Sarah Wakeman, MD, and Eric Weil, MD, Co-Chairs of the Mass General/MGPO Opioid Task Force, answer important questions about the Task Force and Mass General’s related efforts to address the opioid crisis.
Q. Why has Mass General made opioid use disorders the highest clinical priority of its hospital-wide strategic plan?
A. Sarah Wakeman, MD: The mission statement of the hospital changed in 2007 to make community an explicit part of our mission, which is a big statement for a big hospital and academic medical center like Mass General. In its most recent strategic planning process, the hospital looked to the committees representing the four parts of the mission–-community, education, clinical care and research–-to help inform how it would focus its efforts going forward. For the first time in this last process, community was a part of that.
Every three years we do a community health needs assessment. The community committees looked to the communities to determine their biggest priority, and all three of our main communities — Charlestown, Chelsea and Revere -- identified substance use disorder or addiction as the main issue that mattered to them by a resounding majority. So whether that was because of public safety, concerns for health or concerns about loved ones, community members felt that was the single greatest issue.
That led the community subcommittee, as well as the population management clinical committee, to identify addiction or substance use disorder as the main clinical priority. The hospital embraced that as a part of the work moving forward with the strategic plan. It was really a response to what mattered to our community members as well as recognizing the health toll that addiction was taking on our populations as we provide medical care.
Eric Weil, MD: It’s important to realize that the hospital and the physicians in it don’t operate in a vacuum from the world outside. We recognized very much that there was and is an epidemic of substance use disorder. As an organization we felt it was both our responsibility and our obligation to help be a part of addressing that challenge.
Q. How did the Mass General/MGPO Opioid Task Force come about, and what are its main purpose and primary initiatives?
A. Dr. Weil: Since 2012, at least within primary care, there has been a lot of effort and attention around engagement with physicians and other members of our care teams on the safe and appropriate prescribing of opioid pain medications. We started in primary care because that’s where more of our patients interface with the health care system than almost anywhere else. Primary care also represented one of the larger prescribers of opioid pain medications. However, after focusing on primary care, we also acknowledged that it was quite important to focus on the entire healthcare system: the ambulatory arena, the inpatient arena and all of the providers in all of those places that are involved in prescribing and monitoring pain medications.
The Task Force began in the fall of 2015 in the setting of everything that [Dr. Wakeman] just spoke about in recognition of some mandates from the state and the realization that we really have a responsibility to be responsible stewards of health care, pain management and substance use disorders. The president of the hospital and the president of the physicians organization reached out to [us] and asked us to put together a consortium of clinicians from across the Mass General health care system to help think through the way to create a streamlined approach to the prescribing, management and education involving opioid pain medications. The task force includes physicians, nurses, pharmacists and social workers, really all of the internal stakeholders that are involved in prescribing.
Dr. Wakeman: It’s really being part of the solution. A lot of the narrative around the opioid crisis is that doctors have been a part of the problem and that changes in prescribing practices have been at least one component that’s helped drive the current crisis. From the very highest leadership at Mass General, it was clear that we wanted to be a part of the solution, to address the needs of our community and minimize any unnecessary exposure to these medications, which can be quite harmful. Yet we also want to ensure that we are compassionately caring for patients who have severe pain and need effective pain management. This is a very nuanced issue, and we wanted to approach it in a thoughtful and comprehensive way.
Dr. Weil: I totally agree, especially with that last point. The biggest concern that people have expressed over and over again is: is it possible, if you are beginning to be more proactive and thoughtful about the way in which you prescribe opioid pain medications, does that mean that you’re going to have more patients in pain? Part of the purpose of the Task Force really is to make sure we serve as a balancing force to make sure the pendulum doesn’t go all the way in the other direction and to avoid a situation in which we’re not thoughtfully and compassionately treating our patients.
Dr. Wakeman: I also think the Task Force working alongside the hospital’s other efforts around substance use disorders is essential. The other challenge with focusing purely on access to prescription medications is that you must simultaneously address addiction when it’s already developed: people aren’t going to get well just because it’s harder to find pain medication. We want to be sure we have a balanced approach for folks who are having severe pain, but we also want to make sure we have treatment available for those who have actually developed an addiction.
Q. Describe the importance of the best practice guidelines you helped develop for clinicians prescribing opioids and how they will make a difference for patients.
A. Dr. Wakeman: Partly, we want to support our prescribers. These are tough issues to navigate. There are a lot of external checks and balances and requirements through the new legislation that prescribers have to be sure they’re meeting. Having a balanced approach, as Eric mentioned, can be tough. We wanted to develop a framework and a toolbox so that our prescribers know the parameters within which to operate and understand the new requirements. We also want to help them develop a strategy for addressing what can be really difficult clinical situations and to ensure that all patients are getting the same type of excellent care regardless of the clinical context in which they’re encountering a provider.
Dr. Weil: I would say that part of the importance of developing our own best practice guidelines is that our clinicians now have a real sense of ownership regarding their content. There are lots of guidelines and checklists that have been created by many very reputable organizations, and those are important. But to be able to say that your colleagues created this internally within your organization increases the chances that it’s going to be embraced.
Dr. Wakeman: I think this will make a difference for patients in that they can be assured that all providers are going to be functioning within the same guidelines. There shouldn’t be a different experience if a patient goes to one provider versus another provider. Patient safety and experience is at the forefront of our intentions with these guidelines, to keep both our patients and communities safe and to ensure that we’re addressing their pain in a meaningful and comprehensive fashion.
Q. Describe the Task Force’s partnership with the Substance Use Disorder Initiative (SUDs). What is the role of the clinical champions in Mass General’s efforts to implement the new guidelines?
A. Dr. Wakeman: I think the partnership with the Substance Use Disorders (SUDs) Initiative has been crucial. I’m medical director of the SUDs Initiative, and I also practice as a primary care physician at one of our health centers. Working in partnership with Dr. Weil, part of my role on the Task Force has been ensuring that its work is very tightly linked to the work of the SUDs Initiative. With both of those efforts, the goal is excellent patient care, be it patients suffering from substance use disorder or those suffering from pain.
Dr. Weil: In a big organization it’s easy for really good, well-meaning people to work in silos, and so having people like Dr. Wakeman, who can cross between related programs, means that those programs won’t move in different directions. It really makes them both more effective.
Our hope for the clinical champions is that they have the capacity to implement the work through the lens of whatever their specialty is. What a urologist is going to need to do around the guidelines is probably quite different from what a dermatologist or a primary care physician is going to need to do. The general concepts are the same, but how you actually make it happen, and how you communicate with your own organization, is different. Our hope is that those clinical champions can take the work, understand it in the context of their own profession and then translate it appropriately.
Q. When should opioids be prescribed?
A. Dr. Wakeman: That’s a challenging question, but we would say in general opioids should be prescribed for severe pain that isn’t relieved by other interventions, such as other medications that perhaps have less risk than opioids, like anti-inflammatory medications. Some pain can be better managed with things like an injection to treat inflammation, or even acupuncture or physical therapy. I think opioids are a very effective medication. They can be life-saving and certainly improve quality of life for some patients, but they also carry risks. Prescribers have to be thoughtful about using them only in circumstances where the benefits outweigh the risks.
Q. Given the stigma surrounding opioid misuse, how do clinicians help patients openly communicate their substance use disorders?
A. Dr. Wakeman: A main goal of the Substance Use Disorder Initiative is really addressing the stigma surrounding addiction or substance use disorder. Part of that is beginning to help people see addiction as truly a chronic medical disease that isn’t any different from diabetes, hypertension, obesity or other mental illnesses like depression. Addiction is something that’s not the patient’s fault: it’s caused by a mix of genetics and environment or exposure. There’s treatment that’s effective, and most people will recover. We’ve done a lot of work around educating our medical staff, our patients and our communities about coming to see addiction this way, because we know that fear of stigma is one of the main reasons people don’t seek out treatment. Only one in 10 people with addiction get treatment in any given year.
I think talking about it openly helps reduce stigma: having everyone from the president of our hospital to the president of our physician’s organization on down talking about this as a chronic medical disease that’s treatable sends a strong message about culture change. We must then make sure that treatment is available. Part of the stigma that gets perpetuated is because of a lack of treatment, resulting in a feeling of helplessness both for patients and their loved ones and for clinicians, who want to take care of patients, but maybe feel like they don’t have the resources to offer. Clinicians really trying to step up and offer effective treatment at any encounter with a patient makes a big difference.
Dr. Weil: To be clear, however, we have a long way to go. I think that a lot of our clinical colleagues still have very significant conscious or unconscious preconceived notions about substance use disorders, pain medications and how patients approach receiving those medications. So part of the strategy of the Task Force is to make sure we’re really educating people on the approach to stigma and to thinking about patients with an illness as opposed to patients with a problem that they’ve chosen.
Dr. Wakeman: I think the other thing that having universal guidelines helps with is that if you standardize something, it’s no longer necessary to single a patient out. A patient isn’t going to get a toxicology screening because a clinician is suspicious of the individual, but instead it’s a standard part of clinical care for every patient as a safety check. That’s how we’ll make these guidelines universal.
Dr. Weil: It’s really great to be able to say to a patient, “This isn’t about you. This is what we do for everybody. Yes, I know that you’ve been on this medication for 10 years, and you live in a reputable community. There’s really no reason for us to believe anything about you any more or less than anybody else.” This is the approach we take for all of our patients in a very egalitarian, fair fashion.
Q. How will the wider availability of intranasal naloxone (Narcan) benefit patients?
A. Dr. Wakeman: I think that naloxone is life saving. No one should die from an opioid overdose when we have an effective antidote. We know that anyone can be at risk of an opioid overdose, not just someone with addiction or someone who is misusing a prescription, but even someone taking a prescription as prescribed.
Just like we don’t prescribe insulin to a patient with diabetes without talking to them about having something around in case their blood sugar goes too low, we shouldn’t be prescribing medications that as a side effect can cause an overdose unless we ensure that people have access to a medication that can reverse that. It is already saving lives, and we need to get it out into the community. Four or five people die every day across the state from an overdose. Anyone can save a life. Having this medication that can reverse an overdose in your medicine cabinet, in your purse or in your car can save a life anywhere.
Dr. Weil: Some might ask, “Isn’t that giving people who use heroin or opioids recreationally in some fashion the freedom to use more because they know they can reverse their overdoses?” That’s really not what we’ve seen, and it’s not what the evidence shows. It’s a tool with which we can save lives. As health care providers, our responsibility is to make tools available that can save people’s lives. There’s no reason for us not to do that.
Dr. Wakeman: The research shows that it doesn’t increase people’s use and if anything engaging with them around safety makes people more likely to get into treatment. We would never not recommend wearing a seatbelt because we think people would drive in a riskier fashion. We should be encouraging other ways to keep our patients safe.
Q. How has addiction treatment been incorporated into Mass General’s community health centers and other primary care practices?
A. Dr. Wakeman: A key part of our initiative has been integrating addiction treatment into the outpatient setting. As I mentioned this is a chronic treatable medical condition, just like diabetes or heart disease, and so patients should be receiving care for it at the same place they receive care for all their other chronic medical conditions. So what that’s looked like is increasing access to all of the life-saving and evidence-based types of treatment for addiction. That includes medications, which are proven to be incredibly effective in helping people sustain recovery. It includes making sure there’s counseling available. It’s also included hiring recovery coaches, which has really been a game changer. They function like community health workers in that they can go wherever the person is, and they can address any barriers that exist to recovery.
We want to bring together teams of champions in the health centers so that patients are getting the best care possible, with lots of minds thinking about their cases. This can be a very severe, very debilitating disease, and watching patients suffer with it without having support as a caretaker can be really challenging. One of the main reasons historically providers haven’t wanted to take care of patients with addictions is the feeling that they don’t have the support or tools to do that. Bringing together these multidisciplinary teams has enabled clinicians to provide this care in a way that’s effective for patients.
Q. How else is Mass General connecting with and nurturing patients on the road to recovery from opioid misuse?
A. Dr. Wakeman: We need to build a system that provides that support, the same as we would for any other illness. We’ve started hiring some of our former patients who now work as recovery coaches with the initiative. We must ensure that patients are getting the best treatment possible when they need it most, whether that’s in the emergency room, in our hospital or in our health centers. We must support them through recovery, recognizing that this is a chronic disease that needs long-term management, so that the care doesn’t stop after a week, after 30 days or after a year. This is something they need support with for the rest of their life.