Nurses, peers pivotal to health system`s opioid disorder initiative

Inquiries from other hospitals have streamed in as Delaware-based Christiana Care Health System has refined and expanded its efforts to engage opioid use disorder patients when they enter the hospital for other problems. One message its leaders consistently communicate to interested parties is to think of this as an effort that should target every hospital bed in the health system.

“We inevitably say, 'Go into the inpatient setting with this,'” Terry Horton, MD, FASAM, Christiana Care's chief of addiction medicine, tells Addiction Professional. “The hospitals usually want to do something in the ER.”

But the problem of undetected and/or unaddressed substance use disorders in hospital systems goes well beyond the emergency care part of the operation. Christiana Care recognized this years ago, and Horton (who formerly worked at Phoenix House, one of the nation's largest nonprofit addiction treatment organizations) spearheaded an effort to use peer counselors to help lead hospitalized patients on a path to recovery. Addiction Professional first wrote about that initiative, called Project Engage, in 2014.

More recently, Christiana Care in the past year initiated an Opioid Withdrawal Clinical Pathway that seeks to identify the presence of any opioid use problems among all hospital admissions, which then is followed by aggressive interventions to combat withdrawal and connect individuals to ongoing treatment. The use of Project Engage has become a critical component of this clinical pathway initiative.

These efforts have placed Christiana Care in demand for offering advice to other hospitals that have seen the damage that the opioid crisis has inflicted on their patient populations. For example, hospital leaders from West Virginia visited Christiana Care late last month to learn more about innovations such as Project Engage and the Opioid Withdrawal Clinical Pathway.

Christiana Care embraces the philosophy that admission to the health system can provide a “reachable moment,” as coined by Christopher Shanahan of Boston Medical Center, for individuals with opioid use disorders.

How the clinical pathway works

In an interview with Addiction Professional, Horton outlined the key steps that make up the Opioid Withdrawal Clinical Pathway. He says that if a patient with an opioid use disorder enters the hospital and this issue goes undetected, withdrawal will ensue and one of several negative outcomes will result: a departure against medical advice, which exacerbates the risk of overdose; resumption of use of heroin while in the hospital (“anecdotally you hear this is happening,” he said); or simply being challenging to staff because of constantly asking for opioids in order to relieve withdrawal.

Opioid withdrawal is “a primal misery,” says Horton. “It is not 'a bad case of the flu,' as people used to describe it.” It can lead to infectious complications, and it makes pain worse, he says.

Here are some of the key components of the clinical pathway:

• Nurses have the task of administering a simple two-question screener for all medical admissions at Christiana Care. Admitted patients are asked if they have used heroin or a prescription opioid non-medically in the past two weeks, and, if so, if they feel sick if they don't use.

• An affirmative answer to either question sends the nurse to the computer to complete a multiple-question instrument on withdrawal that in turn may trigger notification of the patient's treating physician.

• Patients will begin treatment with a 72-hour buprenorphine-naloxone based taper; Horton points out that this does not require administration by a physician certified to prescribe buprenorphine. At the same time, Project Engage teams made up of a peer counselor and a social worker are notified. At present, the specialty treatment agency Connections furnishes the peer workers that Christiana Care uses, Horton says.

• The Project Engage teams immediately begin working with the patient's medical team on a discharge plan that will allow the patient to transition to a community-based provider upon discharge from the hospital. “We encourage patients who want to remain on Suboxone to remain,” Horton says. “They can get on a standing dose. … We must have safe discharge plans.”

• Because Delaware is a Medicaid expansion state that has established Medicaid-funded treatment slots, “We have been able to develop what is essentially treatment on demand,” Horton says.

One of the ways in which Christiana Care measures the success of the pathway involves the number of patients initiated on buprenorphine-naloxone, and that number is rising. The system has found that around two-thirds of patients who are started on treatment in the hospital are interested in continuing care post-discharge, and two-thirds of them are still receiving medication treatment one month post-discharge, Horton says.

Hospital staff's experience is also an important measure of success, however. “Nurses want to improve their experience,” Horton says. “They are often frustrated when they can't make an impact. Most of us don't do well with hopeless.”

He adds, “The nurses now see this as part of their duties, to address withdrawal.”

What they're learning about peers

Horton says the attributes that a peer brings to the work tend to be more important than the details of the peer's personal addiction and recovery history. “How do you integrate into the floors [of the hospital]?” he said. “The hospital is an entirely different work setting.”

On some occasions, a peer is matched to the characteristics of a patient. A mother might be assigned to a pregnant patient, or a male peer might be matched with a man who does not appear to relate well with women.

“We have peers who come from all walks of life,” Horton says. “We have a cement worker who is good with the construction guys.”

Integration of peers into the care teams generally takes considerable effort, however, Horton insists. “Some have far too simplistic an understanding of how to use peer programs,” he says. “Some think you just go and hire peers, and away they go. That's unfortunately not how it works.”