Opioid use has been on the rise in post-pandemic America, and its effects on communities have been devastating. Decreasing opioid use is a major priority for health systems across the nation. In this conversation, Vinnidhy Dave, D.O., hospice specialist and director of palliative medicine at Englewood Health Physician Network, and Lauren Savage, director of population health at Englewood Hospital, discuss what Englewood Health is doing to prevent opioid use in its communities, and how an opioid risk tool provides guidance and protocols to protect higher-risk patients.

Tom Haederle

Welcome to Advancing Health. Coming up in today's episode, a conversation with Englewood Health about the rise in the use of opioids since the pandemic. We'll talk about what providers can do to decrease their use and what Englewood Health is doing right now by way of prevention. Your host is Rebecca Chickey, senior director of behavioral health services with the AHA.

Tom Haederle

She's speaking with Lauren Savage, director of Population Health, Englewood Hospital, and Dr. Vinnidhy Dave, director of palliative medicine, Englewood Health Physician Network.

Rebecca Chickey

Dr. Dave and Lauren, thank you so much for being here with us today to talk about this incredible topic. The opioid crisis during Covid did nothing but escalate, unfortunately. And the more creative the suppliers of opiates and synthetics become, I think the more challenging your job, our role in helping individuals with opioid use disorder, the more challenging it becomes.

Rebecca Chickey

Rebecca Chickey

And I'm going to break this down in a number of ways. My first question to you is that I'd like you to provide some statistics. What are the driving factors that really allowed you to say this is a problem? This is a challenge, and we have to focus on it. So can you start there? Everyone knows what's going on in their community, but they don't know what's going on in yours.

Lauren Savage

Yeah. I mean, I can start and Dr. Dave, feel free to add to the conversation. I think you said it best, Rebecca. This is a problem in everyone's community, and nobody is surprised by the concerns that we're seeing. We do use our community health needs assessment to better understand our community and their needs.

Lauren Savage

Lauren Savage

And this center is dedicated to behavioral health and to substance use. The Shattuck family lost a family member to substance use. And they were clear that part of this center should be focused on our treating our patients and our community on substance use, as well. And it was through the Shattuck Center that we were also able to form an opioid stewardship committee, so that we were really able to get a group of dedicated providers, mostly disciplinary team at our hospital, to come together to talk about the epidemic, to learn, you know, what's happening in our community amongst our patients, and to begin to address it.

Vinnidhy Dave, D.O.

I would say from the physician side of things, you know, my background is internal medicine. And then I trained in palliative care. For years we always, you know, thought about surgeons as the ones that were giving opioids first to patients. But there's been data over the last few years showing that hospitalists and internist were actually the ones that were exposing patients to opioids

Vinnidhy Dave, D.O.

first from the hospital side. So, I think that's where my interest came in, was really how do we work on decreasing the use of opioids in the hospital? How do we decrease the amount of patients we're sending home with opioids? After I read this article in the New England Journal medicine, where it was showing that internists were probably the ones that were exposing patients to opioids first, before surgeons and surgeons have done better job with the last few years.

Rebecca Chickey

So a couple of things. One, I heard in terms of key success factors, Lauren, that you said is when you identified the need, you had the data, you replicated it, you shared it, you then found a generous philanthropist to be able to provide you with the funding and the backing that you needed, but then you also created a committee.

Rebecca Chickey

So this was not being done in isolation. And that really leads me to my next question. One key part if I understand your program correctly, one key component is around prevention. And it is in terms of what are some alternatives to opiates as well as what are best practices around prescribing privileges?

Vinnidhy Dave, D.O.

This is where my kind of work has been with the team and the task force, is really creating what a lot of hospitals are now calling out alternatives to opioids, in the emergency room when we started it and then we started in on the floors in the hospital as well to provide it to our internists hospital as surgeons for normal pain, things that we commonly see.

Vinnidhy Dave, D.O.

So in the emergency room we've created a protocol for back pain, kidney stone pain, headaches, intractable abdominal pain that's not surgical. And there's an order set in our Epic system where we put in non opioids that can be given for those types of pains. So you would just type in alto and in that let's say back pain comes up.

Vinnidhy Dave, D.O.

And then under back pain there's options of steroids, muscle relaxants, anti-inflammatories, reminding providers that have been trained for years just to go to opioids automatically when someone's in severe pain that these are all the other options we have. And sometimes, you know, as physicians, sometimes when you're in the E.R. you're seeing 40 patients it's hard to remember. But now when you type in pain and your alto pops up and now you see back pain, you can check off these things.

Vinnidhy Dave, D.O.

It makes it easier for the providers. And then, of course, we've done a lot of education with the providers. We've done education with the doctors on the floors in the E.R. Most recently now we're working on pain protocol or pain order set, where basically what a lot of hospitals have done for insulin, where there's long acting insulin, short acting insulin, how to check sugars more frequently so that you run into less problems with hypo and hypoglycemia is now we have a whole pain order set that is smart and it uses like if someone has kidney function issues, a liver function issues, certain medications will automatically not pop up so that patients won't accidentally get

Vinnidhy Dave, D.O.

like an ibuprofen if they have kidney issues. This will be the only way to order opioids. They can't just give someone oxycodone. They want to give them oxycodone, they have to go to the order set and the order that has your non-opioids there, your opioids there. So you're always actively thinking about other options to give than just automatically going to opioids.

Rebecca Chickey

Absolutely. Thank you for that. I may come back to you here with a question, but I want to give Lauren the opportunity to jump in a little bit as well.

Lauren Savage

I think we always say this in our department, but we will never have enough providers to provide the treatment needed for the need of our community. So we really have focused a lot on prevention. So a lot of what Dr. Dave is saying in terms of limiting opioid initiations and leveraging our electronic medical record to provide better care.

Lauren Savage

He's gone out and done lots of trainings. We've done some targeted trainings to certain providers who need that further education, but we've also done training for our patients when they are prescribed opioids. So, any time a patient is prescribed opioids at discharge that are provided, automatically provided educational materials to better understand what they're being prescribed and how to not, you know, misuse that prescription.

Rebecca Chickey

I should share with you. We worked with the CDC, AHA worked with the CDC probably about five years ago now, but I think it is still very on point and helpful. We have a two-pager that we can provide to families and patients. So not just the patients, but letting the family know what are some of the signs and symptoms if they start to see you know, perhaps abuse of the opioids if they do go home with them.

Rebecca Chickey

So my next question is, I think you've also developed a screening tool for OUD, probably, much broader, but for all substance use disorders, particularly given the statistics that you just said, Dr. Dave, regarding, you know, what happens upon admission and discharge. So can you tell me a little bit about the screening tool and how you baked it into your EHR?

Vinnidhy Dave, D.O.

So we've implemented the opioid risk tool, which is probably the most studied one out of what we have right now. And it's implemented into our EHR, where anybody can put the phrase in: dot.org.key or dot.risk. And it pops up and it's also part of our preoperative screening as well. So in the preoperative area, if someone is tagged to be high risk, then they're referred to a pain management provider so that we can follow them

Vinnidhy Dave, D.O.

postoperatively if there's any concerns. We've done education with the residents and the hospitals about using this tool. So if they do start someone on opioids in the hospital, they're able to understand what risk factors the patients have. And then we've shared this with our outpatient providers as well, because we have hundreds of primary care doctors that are part of our network.

Vinnidhy Dave, D.O.

So they can use that as well when they're prescribing opiates to their patients.

Rebecca Chickey

Lauren, what would you like to add?

Lauren Savage

Yeah. So in addition to the opioid risk tool, we've also implemented a screening tool in our emergency room. So I'm going to go back to my point of prevention. And if we can screening individuals and earlier determine whether or not they have a substance use concern, we can provide them the correct resources and connect them to the appropriate level of care.

Lauren Savage

So all individuals who come to our emergency room, I believe it's 18 and up. We are screening for all substances, opioids included. And any patient who screens positive will receive counseling by one of our emergency room doctors, by our social workers. And if needed, a social worker will make a referral for that patient for additional services.

Rebecca Chickey

I have to admit, one of my biases is that that's the wave of the future, to screen for psychiatric and substance use disorders for every admission, it's somewhere between 1 in 4 or 1 in 5 admissions to the hospital has - and is probably much higher than that in the emergency room - has a comorbid psychiatric or substance use disorder.

Rebecca Chickey

That is not, as you said, they're presenting diagnosis or the presenting reason for their admission, but it's there nonetheless. And we should always take the opportunity to identify and treat, if needed. And also, you know, that happens sometimes to improve outcomes and shorten length of stay. And anyway, I could speak on that for hours. I won't here.

Lauren Savage

You are correct though. It's about 20% of the individuals we are screening have a positive screen for substance use.

Rebecca Chickey

As we begin to bring this to a close, let me ask you this key important fact. What's the impact then, for all this work, for creating the center, for implementing the screening programs, for doing the training, for changing the culture, quite honestly? For using technology to help in decision-making process. What's the impact you've seen?

Lauren Savage

One impact I can share. I think you touched it when you just said changing the culture. Englewood Health has really recognized that 20% of the patients that we've screen in the emergency room are in need of additional counseling and support. So, just two months ago we have now opened an outpatient addiction medicine office so that we are more easily able to treat the patients that we identify within our own system.

Vinnidhy Dave, D.O.

And I can follow what Lauren said. I think, you know, we've seen a huge difference just from the hospital side, from our providers, from our residents when you know, they're ordering, I'm seeing less opioids being ordered if we're ordering opioids. Even the nurses are sometimes questioning it or they'll ask me on the side like, is this appropriate? So there's this huge culture shift that we've seen with education.

Vinnidhy Dave, D.O.

And I think making the providers feel comfortable using other medications and not feeling like they have to go to an opioid first, that it's kind of a domino effect throughout the program. And, you know, we're seeing outpatient providers, inpatient providers really trying to make sure that they're only using the opioid when they feel it's really appropriate. And it's not the first thing that they're going to do in terms of treatment.

Rebecca Chickey

That's phenomenal. What would you say are two key success factors that allowed you to do this? Was it a champion like Dr. Dave stepping up and saying, we've got to do this, and I'm here to be a team player to make it happen. Obviously, I think earlier you mentioned, a wonderful philanthropist that allowed you to have the funds to do that. But what are a couple of key success factors that the listeners would need to know about to implement something similar in their own organization?

Lauren Savage

I think for our stewardship, it really was a collaboration of different disciplines coming together and recognizing the role that each of us plays in this process. Because it was all of us working together that we were able to implement all of these workflow changes and utilizing our electronic medical record and the education of our providers and the education of our community.

Lauren Savage

It required all of us to work together to achieve the goals we set forth.

Vinnidhy Dave, D.O.

I was thinking the same thing that Lauren said. I think it's really getting the providers in different areas to really bring this together and make it move forward quickly, whether it's, you know, someone from IT, whether it's you know, someone from social work, whether it's ER doctor, the chief of anesthesia, you know, chief of medicine, chief of psychiatry, and then, you know, Lauren making sure these meetings happen on top of it.

Vinnidhy Dave, D.O.

and we're making sure we're planning for it beforehand. And then making sure we have a plan for the next one, and really, I think, a point person and then being able to get the right people together to implement it, and then everyone being passionate about it. Everyone on the team was excited about, we want to try to do this, and we want to try to reduce opioids and we want to try to, you know, get better care for our patients.

Rebecca Chickey

Awesome. Well, thank you so very much for your willingness to share your time and your expertise. I'm hoping that this podcast, along with other work that AHA has done and that you have done, will inspire others to go on this journey for this very, very important clinical disease and disorder. And I again say congratulations on being one of AHA's Foster McGaw Prize finalists, and I will point the listeners to AHA's resources on opioids at AHA.org/opioids.

Tom Haederle

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