How North Carolina Hospitals, Health Systems, and Care Providers are Uniting to Fight the Opioid Epidemic

North Carolina, like many other states, is enduring an overdose epidemic primarily driven by prescription opioids and increasingly heroin, fentanyl, and fentanyl analogues. Medication and illicit drug overdose deaths have increased by 413% from 1999 through 2015, including more than 1,000 deaths each year since 2010 [1]. In 2015, there were 1,498 deaths due to medication and drug overdose. Heroin deaths have increased more than 884% since 2010 (in 2015, there were 364 heroin deaths) [1]. Since 2009, there have been more than 32,000 overdoses that resulted in an emergency department visit [1].

As North Carolina communities continue to face the growing challenges presented by the opioid epidemic, health systems are striving to adopt an ecosystem approach to reduce opioid misuse, abuse, and overdose deaths. As such, the Coalition for Model Opioids Practices in Health Systems represents a partnership between the North Carolina Healthcare Association and the North Carolina Department of Health and Human Services [2]. The coalition's 3 working groups, including Prevention and Safe Pain Management, Health System Response, and Healthcare Worker Diversion Efforts, help to frame the areas of focus that North Carolina health systems must prioritize as they develop best practices and tools to combat the ongoing crisis. Coalition members include representatives from 130 hospitals in North Carolina, professional societies, and government agencies that are working to address the epidemic at a system level. Many provide organizational leadership around their opioid efforts with a focus on communication across sectors to maximize resources and avoid duplication of efforts.

When planning an approach, leaders need to consider the mechanism of opioid drugs. They can create pleasurable effects while relieving pain [3]. As such, Opioid Use Disorder (OUD) is characterized as a primary, chronic, relapsing brain disease, in which an individual continually seeks relief/reward via substance use [4]. Research indicates that OUD, while potentially fatal, can be effectively treated with several proven approaches [5]. In North Carolina, health systems are ensuring that patients with OUD have access to treatment, including peer support programs, individual counseling, and medication-assisted treatment. Health systems are also supporting and helping to refine legislation such as the Strengthen Opioid Misuse Prevention (STOP) Act, working to develop new and improved workers' compensation guidelines, and improving emergency department guidelines [6].

Because of these strategies and effective educational outreach initiatives, our clinical providers have improved their management of patients with pain. Opioid prescriptions have decreased 24% in the last 12 months while providers have embraced the CDC/NC Medical Board guidelines (John Stancil, Division of Medical Assistance, personal communication, February 2018). Registration for the North Carolina Controlled Substance Reporting System (CSRS) has been steadily increasing and clinicians are utilizing non-opioid pain management strategies.

We performed an informal survey of providers from all the major health systems across the state, noting several themes. First, all are developing documentation tools and implementing changes to default prescription choices to facilitate compliance with current standards of care and requirements under the STOP Act. Some systems have implemented decision support within the electronic medical record and links to the CSRS. Decision support might include recommendations for avoiding concomitant benzodiazepines or identifying patients who should receive naloxone. Second, most have instituted formal educational programs for providers, nurses, and students. Curricula include safe opioid prescribing, recognizing opioid misuse and abuse, and managing chronic pain with controlled substances, all in keeping with requirements of the NC Medical Board. Some systems have broader curricula and include training and support for buprenorphine prescribers, non-opioid pain management, motivational interviewing, and related mental health topics. Third, all are working on efforts to connect with broader systems in their communities or statewide to address issues such as the increase in neonatal abstinence syndrome and the need for prompt connections to community based OUD treatment. A number of providers are also collaborating with crisis coalitions. Several health systems are studying opioid needs in postoperative patients and reducing quantities prescribed.

From what we have seen, we have great confidence in our health systems' efforts to tackle unsafe prescribing and reduce prescription drug abuse. However, over the next few years, we anticipate a worrisome, continued increase in abuse of illicit opioids. This will be fueled by the ease in obtaining illicit opioids, the great difficulty in stopping use of these drugs, and the barriers many North Carolinians legitimately face in finding affordable and effective treatment. We believe state and local governments, hospitals and health systems, insurers, and individual providers must continue to collaborate to align and improve strategies to further reduce unsafe or unnecessary prescribing, make OUD treatment readily available and affordable, and change community attitudes toward prescription and illicit opioids. The prison population should receive increased attention in combating substance use disorders and well-informed public policy will lead to effective treatment prior to release. As health systems continue to make progress and strides in care, it is imperative to share lessons and successes with our other community partners, including the justice system, as we attempt to turn the tide of the opioid epidemic in our state and nation.

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