Cartersville Medical Center pursuing protocols, procedures to curb narcotics misuse
It’s the undergirding principle of the Hippocratic Oath — “first, do no harm.”
As the case with virtually all health care providers in the nation, Cartersville Medical Center (CMC) finds itself in a difficult position in the wake of the national opioid crisis. On one hand, physicians want to do everything they can to ensure patients with legitimate pain problems are given proper — and sometimes, life-saving — treatment.
But at the same time, medical providers are also aware that many individuals frequenting emergency rooms are feigning symptoms to get their hands on prescription medications. And in other circumstances, there’s the fear that opioid treatment for genuine medical conditions could spiral out of control, with individuals using — and oftentimes, getting hooked on — such medications long after what was supposed to only be a temporary regimen.
It’s a subject top of mind for Jan Tidwell, CMC’s chief nursing officer.
“Four out of five new heroin users report prescription opioids first prior to abusing illegal drugs,” she said. “So there’s several things, really, that we’re doing here at Cartersville Medical Center to help develop safer management protocols and to assist in the reversal of the opioid crisis.”
CMC Emergency Medicine Director Dr. Garrett Gore said physicians are well aware of the potential consequences of prescribing narcotics to patients.
“A doctor’s first responsibility is to his patient, and his first responsibility is to believe the patient,” he said. “We do our best to try to implement things to minimize that, but there’s no golden rule … you don’t want to blow off a patient’s pain, you don’t want to miss a patient’s illness just because your gut instinct tells you they may be shopping for narcotics.”
And on that front, Gore said CMC and its parent company, Nashville-based HCA Healthcare, has been ahead of the curve.
“I implemented a pain policy about three years ago, even before they started to take root,” he said, “just to give some of our providers some good guidelines as to how we want to practice here in Cartersville, how we want to treat the community, how we want to protect them from the opioid crisis.”
Addressing opioid misuse, Tidwell said, has required a joint effort across providers, CMC’s pharmacist team and its departmental leaders.
“Rather than using opioids like Oxycodone, Hydrocodone or Fentanyl medications, we’re trying to look at other medications or other modalities like Ketamine or other things that might be better for the frontline management support for patients,” she said. “One thing we really focus on is using our Alternatives To Opioids (ALTO) program, approaches that are able to utilize pain management guidelines [and] focus on multimodal approaches for acute pain, which is what people usually seek when they’re coming to our emergency department.”
Part of that approach, she said, is targeting specific pain receptors, where non-narcotic medications may be just as effective, if not more effective, than opioids.
“We look for patients who are opioid naive, meaning they’ve not taken very many medications such as that, and those who are opioid tolerant, because that helps guide us in our protocols or practices in managing their pain and keeping patients comfortable,” she said.
The opioid alternatives may not work for all patients, but Gore said the local hospital is seeing quite a bit of success with the ALTO program.
“A lot of patients never even have to receive a narcotic for something like a kidney stone,” he said. “They can receive intravenous lidocaine or something along those lines that will take their pain from a 10 to a one.”
Over the last 10 years, Gore said new State and federal regulations and requirements on opioid prescriptions have been effective at deterring and reducing medication misuse.
“There’s a lot of transparency now, a lot of accountability and that’s been a very good, welcome change from my perspective,” he said. “You’re not going to see the results immediately, it’s going to take a couple of years to see this, but we track each doctor’s opioid prescription rate at every meeting … the doctors get that information, and once they’ve seen 400 or 500 patients or however many it is, they get feedback on it.”
Tidwell said CMC started an Electronic Prescribing of Controlled Substances (EPCS) program last year.
“Every different department phases into that, and the implementation of that will be fully in effect by 2020,” she said. “Physicians now have access to electronic medical and health records — they can see medication histories and this really helps them prescribe opioids more judiciously.”
Through the program, prescriptions can be sent to pharmacies through a secure electronic transmission — thus, eliminating the risk of patient forgeries.
“These programs decrease opioid-related addiction, misuse by diversion and even potentially death by making it very difficult for medication-seekers to get medications and alter any prescriptions that they may potentially have in hand,” Tidwell said.
While “narcotics shopping” in the local emergency department remains common, Gore said steps are being taken to curb those numbers.
“The State of Georgia and the [Drug Enforcement Agency, or DEA], they continue to work on their data banks and how everything is electronically networked together, so we can see what’s going on with peoples' habits and where they’re getting narcotics and so forth,” he said. “That from the DEA has still got a lot of evolution to take place, talking between states. I’d like to see it ultimately evolve to where controlled substances are even tracked that a patient’s gotten at a hospital … we have no idea if a patient went to seven different hospitals and gotten narcotics at all seven hospitals.”
Yet Gore acknowledges that may have its downsides, as well.
“Sometimes it may be obvious that’s what’s going on with a patient, so it falls on every physician how to battle or deal with that, but it’s a tough problem to handle when you’re taking care of people,” he said. “I hate to say, though, as it gets better in the E.R., it may get worse on the illicit side of things, but that’s for the legislators and the local authorities.”
To optimize patient outcomes, Tidwell said CMC relies upon a host of evidence-based pre-operative, inter-operative and post-operative orders. She brought up the hospital’s Enhanced Surgical Recovery (ESR) program.
“In years past, common surgical practice was to prescribe pain medication for comfort for extended periods of time,” she said. “You saw those prescriptions last for a month or two weeks, so we’re really trying to peel those things back and make them more appropriate to when that acute pain phase is and not last as long.”
And when it comes to opioid-related emergency departments visit rates, last year Bartow easily doubled the state average. For heroin-related emergency department visits, Bartow’s rate was more than triple Georgia’s average.
Gore said the amount of narcotics-related hospitalizations and emergency department visits in the local community is "staggering. "
“I’ve been here for 13 years and I have seen the usage of reversal agents, we’ve seen the overdose rate, just like everywhere else, skyrocket,” he said. “One week, we had multiple overdoses come from the same location.”
He said he’s especially concerned by the number of hospitalizations and overdoses involving heroin, Fentanyl and other drugs laced with Fentanyl.
“Atlanta is the No. 1 hub in the country for the distribution of this stuff now, especially Fentanyl,” he said. “We’re just barely in that capture area in the outer rim.”
While Gore said he believes the State has taken a step forward by requiring physicians to at least look at patient’s prescription medication histories, he said more can certainly be done to address the issue.
“To enforce that a little bit, that would be another step to take,” he said. “Hospitals and E.R.s are very scrutinized … but I think in your private settings, I think that’s going to be your biggest opportunity, whatever our great legislatures come together with to maybe take the next step.”
With Centers for Disease Control and Prevention data from 2017 indicating more than 70,000 Americans died from overdoses that year alone, Tidwell said all health care entities are “onboard for better initiatives to put into place to manage patients’ pain, but to do it in a safe and effective manner.”
In that, Tidwell likened the substance abuse crisis to cancer — a major public health issue that simply does not discriminate along sociodemographic lines.
“A lot of times you have patients with chronic conditions that might be more susceptible to taking certain medications like opioids,” she said. “But a lot of times, you do see people with comorbidities that are more at risk for developing addictions.”
That’s especially true, she said, for those with behavioral health disorders without adequate support systems.
“It affects families, it affects children, it affects homes — certainly, we’re seeing the socioeconomic challenges that these families face as we see and treat them everyday,” she said. “We try to take care of them holistically. We make sure that we have case management and social workers involved to help support them, and try to have opportunities for them to have their best success in achieving their health care goals once they leave the facility.”
She said that makes behavioral health services, such as those provided by Willowbrooke at Tanner and Highland Rivers Health, instrumental in addressing the community’s substance use epidemic.
“They do assess patients and help us find options, once they leave our facility, to seek treatment," Tidwell said of hospital partner Willowbrooke at Tanner. “Or sometimes they’re transferred out of the facility to appropriate places to achieve the goals that they need for addiction purposes.”
“A WHOLE COMMUNITY PROBLEM”
Both Tidwell and Gore agreed that solving Bartow’s substance abuse problem requires the input, effort and assistance of numerous community stakeholders.
Tidwell cited CMC’s “Crush the Crisis” event as an example. Each year, the local hospital teams up with the Bartow County Sheriff’s Office to host an event where members of the community can safely dispose of powerful prescriptions drugs such as Codeine, Hydromorphone and Fentanyl.
She said simply getting unused and expired opioids out of homes — and out of the black market — could be a pivotal step forward in addressing the crisis.
“It can happen to any family, to any person,” she said.
Overall, Gore said he’s seen a drastic cutback in the volume of narcotics administered at CMC.
“I’m proud to say our E.R. has been on the frontline of that, compared to other E.R.s in the northwest Georgia area,” he said. “We do firmly believe in ‘do no harm.’”
Gore said he’s also pleased to see that, in the midst of the opioid abuse epidemic, that the proverbial pendulum hasn’t swung in the opposite direction.
“We’re not letting patients lie there in the hospital bed, writhing in pain from whatever process because we’re afraid to give them [opioids],” he said. “I feel strongly that patients are still being very well taken care of, their problems are very well being managed.”
Increasing public education on medications, he said, could also go a long way in addressing some of the opioid abuse problems on the front end.
“Back in the old days, what a doctor said, a patient did,” Gore said. “Medicine’s a lot more complex now. I think patients should be engaged … if you didn’t get good communication from your doctor, they just gave you medicine, well, challenge it, or just ask them ‘Why am I taking this, is there an alternative?’ I think I may have had that question three times in 15 years. Patients just don’t think they can ask that.”
A long-term response to the crisis, Gore said, is ultimately something legislators will have to tackle.
“We can only do so much. I think every American is aware of what happens and where a lot of this stuff comes from, illicit drug-wise," he said. “I think that’s a question for your senators and your congressmen."
And on the local level, Gore said the war on substance abuse is far from just CMC’s fight.
“This is a church thing, a community thing, law enforcement, school teachers, you name it,” he said. “It reaches all fronts, there’s no way [CMC alone] can put a huge dent in this problem. It comes from your local government leadership, your sheriff — it’s a whole community problem.”
Community Torn is a five-week series exploring the many ways substance abuse impacts Bartow, with an emphasis on the voices of those most impacted by the community's drug crisis. Using a multidisciplinary approach encompassing public policy specialists, health care providers, law enforcement officials and judicial system representatives, the series seeks to demonstrate the true toll of substance dependency throughout the county.