The Brigham Comprehensive Opioid

Response and Education Program Scott Weiner, MD, MPH

Director, Brigham Comprehensive Opioid Response and Education (B-CORE) Program

Brigham and Women’s Hospital

Assistant Professor

Harvard Medical School

Objectives – In 10 Easy Steps

1) Describe key elements needed to implement a hospital-wide opioid stewardship program.

2) Measure opioid-related interventions to determine success and further needs.

http://www.mass.gov/eohhs/docs/dph/stop-addiction/current-statistics/data-brief-overdose-deaths-may-2017.pdf

Pressure to do something…

• Patients • Clinicians • Community • Government

Step 1: Identify a Champion

• Identify a director

• Non-departmental

• Surrogate of CMO/CQO

• Provide funding

• Initial goal: break down silos

Step 2: Consolidate current efforts

Bottom Up: Task Forces

•Work Already in Progress • RADEO • EAP • Addiction psychiatry • EM/hospital guidelines

Step 3: Top Down: Executive Support

• CMO

• CNO

• CQO

• Chairs (Anesthesiology, Psychiatry)

• Director of Pharmacy

• Director of Graduate Medical Education

• IT(!!!)

• Anyone else that wants to help

Step 4: Mission Statement, Timeline, Governance

• By the end of CY2016, develop a comprehensive program that measurably demonstrates implementation of Brigham-wide guidelines for opioid prevention, opioid prescribing, managing chronic pain, and managing opioid addiction through technology, data, outreach, clinical support, and training.

• Data Capture Training

• Benchmarks, Reporting & Performance Improvement

• Technology Development Outreach

Activities

• Model Development (capacity, roles, responsibilities)

Addiction Task Force

Chair: Joji Suzuki Representation from:

Addiction, Oncology, Pain, Pharmacy,

Rheum, Hospitalists, Surgery, Ortho,

Primary Care, EM, Pharmacy

Implementation Responsibilities:

Prescribing Task Force

Chairs Alev Atalay, Ed Ross Representation from:

Addiction, Oncology, Pain, Nursing,

Pharmacy, Rheumatology, Hospitalists

Surgery, Ortho, Primary Care, EM, Pharmacy

Executive Committee for

BCORE Program Scott Weiner, Director

Shelly Anderson, BH VP

Craig Bunnell, DFCI CMO

John Co, Partners GME

Jessica Dudley, BWPO CMO

Peggy Duggan, BWFH CMO

Sunny Eappen, BWH CMO

John Fanikos, BWH Pharmacy

Advisory Groups:

•PFAC Social Work (Martha Burke)

•Information technology

•Partners Health System Opioid Task Force

•Employee engagement – EAP

•RADEO Project (Hospitalists) Nursing

Clinical

Consultant/Project

Manager:

Christin Price

Other Key Stakeholders to

keep Informed/Involved: Matt Fishman

James Tulsky/Doug Brandoff

Mike Hession

Liz Harry/Raj Patel

Jennifer Kales

BWH Psych Resource Nurse

Service/Christine Murphy

Task Force Coordinating Committee: Shelly Anderson, Alev Atalay, Mike Healey, Christin Price, Joji Suzuki, Scott Weiner

Chris Gilligan, BWH Pain Medicine

Richard Gitomer, Director, BWH Primary Care

Mike Healey, BWPO eCare Ambulatory CMIO

Allen Kachalia, BWHC CQO

Jessica Logsdon, BWHC PA Director

Wanda McClain BWHC VP Community Health

Maddy Pearson, BWH CNO

Jim Rathmell, Chair BWH Anesthesia

David Silbersweig, Chair BWH Psychiatry

Joji Suzuki, BH Addiction Psychiatrist

Education Task Force

Chair: Darin Correll Representation from:

Addiction, Palliative Care, Orthopedics,

ENT, Primary Care, Emergency Medicine,

Nursing, Physician Assistants, Hospitalists

Step 5: Launch!

Step 6: Guidelines and Metrics • Laws

• Guidelines

Massachusetts Opioid Law 3/2016 • First time prescriptions for <7 days • Partial fill • PDMP check prior to every opioid

prescription • Educate patients on risk • Mandatory SUDE from ED • Voluntary non-opioid directive

Guidelines

• MHA

• CDC

• Specialty specific

Guidelines

Guidelines Metrics

• MHA

• CDC

• Specialty specific

Metrics

Task Numerator Denominator Goal

Overall Goals

Reduce # fatal overdoses # fatal overdoses in system’s

covered lives

2015 until year-to-

date

50%

Reduce # non-fatal overdoses # non-fatal overdoses in

system’s covered lives

2015 until year-to-

date

50%

State Opioid Law Metrics

Pain treatment agreements for

patients taking opioids >90 days

# signed pain treatment

agreements in EHR

# patients on opioids

>90 days

100%

Utilization of a screening tool for

risk assessment

# risk assessments

documented in EHR

# patients on opioids

of any length or dose

100%

Review of state prescription

drug monitoring program

# documented look-ups # patients on opioids

of any length or dose

100%

Metrics

Safe Prescribing Task Force Metrics

Urine toxicology screening for

chronic opioid patients

# urine toxicology screens

ordered

# patients on opioids

>90 days

100%

Concurrent naloxone for

patients on >50 MME per day

# naloxone prescriptions # patients on opioid

doses of >50

MME/day

100%

Visits every 4 months for

patients on chronic opioids

# patients on chronic

opioids with visits in the

past 4 months

# patients on opioids

>90 days

90%

RADEO (Inpatient) Metrics

Major adverse drug events # major ADE’s after first

dose of opioids (e.g. death,

transfer to ICU, code blue)

Total # patient days 50%

reduction

Minor Adverse drug events # minor ADE’s after first

dose of opioids (e.g.

pruritis, delirium, excessive

sedation)

Total # patient days 25%

reduction

Metrics

Addiction Task Force Metrics

Naloxone Rx at ED discharge

after overdose

# naloxone kits or rx

dispensed

# pts presenting to

ED with OD

100%

Increase # of patients

receiving medication-assisted

substance use treatment

(MAT)

# patients prescribed

MAT

# high risk patients

on opioid registry

N/A

Increase number of providers

waivered to prescribe MAT

# providers waivered # primary care

providers

40% of all

PCPs

Increase proportion of

providers that prescribe

# providers who have

written > 1 MAT Rx MAT

# primary care

providers

50% of

PCPs

waivered

# pts offered SUD evaluation

within 24 hrs of OD in the ED

# SUD evaluations

offered in 24h

# pts presenting to

ED with OD

100%

Naloxone

Drug Takeback

Grand Rounds

Guidelines Metrics

Partners Pain Order Set

Bridge Clinic Decrease OUD, OD

SUDE

IT

Step 7: Pluck the Low-Hanging Fruit

bcore.brighamandwomens.org

Recovery Month

Step 8: IT (and patience)

• Guidelines IT

Inpatient Acute Pain Order Set

Medication Management Agreement

Opioid Refill Module

ePrescribing

Step 9: Get that High-Hanging Fruit

Some Metrics

Step 10: Save Lives

sweiner@bwh.harvard.edu