Anne Arundel Health System doctors found wide variation when they looked at how they prescribed opioid painkillers.
Patients with the same medical conditions, such as a back injury, were given the potent, addictive drugs in some instances and not in others. Doctors prescribed a wide range of doses; one person might get 15 pills and another 30.
Health system officials found the highest prescribing primary care doctor gave patients 10 times the opioids of the lowest, though the disparity was only three times between the highest and lowest 20 percent of prescribing doctors.
The review, conducted last year amid a nationwide opioid epidemic, troubled hospital administrators. They decided they had to act to address the inconsistent prescribing of the highly addictive drugs.They established a goal to reduce the amount of opioids prescribed by 50 percent by 2019.
"We don't want to create a new generation of addicts," said Dr. Barry Meisenberg, chair for quality improvement and healthcare systems research at Anne Arundel Health System, who is heading an opioid task force there. "We don't want to contribute to the problem."
Anne Arundel Health System joins hospitals across the region and state attempting to eradicate a problem medical institutions now realize they helped create. While Maryland and the rest of the country struggle with a unprecedented epidemic of opioid-related addiction that has has killed thousands of people, hospitals are working to reduce opioid use as the first line of defense in pain management.
Many people become addicted to opioids after a doctor prescribes the drugs for a medical condition and the patient becomes dependent. Some patients also build resistance to the drug's effects and need increasingly higher doses. When they can no longer get the drugs through prescriptions, they seek out illicit opioids such as heroin, which is more potent and less expensive than prescription painkillers. Most of the recent fatal overdoses in Maryland were caused by heroin laced with deadly additives such as fentanyl.
Anne Arundel Health System started a pilot program this year that has already made some headway to reduce the prescribing of opiods. Doctors in the orthopedics, emergency medicine and primary care departments deliberately looked for alternatives for treating pain and prescribed opioids as a last resort.
There are no nationally accepted guidelines for how much of an opioid should be prescribed for a specific procedure, Anne Arundel health officials found. The U.S. Centers for Disease Control & Prevention only says doctors should prescribe the least amount possible for the shortest period.
The medical system set up dosage guidelines based on research published in medical journals. For instance, patients who undergo trigger finger release surgery, to straighten a finger stuck in a bent position, are given five pills or less of 5 milligrams of hydrocodone. Before they might have been given 15 to 25 pills. Those who get carpel tunnel release surgery, to relieve pain in the hand and wrist, are prescribed 10 pills of hydrocodone rather than the 30 that were once typical.
After the initial prescription runs out, the patient is reassessed and can be given more pills if pain persists.
The pilot program's result was a 40 percent reduction in overall opioid prescribing in those treatment areas from January to July. The health system is now in the process of expanding the initiative to other departments.
Other hospitals have not set a specific benchmark for reducing opioid prescribing. But they are working to reduce the reliance of patients and doctors on the drugs to treat pain. They're banking on the result being fewer prescriptions.
Hospitals throughout the state are prescribing fewer opioid pills, regularly tracking how much their doctors are prescribing, and doling out ibuprofen and other less-addictive drugs. Their doctors also are using alternative treatments, such as injecting non-opioid drugs directly into the part of the body where the pain originates.
Doctors are having more extensive conversations with their patients about pain management and teaching them the importance of properly disposing of unused drugs to prevent other people from using them. Some people, including youths, take opioids that were prescribed to someone else in their household and left unguarded in medicine cabinets.
"Doctors are now spending more time talking about pain with their patients," said Sharon McClernan, vice president of clinical integration at Carroll Hospital. "They aren't just giving them a Percocet and sending them on their way."
Carroll Hospital has stopped automatically prescribing 30-day doses of opioids, in many cases limiting it to three days, among other initiatives.
Hospitals are also changing their approach to pain management. When opioids first became widely used, the culture of medicine was to help get patients to zero pain. Today, the treatment goal is to help people be functional and live comfortably even if the pain is not completely eliminated.
At LifeBridge Health, doctors are paying special attention to patients who have taken opioids for long periods. They are taking a multi-disciplinary approach, addressing a patient's other needs, such as stress, anxiety and insomnia that may contribute to how they deal and live with pain.
"For those folks, there is much more to do than to just ween them off of their medication," said Dr. Scott E. Brown, chairman of LifeBridge's department of physical medicine and rehabilitation.
The emergency departments at Johns Hopkins Medicine hospitals have implemented opioid guidelines that prohibit refilling opioid prescriptions, limit the number of doses prescribed and require alternative pain management techniques as first approaches, Hopkins said in a statement. They also opened a clinic at Johns Hopkins Hospital to evaluate patient pain needs before, during and after surgery.
The University of Maryland Medical Center established an opioid task force in March that is working to standardize opioid prescribing and other practices where possible, a spokesman said in an email.
The University of Maryland Baltimore Washington Medical Center no longer prescribes the opiate hydromorphone, known as Dilaudid, in the emergency department, a spokesman said. Doctors in the emergency room will write a prescription for an opiate for no more than three days. Patients must follow up with their own doctor or return to the emergency room for another evaluation if the pain persists.
Some hospitals worry that setting specific goals like Anne Arundel Health System creates a one-size-fits-all prescribing culture for certain conditions. Pain is different for every patient, and treatment should be as well, LifeBridge's Brown said.
"What we need to do is focus on trying to avoid opioids as much as possible," he said.
Anne Arundel officials said their approach gives them options to increase pain medications for individual patients. They regularly survey patients to make sure dosages are working for them. They set up pain guidelines using scientific research as well as an analysis of their own prescribing practices. Doctors and administrators are discussing how the drugs are prescribed.
The guidelines they developed now pop up in the electronic medical system when doctors input a diagnosis.
"We know that surgery can be very painful," said Dr. Jeffrey Gelfand, medical director of orthopedic services at Anne Arundel Health System, who led development of the prescribing guidelines for pain medication in orthopedics. "We tried to come up with a way to adequately treat pain without overprescribing."
Anne Arundel health officials said opioids remain a viable option for treating pain, and they are not trying to eliminate their use altogether.
"We just want to make sure we are prescribing cautiously and appropriately," Meisenberg said.