In North Carolina, the Burke Substance Abuse Network’s approach to creating and implementing a prescriber alert system offers a model for other communities looking to reduce the overprescribing of opioids.
About the Collaboration
Like many communities around the country, Burke County, North Carolina is facing increasing rates of opioid overdoses, resulting in high numbers of emergency room visits, hospitalizations, and deaths. Analysis by the North Carolina Department of Health and Human Services in 2014 revealed that Burke County physicians prescribed opiates more frequently than physicians in other North Carolina counties.
In March 2015, Burke County received funding through SAMHSA’s Partnerships for Success (PFS) grant program to address the non-medical use of prescription drugs in the county, including the overprescribing of opiates by local physicians. The funding is managed by Burke Recovery, a non-profit organization with a long history of leading collaborative prevention initiatives across the community. Since 2011, Burke Recovery has led the Burke Substance Abuse Network (BSAN), a coalition dedicated to connecting community partners, identifying gaps in service, and planning strategic, action-oriented responses to community needs.
With its PFS dollars, Burke Recovery created the RxEAP (Prescription, Education, Awareness, Prevention) task force, a dedicated subgroup of the coalition charged with reducing access to prescription medications and to empowering community members to help stop the problem. The task force boasts a diverse membership that includes multiple administrators and physicians from the Carolinas HealthCare System (CHS) Blue Ridge, law enforcement officers, pharmacists, mental health and social service professionals, and leaders of community organizations.
Within six months of receiving funding, the task force launched its first initiative: a prescribing alert integrated into the electronic health records of all 38 practice locations of CHS Blue Ridge. The alert system has two goals: (1) to flag patients who are “doctor shopping”—that is, visiting multiple doctors to see who will prescribe the prescription drugs they want; and (2) to provide physicians with the information they need to make informed prescribing decisions that reduce controlled substance duplication or overprescribing. For example, doctors are immediately alerted if their patient has three or more active opioid prescriptions in the past 30 days. Doctors in CHS Blue Ridge began using the system in October of 2015 and the coalition is now exploring opportunities to expand this well-supported program to other settings.
Elements of Success
Never Underestimate the Importance of Readiness
Joe Marks, Executive Director of Burke Recovery, explained that physicians on the Burke Substance Abuse Network were the impetus for the creation of the alert system. CHS Blue Ridge physicians were among the founding members of the BSAN—and eventually, the RxEAP task force—and came to the table because they were alarmed by the number of babies born in withdrawal from opioids they were seeing in their exam rooms, as well as opioid-seeking patients. Many also reported knowing colleagues who were overprescribing opioids. “The doctors came to the table knowing that they had been part of the problem and now wanted to be part of the solution,” Marks remembers. “The perfect storm was there: we had people who really wanted to do something about this problem, they wanted to form a task force, and the funding [PFS] was there to help us coordinate the effort.”
Build on Existing Connections
Two of the RxEAP task force’s most dedicated members are CHS Blue Ridge hospital physicians. Their support of the prescriber alert project and integral role in its development helped the task force forge critical connections with other key hospital administrators, including the hospital’s vice president of nursing. With her strong backing, the task force was able to connect with every nursing director, continuing education director, and practice manager in the health system. According to Sarah Dergins, a prevention specialist with Burke Recovery, “Relationships have been our biggest foot in the door.”
Think Strategically about Implementation
The RxEAP task force had concrete reasons for limiting the alert program to just the CHS Blue Ridge system. First, most physician practices in Burke County operated under the umbrella of CHS Blue Ridge. The CHS Blue Ridge system also used electronic health records, unlike some of the smaller physician practices in Burke County, which used paper records. Using an existing electronic record system that served 38 clinics meant that the RxEAP’s prescriber alert could reach a large number of physicians with one programmatic change in the system.
Don’t Operate in Isolation
One of RxEAP’s greatest strengths is that it functions as part of the larger BSAN coalition. As such, BSAN members are frequently tapped to grow the alert program and find new ways to decrease non-medical use of prescription drugs. “We strategically use BSAN meetings to identify and address gaps—in both our services and in our capacity to provide those services,” says Marks. “We are continually in ‘capacity-building’ mode.” For example, at one point Marks realized that the RxEAP task force lacked representation from the dental/oral surgery fields—two specialties that frequently prescribe opioids as part of care. When Marks mentioned this gap at a BSAN meeting, two BSAN members immediately stepped forward to join the task force.
Leverage Early Successes
Successful implementation of the prescriber alert system brought much-needed visibility to the BSAN’s other prevention activities. It also laid the groundwork for other interventions, such as the coalition’s “Lock Your Meds” communication campaign, comprising billboards, newspaper spots, and information cards for local pharmacies. In 2016, BSAN also distributed 139 medication lock boxes in “at-risk” homes throughout Burke County—homes with unlocked, controlled medications and children in residence.
Get Things Done
Both Dergins and Marks recognized the importance of moving BSAN, and eventually the RxEAP task force, beyond networking into action. Since the inception of the BSAN in 2011, every project they have taken on, from substance misuse awareness campaigns to the prescriber alert system, has been completed successfully. “They are not a group that sits around and talks about their problems every month and nothing happens,” says Dr. Melinda Pankratz, SPF-PFS State Grant Coordinator at the North Carolina Department of Health and Human Services, “They are very action-oriented. I think that helps keep people at the table.” Being solution-focused has helped both the BSAN and RxEAP develop new partnerships and forge new directions.
In the year since the prescriber alert was implemented, RxEAP task force leaders report successful integration of the system into CHS Blue Ridge health records and evidence that it provides an extra layer of safety to prevent overprescribing. The success of this initial project has also laid a strong groundwork for other components of the BSAN’s comprehensive prevention plan, including a communication campaign, medication lock boxes, and community education programs.
While data on changes in opioid prescribing rates are still forthcoming, the group is excited about its progress. An internal survey of CHS Blue Ridge physicians revealed that 100% of respondents were aware of the new alert system, and 70% reported that it helped them make better decisions regarding the use of controlled substances for patient care. Specifically, physicians highlighted the alert system’s utility for providing quick notification regarding controlled substance prescriptions (especially for patients with a very extensive drug list) and for providing an additional layer of safety to prevent duplication when a patient has recent or active prescriptions.
Looking forward, the RxEAP task force will continue to work with partners across the county to advance their prescription drug misuse prevention efforts. They are particularly dedicated to identifying new, more untraditional partners such as physician assistants, podiatrists, dentists, and oral surgeons. “We are aware not to rest on our laurels after launching the alert system,” Marks says. Their track record of success promises an exciting future.