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AMITA Health takes steps to limit use of opioid painkillers in emergency rooms

Seeking to counter opioid abuse, AMITA Health has taken steps to tighten the use of opioid painkillers in its emergency rooms and to communicate its pain medication policies to ER patients.

The steps include a move away from the use of hydromorphone as a first-line painkiller in the health system’s emergency departments. Experience has shown that hydromorphone, an intravenous medication sold under the brand name Dilaudid, has high likability and abuse potential.

Patients with psychiatric illnesses and addiction tendencies commonly visit ERs, complaining of bodily pain and requesting Dilaudid, said Carlos Martinez, M.D., an AMITA Health emergency room physician and president of the medical staff at AMITA Health Adventist Medical Center Bolingbrook. “It’s not something that benefits them over the long term,” he said. “It’s addiction, or it promotes addiction. Our thinking is: ‘Why give something that has this potential? Let’s give them something that potentially has less of that effect but still treats pain.'”

Martinez is the leader of an opiate safety team that developed the “Dilaudid-free ED” plan, which was implemented in December 2017. The team consists of ER medical directors and nursing directors from AMITA Health’s six acute-care hospitals.

It receives support from the health system’s senior leadership, including its quality and safety leaders.

The plan calls for using morphine or fentanyl instead of Dilaudid when IV opioids are needed as first-line therapy. Dilaudid still may be used as a first-line treatment in a limited number of cases, such as those involving patients with pain related to sickle cell anemia and dialysis. Otherwise, Dilaudid is reserved for use as a second-line therapy when first-line treatments are inadequate. Under the plan, AMITA Health also has reduced by 50 percent the amount of Dilaudid stocked in its ERs.

As part of the plan’s roll-out, a question-and-answer document and a series of emails on Dilaudid use were distributed to ER staff. They have welcomed the new policy, Martinez said. “This is something providers and nurses wanted,” he said. “It’s a relief for them because now they’re getting support from the organization for when they have to have difficult conversations with patients about what they will be receiving for their pain.”

By early 2018, the plan already had reduced Dilaudid use by more than half in some of AMITA Health’s ERs.

The opiate safety team developed a poster that is now displayed in the ERs, spelling out the hydromorphone policy and AMITA Health’s other policies on the use of painkillers for emergency patients. The poster makes clear that the ERs will not prescribe long-acting opioid painkillers, such as oxycodone, morphine, fentanyl patches and methadone; will not prescribe more than a short course of opioid painkillers; and will not refill lost, stolen or destroyed prescriptions.

“We’re trying to reduce the amount of prescribed narcotics that can end up on the streets or diverted for other patients, and the amount in homes that patients can’t use but someone else can get ahold of,” Martinez said. “We’re changing the types of narcotics we’re using to less-addictive ones, and we’re using other non-narcotic pain-control methods to treat our patients. We’re treating pain, but we’re treating it appropriately.”

Opioids – both prescription and illicit – are the main driver of drug overdose deaths in the United States, according to the Centers for Disease Control and Prevention. Opioids were involved in 42,249 deaths in 2016, and opioid overdose deaths were five times higher in 2016 than in 1999.

Read more on AMITA Health’s Dilaudid-free ED initiative in this story from the Chicago Tribune.

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