How Geisinger Health System Reduced Opioid Prescriptions

The devastating opioid epidemic in the U.S. is a crisis that was created, in part, by healthcare itself as prescriptions for pain-relieving medications rapidly increased in the 2000s. Now, healthcare is at the forefront in trying to fix the problem. At Geisinger, a healthcare system serving more than 1.5 million patients in Pennsylvania and New Jersey, where we work, we are taking a multifaceted approach and seeing a big impact. By combining data-driven assessments, targeted engagement of high prescribers, EHR-based interventions, and pharmacist support in care management, Geisinger has dramatically reduced opioid prescribing. In addition, programs promoting safe medication disposal in the surrounding communities reduced the number of left-over opioids in medicine cabinets, helping to stem opioid abuse in the surrounding communities.

Data-driven assessment

Using our robust data archive system which captures electronic health record, medical and prescription claims, and other information, we create dashboard displays for use by leadership, operational teams, and clinicians to reveal population-level trends and identify patients and clinicians for targeted interventions. For example, in 2012 we launched a controlled-substance monitoring dashboard to better understand use of controlled substances in our system, with a focus on improving pain management. This dashboard, updated in real-time, displays a myriad of types of information on a population and patient level including counts of patients prescribed opioids, those co-prescribed other controlled substances, patient use of naloxone, visits to emergency departments, medication use agreements, location heat maps, and other data to help us identify gaps in care and opportunities for improvement.

Engaging high prescribers

Using the dashboard, we quickly saw that clinicians were prescribing opioids at vastly different rates. In addition to developing programs on pain-management for our broad clinician population, we targeted a focused group of high prescribers. Generally, high prescribing clinicians were unaware of their rates. After alerting them about their pattern, we began regular feedback sessions where the prescriber, practice-site medical director, and a specially trained chronic-pain pharmacist reviewed individual patient cases and provided guidance on dose reduction strategies, risks associated with certain co-prescribed agents such as benzodiazepines, alternative treatment options, clinical support tools, and referral options. The combination of prescribing transparency, education, and one-on-one counseling has helped to dramatically reduce the number of high volume prescribers and cut the prescribing of new opioids by 44% over the past three years.

EHR-based interventions

Concurrent with our work with high volume prescribers, we deployed population-level approaches to modifying prescriber behavior. We transitioned from paper to electronic prescriptions for controlled substances, which reduces the likelihood of prescription tampering, and linked our state prescription drug monitoring program to prescriptions made within our EHR, making it easier for providers to review a patient’s profile for other controlled substances before completing a new opioid order. Additionally, our EHR limits the number of days worth of medication allowed for any new opioid prescription resulting in a reduced number of opioids dispensed per prescription.

Pharmacist-supported pain management

Since 2011, Geisinger pharmacists specializing in pain management have worked closely with patients and the rest of the healthcare team to reduce patients’ dependence on opioids while still managing their pain. In addition to optimizing the medication regimen, pharmacists recommend activities, physical therapy, and behavioral health interventions that can help patients cope with pain and reduce dependence on opioids.

Now deployed in 15 primary care and specialty sites across Geisinger, these pharmacists actively manage pain medications for over 1,500 patients. Within 12 months of enrollment in pharmacist care, patients’ morphine milligram equivalent (MME) dose per day (a measure of how much prescription pain medication a patient takes per day) is on average reduced by half from 50 MME to 25 MME with 33% of patients tapering off opioids completely.

Medication disposal

Pain medications are frequently not completely used and are the most common type of drug to result in leftovers. These may then be sold, shared, or sit in medicine cabinets where family members or others may find them. According to the Pennsylvania Youth Survey, which is administered every two years to students from 6^th through 12^th grade, 39% of young people reporting drug use acquire prescription drugs from a family member in their household. Geisinger has led a community effort to raise awareness of the problem, hosting community hearings, producing public service announcements, engaging students in schools and developing a robust media engagement campaign. Geisinger also leads efforts by local organizations to facilitate proper disposal of medications. Since 2014, Geisinger has collected over 15,000 pounds of medications from the community, largely through “take-back” services at its hospitals, pharmacies and other community locations; an estimated 10% of these medications are controlled substances.

Good outcomes

Because of these efforts we have seen a 30% decline in total opioids prescribed over the past two years. Among patients with chronic non-cancer pain, we’ve seen reduced health care utilization, including fewer emergency department visits.

We are now exploring additional approaches to reducing opioid prescribing while effectively managing pain, including using behavioral “nudges” to encourage appropriate prescribing as well as engaging patients through mobile technology to better monitor and manage pain. We encourage every health system to adopt these and other best practice strategies while sharing new approaches to combatting the opioid epidemic.