Informing Patient Care and Preventing Opioid Abuse

The orthopaedic surgery research team at Atrium Health Musculoskeletal Institute aims to address the opioid epidemic through objective and evidence-based clinical decision support in the outpatient and acute care setting. Our work, led by Rachel Seymour, PhD, and Joseph Hsu, MD, has been awarded several CDC-funded grants for this research. Our projects include:

• Developing a clinical decision support tool for Prescription Reporting with Immediate Medication Utilization Mapping (PRIMUM)
• Enhancing PRIMUM and creating a toolkit to follow the Centers for Disease Control and Prevention Clinical Practice Guidelines for Prescribing Opioids for Chronic Pain
• Implementing a Multimodal Path to RecOVEry (IMPROVE): Identifying Risks in Acute Care

High-risk patients are identified by PRIMUM through alerts to prescribers. In response, the prescriber may continue or cancel the prescription.

In its first three years of use, PRIMUM identified one in four patients at risk for abuse and prevented nearly 43,000 high-risk prescriptions for controlled substances across Atrium Health. The alert influenced the prescribing decision in 1 in 5 encounters, and this result has been sustained for nearly four years. Learn more about how Atrium Health is addressing the opioid crisis in the Carolinas.

With additional funding from the CDC, our team enhanced PRIMUM by incorporating the CDC clinical practice guidelines within the EMR. These clinical decision support tools encourage prescribers to follow CDC recommendations when prescribing opioids for chronic pain.

We also built a controlled substance review component in the EMR that serves as a comprehensive toolkit for prescribers. The EMR now has all patient prescription history and risk information in one centralized location.

Other upgrades to PRIMUM include:

• Additional high-risk patient alerts:
• A recommendation for naloxone, the opioid overdose reversal drug, for especially high-risk patients
• New alerts to discourage prescribing:
• Extended release opioids to patients who are not already taking opioids
• Opioids and benzodiazepines at the same time
• A morphine milligram equivalent (MME) calculator with the patient’s total daily dose and guidelines for prescribing opioids
• A reminder for prescribers initiating chronic opioid therapy to:
• Create a pain agreement
• Conduct drug screening
• Schedule a follow-up visit
• Various links to:
• A standard pain agreement
• The NC and SC Prescription Drug Monitoring Program websites
• Discharge instructions, including patient education for the safe use and disposal of opioids

IMPROVE – Identifying Risks in Acute Care

Much of the attention on the opioid crisis nationwide has focused on the outpatient setting, opioids prescribed for chronic pain, and patients who are already dependent on opioids. Addressing the need for a tool for the acute care setting and primary prevention, our team developed “Implementing a Multimodal Path to RecOVEry” (IMPROVE).

With IMPROVE, prescribers can manage pain while optimizing patient safety through safe opioid prescribing and increased use of multimodal pain management. Not only does it identify risk factors for opioid dependence, including alcohol use and mental health issues, the platform offers actionable guidance on a number of well-researched pain management strategies, from non-opioid medications to cryotherapy to cognitive therapy.

IMPROVE utilizes secure and authorized medical records to collect and provide information on risk factors for opioid dependence and overdose, including substance use and depression.

Through early identification of risk factors, the goals of this study include:

• Reducing the number, dose and duration of opioid prescriptions for patients at the highest risk for developing opioid dependence
• Reducing reliance on opioid monotherapy
• Providing a pathway for intervention on modifiable risk factors

Orthopaedic Trauma Association Clinical Practice Guidelines for Acute Musculoskeletal Pain

Joseph Hsu, MD, Rachel Seymour, PhD, and Meghan Wally, PhD, led a national taskforce to develop clinical practice guidelines for pain management for acute musculoskeletal pain. A panel of 15 members with expertise in orthopaedic trauma, pain management or both was convened to review the literature and develop recommendations on acute musculoskeletal pain management. The guideline was submitted to the Orthopaedic Trauma Association for review and was approved on October 16, 2018. This work is detailed in ‘Hsu et al. Clinical Practice Guidelines for Pain Management in Acute Musculoskeletal Injury. (2019). J Orthop Trauma, 33;5. E158-82.’ It was subsequently endorsed by the American Academy of Orthopaedic Surgeons and the American College of Surgeons.

Patient Materials

• Acute Pain Management Education
• Acute Paint Management Handout (Spanish)
• Compression Patient Handout (Spanish)
• Cryotherapy Patient Handout (Spanish)
• Desensitization Therapy Handout (Spanish)
• Guided Imagery Patient Handout (Spanish)
• Pain Agreement
• TENS Unit Guidelines for Patients (Spanish)