March 22, 2021 (Williston, VT)—While the COVID-19 pandemic consumes our newsfeeds and public health efforts, the opioid epidemic continues in tandem. Some call it a “crisis on top of a crisis” with early numbers indicating that all the progress made to reduce opioid overdoses in recent years could be lost and 2020 could be the worst year we have ever had1. The most recent numbers in Vermont show prescription drug overdoses held steady from 2016 to 2018 at 27 deaths, while nationally the number slightly declined in the same time period2. With experts anticipating a national increase in opioid use as people grapple with loss, depression, and anxiety exacerbated by the pandemic, we can expect the same could be true in Vermont. Given this context, the recent chronic pain management quality improvement project at Thomas Chittenden Health Center (TCHC) offers a sustainable model to reduce opioid prescribing for other health care providers and clinicians—one that emphasizes mental health screening as part of its strategy to improve its chronic pain management practices and provide more appropriate care to its patients.
In 2019, Thomas Chittenden Health Center determined they had a significant variability among practitioners prescribing opioids. Given the cultural shift away from opioids in the medical world, and at TCHC in particular, the practice embarked on a quality improvement project to better evaluate the need for opioid prescriptions and consider alternative care plans to manage pain. The project to improve chronic pain management at TCHC was informed by increased knowledge of how opioids work in the human body to become addictive, as well as an understanding of the link to mental health conditions like depression, anxiety, adverse childhood experiences, and previous trauma. Mental health screening was implemented as part of the project, having a high impact on reducing opioid prescriptions when underlying mental health issues were identified and treated properly. When comparing overall 2018 to 2019 annual morphine equivalents prescribed, TCHC saw a reduction of 22.
“Providers want to do what is right and better for the patient—they don’t want to prescribe opioids if effective non-opiate alternatives are available,” remarks Rick Dooley, physician assistant and lead of the quality improvement project at TCHC. “So we decided to look at the structure and see if it supports staff to have time and tools they need to effectively prescribe and manage our patients’ chronic pain.” With funding from OneCare Vermont, TCHC started the project by forming a team that represented every touchpoint a patient with chronic pain might have when interacting with the practice—from initially speaking with a nurse on the phone during scheduling, to seeing a provider. The goal was to create a practice-wide workflow to increase the rate of appropriate screening and treatment goals for chronic pain patients—as well as to increase support for providers prescribing opioid medication.
In addition to better aligning with the cultural shift at TCHC, the drive to reduce opioid prescribing came from the State of Vermont’s new rules for opioid prescribing that went into place on July 1, 2017, as well as additional guidelines that were finalized in March 2019. These guidelines were implemented as part of the state’s response to the opioid epidemic in Vermont. In addition to the mental health screenings, TCHC also increased strategies outlined in the state’s guidelines, including: prescribing strategies such as implementation of surveillance urine drug screenings, annual treatment goals, and writing prescriptions in seven-day increments to avoid weekend refill requests.
“The quality improvement project at TCHC is a great example of the kind of work we are proud to support at OneCare,” remarks Dr. Norman Ward, Chief Medical Officer of OneCare Vermont. “TCHC’s commitment to transitioning to value-based care through their membership in OneCare and implementation of projects like this show us how important it is to change the way we pay for care. Fixed payments allow for providers to have the time and resources to work together in innovative ways to provide the right care to our patients—care that improves their health outcomes and quality of life.”
Learn more about the chronic pain quality improvement project at Thomas Chittenden Health Center on the OneCare Vermont website.
 Sweeney, Chris, Barnett, Michael. 2021, February 16. A crisis on top of a crisis: COVID-19 and the opioid epidemic. Retrieved from: https://www.hsph.harvard.edu/news/features/a-crisis-on-top-of-a-crisis-covid-19-and-the-opioid-epidemic/ on 2021, March 10
 NIDA. 2020, April 3. Vermont: Opioid-Involved Deaths and Related Harms. Retrieved from https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/vermont-opioid-involved-deaths-related-harms on 2021, March 10
About OneCare Vermont:
OneCare Vermont is a provider-led Accountable Care Organization working to improve the health of Vermonters and lower health care costs. OneCare partners with health insurance companies, hospitals, independent medical practices, and community collaborators to offer programs that pay for positive outcomes and healthcare activities. OneCare gives doctors and other providers access to data, resources, and tools to improve patient health. Health care providers participating in OneCare pool resources and expertise to help Vermonters become healthier and stay healthier, and focus on improving access to primary care, reducing deaths from suicide and drug overdose, and managing chronic illnesses. By sharing information and working together, providers can do even more to deliver the best care to patients. onecarevt.org