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How One Indiana Hospital Drastically Cut Opioid Prescriptions

Dr. Jonathan Gottlieb, IU Health's Chief Medical Officer
Leigh DeNoon
Dr. Jonathan Gottlieb, IU Health's Chief Medical Officer

As the opioid epidemic continues, hospitals are looking for new ways to treat pain and combat addiction. At Indiana University Health, which has 16 hospitals across the state, that means change. They’re cutting back on opioid prescriptions and giving more advice to patients.

In January 2017, IU Health officials began monitoring when, where, and by whom every opioid was prescribed.

Chief Medical Officer Jonathan Gottlieb said the results were eye opening for his fellow doctors.

“You know, I think no one really knows when they’re operating independently, am I in the middle of the bell curve, am I at one end or the another?” he said. “Just showing the data caused a dramatic reduction in the number of pills prescribed.”

Comparing the first month of monitoring to one of the most recent, this April, nearly 440,000 fewer opioid pills were prescribed.

And that’s important because many people feed an addiction by getting pills from friends and relatives.

IU surgeon Amy Krambeck cut back opioid prescriptions for other reasons. She specializes in removing kidney stones.

“So we use a small scope and go up into the ureter, break up a stone and pull out the pieces,” she said. “So it can be a fairly painful procedure – especially with the stent left in afterwards.”

Krambeck said opioids are the standard pain medication after the procedure. But she found while lecturing in Mexico that’s not true everywhere.

She recalled, “I came back after one of those trips and said, ‘I just want to stop giving narcotics to our patients and start using anti-inflammatories, smooth muscle relaxants – other ways to manage the cause of the pain.’”

Krambeck said her team worried that post-op patients would call for more medication – but that didn’t happen. And in the first year, it kept 4,600 opioid tablets from going home with patients – possibly ending up in the wrong hands.

Gottlieb said another success is the 30 percent drop in opioid prescriptions at IU Health emergency departments. The biggest drop — 90 percent — came in Frankfort.

Phone alerts indicate a patient is waiting for one of IU Health’s peer recovery coaches. The new program helps people who are addicted to opioids and come to an emergency department for more pills.

They’ll meet someone like Spencer Medcalf, and get an unusual welcome: “I’m a peer recovery coach but more importantly I’m a person in long-term recovery from a heroin addiction. What brought you to the ED today? What’s going on with ya?”

He’s one of seven coaches working at a 24/7 hub in Indianapolis. Through video chats, they help patients get treatment across the state. Medcalf’s own experience helps — he got clean when his family cut him off.

“So when I hear patients in the ED talk about those things – where my family is concerned or my wife or husband is really concerned — and they’re talking about divorce or leaving. That’s kind of an internal red flag,” he said.

Cutting back on opioids in post-op and emergency departments is a start.

Gottlieb said it’s more challenging when it comes to patients with chronic pain.

“One of the things that we and others are doing is offering alternatives that are not only to reduce the risk from opioids, but also to offer more effective pain therapy,” said Gottlieb.

His dream is to have IU Health provide wraparound care with specialists in fields like rehab, neurology and psychiatry.

Pain researcher Dr. Kurt Kroenke of the Regenstrief Institute in Indianapolis, said doctors still feel a lot of pressure — especially treating chronic pain.

“Most physicians are feeling they’re being heavily watched, whether it’s by the [Drug Enforcement Administration], or you know, state regulations or their health care systems,” he said. “You’re a good citizen the less opiates you prescribe. And if you prescribe beyond that – you’re being scrutinized.”

He said it’s a tightrope for providers: control pain, don’t under prescribe causing harm, and don’t play a role in new addictions.

Meanwhile, Krambeck is trying to convince reluctant colleagues to reduce opioid prescriptions.

“Just getting it out there and getting it on the table for them to hear, I think sparks the wheels turning,” she said. “And I could tell they were considering how that would affect their practice. And that’s the first step, is to just start thinking about it.”

The change isn’t over for IU Health. Hospital leaders say it will take a couple more decades to address all areas of the opioid crisis.

This story was produced by Side Effects Public Media, a new collaborative covering public health.

Jonese Franklin

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