Responding to the Opiate Epidemic Some Practical Hospital Strategies Kendall L. Stewart, MD, MBA, DLFAPA Southern Ohio Medical Center Ohio University Heritage College of Osteopathic Medicine A Presentation for the Indiana Hospital Association October 6, 2016 East Liverpool, Ohio, Police Department

How many millions of people on earth use drugs to feel better?1,2,3 1The Lancet, January 6, 2012 2WHO 3GreenFacts.org

What is the problem?1 Slide 1 of 2 1CDC Vital Signs, July 7, 2015

What is the problem?1 Slide 2 of 2 1CDC Vital Signs, July 7, 2015

What is the extent of the problem in Ohio?

Where did this problem begin and spread in Ohio?

What is the solution?1 1CDC Vital Signs, July 7, 2015

How did we get here? Physicians who should have known better fell for drug company hype. Our professional societies pushed pain as the 5th vital sign and suggested that untreated pain was a professional shortcoming. Many physicians were seduced by the reliable, easy money of filling pain drug prescriptions. (Many still are.) Because of this, cash-based pill mills blossomed. It turned out that opioids were not very effective for pain, but they were very effective for generating feelings of bliss in susceptible brains. Authorities finally cracked down on the pill mills, and the heroin pushers rushed in to meet the demand with a cheaper, more available product. And now the second generation (Suboxone) pill mills are starting to appear and flourish.1 1While the science supporting the effectiveness of appropriate Medication-Assisted Treatment (MAT) is compelling, both under- and over-prescription are widespread.

Who are we and how did we get caught up in this plague? We are an independent, not-for-profit community hospital located just across the Ohio River from the nation’s first pill mill in Kentucky.1 We are a 222-bed inpatient facility with 2,200 employees and numerous outpatient facilities. At one point, physicians in our market prescribed more OxyContin than anywhere else on the planet. We serve in one of the most unhealthy and challenging environments in the U.S. In spite of our daunting environment, we are one of Fortune’s 100 Best Places to Work in America, a Magnet organization, an OSHA VPP Star designee and our physician and employee satisfaction results are among the best in the world. 1I took my boys to Dreamland Pool and I knew David Proctor very well.

What are some of the things we are doing to make a difference? We are recruiting and supporting SOMC chemical dependency champions.1 We are taking care of pregnant mothers and their babies.2 We are supporting all community efforts by providing needed resources and focusing on our common ground instead of our differences.3 We are urging our physicians and advanced practitioners to follow CDC guidelines for prescribing opioids for pain. We are managing the medical and surgical complications of drug abuse. We are offering medical withdrawal services to assist dependent persons in their transition to the stable management of their chronic disease.4 We are changing our beliefs, our behaviors and, as a result, our feelings.5 1Our success has depended more on individual than organizational initiatives. 2This presentation will focus primarily on this challenging initiative. 3Both these patients and the treatment community are challenging. 4While the disease model of chemical dependency has understandably come under withering criticism from the scientific community, it is the only way to fund treatment, and it encourages both patients and providers to change their beliefs, behaviors and their feelings. 5Most of our challenges as leaders revolve around people and their feelings.

What have we done for addicted mothers and their babies? Slide 1 of 3 What have we done for addicted mothers and their babies? We deliver care to 1200 mothers and newborns each year; we are a Level I nursery. In 2003, we began to see the first babies with Neonatal Abstinence Syndrome (NAS). In 2003, one of our pediatricians began developing and constantly updating our morphine withdrawal protocol for the treatment of NAS. Soon after, we became partners in the Ohio Perinatal Quality Collaborative (OPQC) As the plague spread, our experts were invited to speak to their colleagues across the region. We worked hard to improve our interrater reliability scores on the Modified Finnegan Neonatal Abstinence Scoring System.1 1Our interrater reliability is now consistently > 90% and when the score is > 8, two experienced nurses assess the child independently.

What have we done for addicted mothers and their babies? Slide 2 of 3 What have we done for addicted mothers and their babies? In 2010, we began umbilical cord testing for all at-risk mothers and babies.1,2 In 2011, one of our OBGYN physicians finally persuaded his colleagues to drug test 100% of their patients on admission for delivery. In 2012, we invited a local chemical dependency counselor to educate 100% of our maternity staff on, “Addiction Is A Disease.” In 2012, one of our physician champions started a controversial Subutex (buprenorphine) weaning protocol for pregnant mothers at a local residential facility for addicted pregnant women; their babies have done much better, but the numbers are small and scientific support for this approach is lacking.3 1About 25% of our mothers are judged to be at risk. 2About 13% of our cords are positive for polysubstance use, and the United States Drug Testing Lab (USDL) has informed us that we have more polysubstance positive cords than any other hospital in America. 3The withdrawal from Subutex appears to be easier than from methadone or Suboxone (buprenorphine + Narcan (Naloxone))

What have we done for addicted mothers and their babies?1 Slide 3 of 3 What have we done for addicted mothers and their babies?1 Our nurses consult SOMC Social Services on every at-risk mother. Our nurses consult occupational therapy (OT) for every newborn being treated for NAS. Our nurses and social workers advocate for the mother and baby with Children’s Services. Our nurses have employed skin-to-skin techniques, lighting, positional aids, music, swings, low-lactose formula changes and other evidence-based strategies. Our nurses have “adopted” the residents of our local residence facility and provided gifts, orientation sessions and hospital tours. Our nurses and physicians have created a SOMC task force and participate fully in related state and regional advocacy and scientific organizations. Our nurses provide education to the community on NAS. 1This is just a partial list of the way our caregivers are making a difference.

What is our current reality? We are seeing mothers from jail and the prison system. We are seeing moms with zero social support. Prostitution is an ongoing challenge in Portsmouth. Pain clinics are telling patients that their babies will not withdraw. (Some of the worst of these have been closed by authorities, but more Suboxone clinics just keep popping up in response to the lure of big, easy bucks.) Predictably, we are seeing patients without prenatal care, preterm births, poor maternal health and bad outcomes. Our polysubstance-positive cords have leveled off at about 13%. The switch to heroin and fentanyl is well underway.

What are some of our results?

What have we learned? The health consequences of drug addiction are going to be an challenge for all of us for a long time. We hospital leaders cannot manage this problem by ourselves, but we can certainly help. Identifying and supporting passionate caregivers is a more effective approach than bureaucratic initiatives. Focusing on our common ground is more effective than hardening our missile silos. As with all human endeavors, changing what we believe, what we do and, as a result, how we feel will remain our biggest challenges. We are rarely doing the best we can do; we are usually doing the best we are willing to do.1,2,3 1I encourage you to join me in developing realistic expectations for these sufferers. 2Many will never recover, but some will; giving up is not an acceptable option. 3I am especially indebted to Jone Stone, RN, for her exceptional leadership and for her assistance in preparing this presentation.

Where can you learn more about the SOMC leadership culture? Join the discussion about practical approaches to more effective leadership on the SOMC Leadership Blog. Download, read and reflect on The SOMC Leadership Culture: An Informed Consent and Commitment Document For Aspiring SOMC Leaders. Read Expectations for SOMC Leaders carefully. Learn more about Southern Ohio Medical Center here. Learn how we are transforming SOMC into an anger-free workplace here. Learn more about how to cope with the routine challenges of leadership more effectively by reading A Portable Mentor for Organizational Leaders.

Where can you learn more about the opioid epidemic? Read Dreamland: The True Tale of America's Opiate Epidemic, by Sam Quinones. Download and read Opioid Epidemic in the United States. Download and read Prescription Opioid Misuse, Abuse, and Treatment in the United States: An Update. Read Today’s Heroin Epidemic. Read the UpToDate Summary and Recommendations for the treatment of opiate addiction. Encourage all of your providers to visit the Turn the Tide website, read the letter from the Surgeon General, Take the Pledge and download the Treatment Options. Explore the Ohio Department of Health’s Drug Overdose Data and Publications.

How can you contact me? Kendall L. Stewart, MD, MBA, DLFAPA VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. Clinical Professor of Psychiatry Ohio University Heritage College of Osteopathic Medicine 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com

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