Healthcare News & Insights

Why opioid addiction will persist until physicians have panoramic view of exposure

There are a number of factors involved with opioid addiction, not just long-term use. In this guest post, practicing gastroenterologist, Dr. Mukul Mehra, CTO and co-founder of a company that develops technology that allows for the monitoring of opioid dosing, explains why opioid addiction persists and what the healthcare industry needs to combat it.

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It’s interesting that physicians generally associate opioid addiction and withdrawal with long-term use, not as the result of an inpatient admission treatment, discharge and short-term prescription. However, it does happen, and it’s an overlooked aspect of the hospital system that administrators and clinical teams need to be more aware of. While the opioid crisis we’re now experiencing is easily blamed on pharmaceutical companies, physicians are also to blame.

There’s a lack of timely, accurate and comprehensive opioid exposure data within the hospital setting causing all parties to make uninformed choices when prescribing opioids. A staggering 51% of non-surgical patients, as well as most surgical patients, are administered opioid medications during their hospital stay. The amount of morphine-equivalent doses administered while in the hospital affects the odds of a patient’s chronic use of opioids as well. However, current tracking solutions don’t show clinicians this inpatient exposure, because they contain only outpatient exposures reported to state Prescription Drug Monitoring Programs (PDMP). To make the best treatment decisions, clinicians need a full understanding of both inpatient and outpatient exposure.

Real-life scenario

As a practicing physician, I’ve witnessed this blindspot firsthand while working the case of a nurse who adopted and raised a child from infancy after learning his biological mother was addicted to opioids. Out of concern that the boy was at higher risk for addiction due to his family history, she was careful not to expose him to opioids during childhood.

When he was a teenager, the boy was in a serious motorcycle accident and suffered a painful liver laceration. After being admitted to a hospital, he was treated and discharged with a 30-day prescription for Lortab. As is the case in many such situations, he ran out of pills only to have them refilled several times before his prescription ran out.

Sometime later, he came to my office for an examination, because his mother thought he might be suffering from reflux. I asked him if he had heartburn or trouble swallowing, and he said no on both counts. He then went on to tell me that he had tried a reflux medication, but it hadn’t helped his chest pain. As we continued to talk, he shared that he was experiencing chest pains, and with the pain would come sweats and agitation, so I asked if he had recently used opioids or any other drugs. To my surprise, he admitted he had started using heroin once his hospital prescription ran out. I then realized that what his mother thought was reflux was a symptom of opioid withdrawal.

This young man had never used opioids before he was hospitalized and his mother had made a concerted effort to ensure he wasn’t exposed to them as a result of his biological family history. And yet, he still became addicted to opioids. That made me think about how physicians don’t really understand what prescribing opioids within a hospital setting can do to a patient.

What the doctors and hospital personnel saw as a harmless and necessary way to keep a patient out of pain following a traumatic accident, ultimately led to that person becoming a heroin addict. I then realized how important it is for doctors to be vigilant about tracking the first and subsequent prescriptions for opioids (and other controlled substances) while hand-holding patients through their healthcare experiences. It’s more apparent than ever that these patients often feel they must resort to some sinister alternative once their prescriptions run out. Most importantly, we need to be very careful about tracking the total amount of opioids being prescribed to any one patient, both within the hospital setting and once discharged.

Inpatient use

The extent to which a patient is given opioids within a hospital setting is just as valuable, if not more in some cases, as what gets prescribed after a patient is discharged. It’s often the start of the actual addiction. It begins in the hospital, without the awareness of the hospital staff, which is tragic. Having more insight into what’s being given, how much, and how often – and the potential downside of the dosages – is what’s currently missing from the equation.

A physician who looks at the state-controlled substance database after a patient is discharged might simply see a week or two of prescribed opioids and not think much of it. He or she would be blind to the large volume of opioids the patient received during his or her inpatient admission. That’s not an ideal situation when trying to decide the best treatment options moving forward. The state narcotics database is only 25% of the solution, while the more panoramic view occurs from knowing what happens within the hospital.

Key for solution

It’s no secret that the electronic medical record (EMR) is a cluttered mess, but it’s the key for this solution. We need to address this challenge to address chronic opioid use. Visibility into the state opioid and controlled substance database history, along with the inpatient dosage history, gives physicians the first full picture of a patient’s opioid exposure.

This is important because opioids aren’t all the same; just like getting an X-ray exposes a patient to varying degrees of radiation, peak doses of opioids need to be carefully tracked, to avoid administering more than the absolute necessary dose. Additionally, what the patient is discharged with should be calculated based on what was given in the hospital prior to discharge. Leveraging the ability to calculate morphine milligram equivalents in real-time into a hospital setting to reveal opioid exposure in the last 24 to 48 hours will help guide physicians when writing an appropriate three-, five- or 10-day prescription. New health IT solutions and apps that work within the EMR are finally providing the ability to do this.

As the patient example shows, receiving an excessive amount of opioids over a short period of time while in the hospital can start someone with zero previous opioid exposure on the road to withdrawals and possible addiction. For that reason, physicians need a panoramic view of their patients’ opioid exposure. The current approach is to wait and see if someone is showing signs of addiction, such as when we can see that the patient has multiple prescriptions for opioids in the state database, when, in fact, we could do a better job as physicians if we began managing the situation when it typically starts – in an inpatient setting.

Mukul Mehra, MD, is the CTO and co-founder of IllumiCare and a practicing gastroenterologist in Birmingham. As managing partner of his practice, Southeast Gastroenterology, and the director of Endoscopy at St. Vincent’s Health System, Dr. Mehra understands the limited access physicians have to cost and risk data.

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