Addressing Opioids: Sometimes, Leaders Simply Step Forward

A routine encounter with a heroin-addicted patient thrust an emergency physician into a leadership role that radically changed the way some EDs prescribe opioids for pain.

It’s a late night in early 2016. A car comes to a sudden stop outside the entrance of Swedish Medical Center’s new Belmar emergency department in suburban Denver, Colorado. Responding to the driver’s calls for help, a security guard helps him remove a young woman from the car and wheels her inside.

The attending physician, Donald Stader, MD, FACEP, who had been riding out a slow shift, watches the commotion on a monitor. As the limp woman is taken to the resuscitation bay, Stader observes her skin is blueish and she looks to be “almost dead.” Experience tells him she probably has overdosed on heroin. He directs a nurse to get some Narcan, which is applied and immediately rouses the woman with what Stader describes as almost miraculous effectiveness but also downplays as “run-of-the-mill” emergency medicine.

An hour later, the woman is in mild withdrawal but fully awake when Stader checks in on her. He strikes up a casual conversation, then curiously asks how her addiction to heroin had begun.

“Her answer changed my career and, in a sense, kind of changed my life,” he says, more than a year later. “She said she got addicted through opiates from an emergency doctor like me, who had prescribed her Percocet for an ankle sprain. And the reason why that was so impactful [to me] was because earlier that day I had seen an ankle sprain [patient] and had prescribed that person Percocet.

“That was my practice. I thought for a long time I was practicing good medicine by being very aggressive with pain control — very liberal with opiates — and now I had this young lady who connected the dots and said, ‘I got addicted because of the missteps of a physician like [you].’ ”

As a result of her ankle sprain and ensuing introduction to opioids, the woman had dropped out of college, was estranged from her family, lived transiently on the street, and sometimes prostituted herself for opiates that, she told him, made her problems “fade away” and made her feel like “the world was a good place.” Stader calls it a tragic-but-common story among opiate abusers.

What made this different from previous cases wasn’t just the sudden revelation, but that it inspired Stader to convert thought to action in a way that is helping to revolutionize how many physicians approach the use of opioids in emergency departments across Colorado and beyond.

“It’s a one-patient-can-change-your-life kind of story,” Stader says.

A Case Study in Physician Leadership

It also is a story about the role of physician leadership in sparing potentially millions from death and devastation wrought by opioid addiction.

Millions?

A report from the Center for Behavioral Health Statistics and Quality estimates 2 million people in the United States had substance-abuse disorders related to prescription opioid pain relievers in 2015 — and that 80 percent of heroin users began by misusing prescription opioids. It also says that, from 1999 to 2015, more than 183,000 deaths in the United States were the result of overdoses attributed to prescription opioids.

If physicians were at the root of the problem, Stader was determined to also make them part of the solution: “We are as addicted to prescribing opioids as our patients are of taking them, and we’ve got to change that.” | CPR News / via Kaiser Health News

If physicians were at the root of the problem, Stader was determined to also make them part of the solution. “In medicine,” he says, “we are as addicted to prescribing opioids as our patients are of taking them, and we’ve got to change that.” To that end, his efforts — and those of many other associates — now serve as a case study in how effective leadership can achieve the seemingly impossible.

The results of those efforts include:

• The assembly of a broad-ranging, multidisciplinary task force to address the use (and misuse) of opioids in emergency departments.

• Leveraging the expertise of each task force member to produce one of the nation’s most comprehensive and effective opioid prescription and treatment guidelines.

• A highly coordinated and supported pilot program to test those guidelines and troubleshoot problems in strategically diverse Colorado locations.

• Discussions with the American Hospital Association that could lead to implementation of the guidelines on a national scale.

• Supporting other states — including Arkansas, Florida, Kansas, Kentucky, Michigan, New York, Tennessee and Wyoming — that are interested in the guidelines.

Building Alliances

After years of treating overdose patients, Stader had become calloused to their plight. “It hadn’t bothered me that we weren’t taking good care of those patients,” he admits. But this one patient shifted his mindset, and when it was time to release her, he was alarmed to discover there were no discharge instructions for overdose patients in the system.

That night, he went home and researched the opioid epidemic, the best practices for managing it, then wrote the discharge instructions for immediate use at about a dozen Denver-area facilities. It was a good first step, but a larger issue loomed: Colorado had no specific emergency department opioid guidelines.

A month later, with approval from the Colorado chapter of the American College of Emergency Physicians, he assembled a task force to write opioid treatment protocols for Colorado hospitals and emergency departments.

“We started locally,” Stader recalls, “then it expanded to asking people, ‘Hey, who else do you think should be at the table?’ Soon, it just became self-recruiting. People would say, ‘Hey, I heard what you’re doing. Have you reached out to this person?’ I was always saying if there’s someone who can contribute and has expertise that we’re lacking, I want them reviewing and writing for this publication.”

The result was a 26-member team that included physicians, a toxicologist, addiction specialists and counselors, emergency department administrators and pharmacists, a paramedic, several nurses, the executive director of a harm-reduction center, a thought leader from the Colorado Consortium for Prescription Drug Abuse Prevention — “all the way down to medical students, who we tasked with grunt work,” Stader says with a laugh.

But he was serious about inclusion: “That’s how I run task forces … the more the merrier,” he says. “But if you show up, I’m going to put you to work. I’m very much an equal-opportunity person, but I’m also a person who believes strongly that you have to earn titles, and I wanted to run a meritocracy when it came to the task force.”

After eight months of thorough research and collaboration, the Colorado chapter of ACEP released a comprehensive, 46-page report — the 2017 Opioid Prescribing & Treatment Guidelines, which notably rejects the notion of opioids as a first-option, catch-all, pain-relief modality for all patients, and outlines criteria for effective pain-relieving alternatives.

With the groundwork complete, Swedish Medical implemented the new guidelines as standard practice at Colorado emergency departments within its system. And the early results did not go unnoticed.

Putting Ideas into Action

Even before the guidelines were released in early 2017, a Colorado Hospital Association steering committee already had resolved to attack the opioid crisis at the front lines: with emergency department physicians.

Diane Rossi MacKay, RN, MSN, CPHQ — the association’s clinical manager of quality improvement and patient safety — was urged to attend an opioid crisis symposium at which Stader was speaking. MacKay had never heard of Stader, but “when you find [the right] person, man, the doors open up,” she says. In this case, the doors opened wide to the benefit of both.

MacKay recognized the solutions-driven guidelines from Stader and Colorado ACEP aligned perfectly with the association’s mission to “improve quality patient safety and drive down opioid use and misuse in our hospital partners.” And if Stader wanted to extend the reach and impact of the guidelines across the state, MacKay and the association had precisely the platform from which to make that happen.

Diane Rossi McKay

“I didn’t need to do much at all to get the hospital association’s buy-in,” Stader says. Impressed with the new practice and policy ideas, the association’s board of directors promptly proposed implementing them in a pilot program. “If it works,” they said, “let’s roll it out to every emergency department in Colorado.”

“Then the question was: Who else could we bring to the table?” MacKay remembers. “What other partner organizations could we bring to the table to leverage this work and bring it to the people of Colorado?”

The result was a five-member coalition that comprised the Colorado Opioid Safety Collaborative. The strength of these partnerships and the support of the association board “made all the difference in the world,” MacKay says.

From the start, the association worked to ensure success of the pilot by providing infrastructure and organization; thorough education and training of physicians, nurses and pharmacists; and support for all participants. For the pilot to work, everyone from top to bottom needed to be on the same page.

Challenges and Buy-In

Word of the pilot spread quickly and generated interest. Consequently, the original target of five hospitals soon grew to eight hospitals and three freestanding emergency departments. Selection of pilot participants, however, was anything but random.

“We wanted to ensure we had a Level I trauma center, and then perhaps one that didn’t have a Level I trauma center to see what the difference was there,” MacKay says.

That desire for diversity extended to the strategic selection of facilities in high-population urban centers; remote, underserved rural areas with farming, ranching and mountain communities; college settings; and resort areas with their unique array of ski-related trauma accidents.

Such variety was intended to allow the hospital association to identify and troubleshoot issues distinct to each area. Yet despite the apparent benefits of the pilot, not all who participated did so without hesitation.

Boulder Community Health was among several organizations already addressing the opioid crisis when its leaders were approached about the pilot. As president and CEO, Robert Vissers, MD, was satisfied with his own staff’s progress, but as an association board member, he also had a vested interest in the pilot.

“In some ways, we felt like we [at Boulder] were doing better than most places were,” Vissers says. “But I think we were surprised at how much opportunity [for improvement] we still had.”

There also was concern about whether smaller systems such as Boulder Community had the capacity to support the pilot, Vissers says. But those concerns were allayed with association’s promise of support on every level. That, and Stader’s stated goal of a 15 percent reduction of opioid use in emergency departments, made the decision to take part in the pilot easy for Tim Meyers, MD, who is president-elect of Boulder Community Health’s medical staff and was chair of its surgical and trauma services department from 2014 to 2016.

“From the second [Stader] presented it to me, it seemed like a big win,” Meyers says.

It was also a big win at Yampa Valley Medical Center, another smaller facility where, despite concerns similar to those at Boulder, the Steamboat Springs facility experienced a 46 percent reduction in opioid use in its ED.

Where Things Stand Now

Results of the program, released in January, exceeded goals by more than double. In aggregate, opioid use in participating EDs decreased by 36 percent − or 35,000 fewer administrations than the same period in 2016 — with a corresponding 31.4 percent increase in use of alternative treatments.

Patient satisfaction data is still being analyzed, but early results at Swedish Medical show a 10-point improvement. The next step is to expand the program across Colorado while presenting, training and preparing similar programs in other states.

“The goal here is to get this stuff out, to support whoever we can, to be ready to answer questions, get on a plane if we need to, and get out there so that people aren’t hanging,” MacKay says.

For his part, Stader adds that the action of one physician can change lives of countless patients. “A lot of doctors have said, ‘Hey, this has really changed the way I’ve practiced — and changed it for the better,’ ” he says.

And what of the opioid-addicted patient who triggered it all two years ago?

“I always hope that she’ll read an article and come find me,” Stader says. “I just don’t know what ever happened to her. I just hope she’s not dead, [although] it’s a big possibility. But every life has worth, and her life, in my experience with her, has probably helped a lot of people. And if that was her life’s worth, then she’s contributed an awful lot. She’s already had a huge impact on me if nothing else.”

Andy Smith is a senior editor for the Physician Leadership Journal.

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