And then, he said, “we’d just give more of it.” Slowly, he got doctors, pharmacists, and nurses on board with using non-opioid pain relievers like Advil or Tylenol first, and trying multiple regimens before finally considering something stronger. He also trained them on how to explain the shift to patients.
“Sometimes it’s impossible to bring pain to zero,” Chang said. “But we’re trying to make it tolerable.”
Since 2014, Chang gathered data on 900 patients treated after the new policies were implemented. He was surprised at what he found.
The trauma unit managed to nearly halve the amount of opioids administered to patients who had no prior history of chronic opioid use. That might be helpful in a state that had the third-highest death rate from drug overdose in 2015.
However, the new guidelines had little impact on prescriptions for patients who were already chronic opioid users prior to admission. So UK has stepped up training to help emergency physicians, who are often focused on the immediate need to save a life, to think more for the long term. That might mean prescribing fewer opioids for drug-dependent patients and guiding them toward substance abuse treatment when they’re ready to be discharged.
Chang plans to roll out these new practices across other units of the hospital and then, if all goes well, take them to the statewide alliance of health care networks.
“Everyone of us needs to feel like we’re responsible,” he said. “The feeling of, ‘I’m not an addiction specialist; that’s not my problem’ has to go away.”