To reduce opioid misuse, the Ohio Governor’s Cabinet Opiate Action Team, comprising representatives from the governor’s office, Department of Mental Health and Addiction Services, and health care providers, created a clear set of opioid prescribing guidelines.
About the Collaboration
In response to rising rates of opiate addiction across the state of Ohio, Governor John Kasich established the Ohio Governor’s Cabinet Opiate Action Team (GCOAT) in 2011. With involvement from Prevention Bureau Chief/NPN Molly Stone and others from the Ohio Department of Mental Health and Addiction Services (a Partnerships for Success 2014 grantee), the team was charged with reducing opiate addiction rates and overdose deaths across the state. Understanding the role of opioid over-prescribing as a key contributor to subsequent addiction and overdose,1 GCOAT focused its efforts on developing opioid prescribing guidelines.
To inform guideline development, GCOAT convened a 75-member task force comprising prevention professionals, doctors, dentists, nurses, and other healthcare providers. Together, the team created three sets of guidelines: to inform opioid prescriptions for emergency medicine, for chronic care management, and for acute care settings.
Within two years, the task force produced the emergency medicine and chronic care prescribing guidelines. According to Andrea Boxill, Deputy Director of GCOAT, the process for developing these initial sets went relatively smoothly. “There was quick consensus on what do in the emergency room—don’t send people home with a script for 30 pain pills for a sprained ankle, for example. And it was easy to create thoughtful guidelines for people in chronic pain,” she explains.
Yet when the group turned its efforts toward developing acute care guidelines, the road proved bumpier. Boxill describes the tension: “So much of acute care hits at the heart of how a physician practices medicine. Telling a doctor what they should be doing gets at something very personal. They are resistant to any suggestion that they are doing something wrong.”
Fortunately, the group was able to draw on the solid foundation established by Boxill and others to work through their challenges. “Our focus was to acknowledge and honor concerns respectfully, but to keep the work moving forward,” says Boxill. In early 2016, GCOAT released the final set of prescribing guidelines. While data regarding their efficacy is still being collected, initial reports suggest that they are being well-received.
Elements of Success
Put Physicians at the Helm
As a representative of the Governor’s office, Boxill realized right away that she should not be the task force’s sole leader. “With me at the helm, it would look like the government was mandating these regulations—which wasn’t the case. It was also important that the providers on the task force had leaders they could look up to and see as being on their side.” To provide the needed foundation of legitimacy and autonomy, she convened a five-member leadership team comprising preventionists and three physicians, including the head of Ohio’s Medicaid program, to provide “on the ground” perspectives on the challenges of changing prescribing practices. According to Boxill, her own role was “largely administrative. These guidelines were really created by and for prescribers. It was important to us that they owned the effort from start to finish.”
Facilitate Open Communication
Boxill also included on the leadership team a strong facilitator to help the group navigate difficult discussions. “I know my strengths,” says Boxill. “But my ‘candid’ style of management can present challenges when nuanced leadership is needed.” To co-facilitate the prescribing protocol workgroup, statewide leader and former head of the Ohio Office on Aging, Bonnie Kantor-Burman, known for her mediation skills, worked with Boxill and the medical director of the Ohio Office of Medicaid, Dr. Mary Applegate. “Bonnie knows everyone and gets along with everyone,” says Boxill. “She’s able to make a whole meeting full of folks feel like they’ve been heard.” Kantor-Burman’s people skills diffused tension at the task force meetings. “All of a sudden, we had people talking to each other because Bonnie was able to put them at ease.”
The leadership team met regularly to discuss task force progress, anticipate areas of concern, and practice their responses. This allowed them to respond thoughtfully when tough questions were raised, and to address deeper concerns that might not be voiced directly. Where appropriate, it also helped them reframe concerns into opportunities for empowerment. For example, when the question of what would happen if a doctor didn’t check a patient’s prior prescriptions came up, they were prepared to describe the risks of being known as a frequent opiate prescriber, malpractice being primary. They were also ready to address the concern behind the question—that is, the fear of being monitored. To do this, they initiated a discussion of how physicians might take responsibility for monitoring one another. “The doctors were worried that they were all being labeled as the problem,” says Boxill. “But when we asked them if they knew who those “bad doctors” were—that is, the ones who were over-prescribing—they all knew! From there, it became clear [to the doctors] that they needed to solve this problem among themselves.”
The GCOAT task force’s final set of acute care prescriber guidelines were launched in January 2016. Since then, Boxill has been working diligently with provider boards, hospitals and clinics, and healthcare organizations across the state to get them to adopt the guidelines.
“I’m always on the lookout for new ways to connect with statewide provider boards, hospitals and clinics, and healthcare organizations to get them to adopt the guidelines,” she explains. “I ask them what they need to make using the guidelines easier and then we work on doing that for them.” Boxill is also an active member of Ohio’s SPF-PFS and SPF-Rx Advisory Committees: both provide forums for both learning about prescribing practices and sharing information about the guidelines.
Reports published by the Ohio Automated Rx Reporting System (OARRS) show that user rates are steadily increasing, indicating that physicians are checking a patient’s prior prescriptions with greater frequency. Boxill has also been approached about creating a training video on the guidelines for use by the Ohio State Medical, Dental, and Veterinary Boards. At their request, she is working on tying the training video to the renewal of licenses for prescribing providers.
1. Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annual review of public health, 36, 559-574.