Combating the opioid epidemic: A quality improvement perspective

EMS can apply the four-lens foundation for the science of improvement to reducing opioid overdose deaths within their communities


This feature is part of our Paramedic Chief Digital Edition, a regular supplement to EMS1.com that brings a sharpened focus to some of the most challenging topics facing paramedic chiefs and EMS leaders everywhere. To read all of the articles included in the Winter 2018 issue, click here.

By Mike Taigman

It’s easy to get overwhelmed trying to figure out how you and your team can help stem the tide of deaths from the opioid crisis. It’s hard to know where to start when the diverse group of people involved includes narcotics detectives, parents of addicts, hospitals that have been penalized for ineffectively managing pain, drug dealers and our EMS regulars.

Fortunately, the science of performance improvement provides a framework to help make sense of the complexity we face. The following four lens system through which we can view this crisis was designed by quality guru W. Edwards Deming to help us make more effective interventions.

1. System appreciation

Normally we think of a system as a collection of interdependent processes aligned to accomplish the aim of the system. When I think about the opioid crisis from a systems perspective, it seems like there are competing processes, some designed to create addiction and others designed to treat it.

There are several opportunities to intervene at the earliest stage of the cycle – overprescribing of opioids and recreational opioid misuse – including:

  • The Joint Commission on Healthcare Accreditation is revising its standards for the assessment and treatment of people with pain to include an assessment of their psycho/social situation, risk of becoming addicted and safe opioid use.
  • Pharmacies and insurance providers limiting the number of pills per prescription for opioids. For example, CVS has instructed its pharmacists to contact physicians when a prescription comes through that is for more medication than appears necessary [1].
  • Continued law enforcement efforts to identify and arrest drug dealers and rampantly-overprescribing physicians.
  • Research and development of non-addictive pain medications.
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The second stage is the opioid overdose. Obviously, EMS response with naloxone administration is the traditional intervention at this stage of the cycle. Other opportunities include:

  • Widespread distribution of naloxone to law enforcement, family members, school officials, drug users and even drug dealers. Some communities are experimenting with naloxone distribution associated with clean needle exchange and safe consumption areas.
  • Getting the word out when a new batch of strong overdose-causing drugs lands in the community. Using social media, street outreach, EMS, law enforcement, to let users know that there is a bad batch of drugs in town.

The post-overdose survival phase of this cycle is an area where innovative EMS systems are helping steer people to treatment and rehabilitation.

  • Treating addiction and overdose as a disease rather than as a crime. In Richmond, Virginia, the morning after a person has overdosed, a narcotics detective from the police department will pay them a visit. According to Rob Lawrence, the chief operating officer for the Richmond Ambulance Authority, having a detective show up at the door tends to get the full attention of people who are addicted. The detective is not there to arrest them. He or she is not there to search the house for drugs. He or she is there to offer a ride to a drug treatment facility. Their belief is that more people accept treatment from detectives than other professionals.
  • Some EMS systems are providing referral to treatment programs as part of their overdose management protocol.
  • Administering assessment tools like the Drug Abuse Screening Test or the Opioid Risk Tool to help identify patients who are at risk for future overdose.

2. Understanding variation

All processes have variation. When evaluating the data related to the opioid crisis, it’s important to look at things in the natural time ordered sequence. This is the only way that you’ll know if things are getting better, getting worse or staying the same. It’s also the only way that you’ll know if your efforts to intervene are having their intended impact.

For example, Ohio experienced a dramatic upward trend (defined as six or more continuously ascending or descending points) of opioid-related overdose deaths programs designed to address the problem.

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Data shows programs to decrease opioid overdose deaths in Oregon have been effective at slowing the increase in deaths.

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When it comes to tackling the opioid problem in your community, it’s powerful to have your key measures defined, a method of collecting the data, and a system to analyze it as close to real time as possible. It’s helpful to define outcomes like reduction in opioid overdose deaths, reduction in overdoses, and number of addicted people who complete treatment and stay drug-free.

It’s also helpful to define some process measures that help produce these outcomes, like time from overdose to rehab admission, the percentage of overdose victims that enter rehabilitation, and the percentage of successful naloxone administrations by bystanders.

3. Theory of knowledge

The third lens in this improvement science view is called Theory of Knowledge. Historian Daniel J. Boorstin said, “The greatest obstacle to discovery is not ignorance – it is the illusion of knowledge.” If you spend a little time on your favorite search engine or social media site, you can discover many strongly held beliefs, some would call them theories, about how to deal with the opioid crisis. These include:

  • Needle exchange programs encourage drug use.
  • Needle exchange programs save lives.
  • Providing naloxone to addicts encourages heroin use because there’s no consequence.
  • Making naloxone widely available saves lives.
  • Narcotics Anonymous is ineffective at dealing with addiction.
  • Narcotics Anonymous works very well for many.

Statistician W. Edwards Deming said, “In god we trust, all others must bring data.” When it comes to performance improvement, it’s important to test your ideas – your theories of change – until there is enough evidence-based belief that implementing a change will produce the desired result with the least negative unintended consequences.

Before you start implementing improvements, it’s always good to see what scientific evidence exists. One good resource for the science on opioid addiction and treatment is the National Institute of Drug Abuse [2].

Once you’ve gathered the science, gathered baseline data on the scope of the opioid problem in your community and mapped the system, it’s helpful to gather system stakeholders to brainstorm ideas for addressing the problem. It will be different for each community, and here are a few folks that you might invite to help:

  • EMS
  • Fire
  • Law enforcement, particularly narcotics division
  • Addiction treatment specialists
  • Hospital emergency medicine
  • Social services
  • Homeless services
  • District attorney
  • Community advocates
  • Pharmacists
  • Opioid addicts in recovery

One of the biggest leadership challenges in working with a diverse group is dealing with confirmation bias. With confirmation bias, we tend to latch on to anecdotes or thin evidence that support our personal beliefs and ignore evidence to the contrary.

For example, in one group of EMS providers, a paramedic said with confidence, “If someone overdoses more than once, they are beyond help.” Instantly, the group started talking about plans to divert resources away from repeat overdoses despite the complete lack of evidence associated with her statement.

It’s a good practice to invite your colleagues to explore ideas that gain traction in your dialogue, “Is this idea really convincing based on the evidence or am I just happy that it aligns with what I already believe?”

Once you’ve brainstormed a list of possible interventions, it’s time to evaluate each option based on the evidence of its likely effectiveness. Always start by evaluating the science to see what objective evidence already exists for or against the ideas you’re considering. Then you can test the effectiveness of change ideas in your community by using small, fast plan-do-study-act style testing to help build evidence of the effectiveness of each theory.

4. Psychology

The fourth lens in this system is psychology. The opioid crisis involves a wide mix of people, from drug users, drug dealers, to police officers, paramedics and politicians. Everyone involved has their own fears, motivations, beliefs and biases. To effectively lead a community intervention to prevent death from overdoses, it’s essential to really understand the psychology of the people that you’re working with.

A politician may be driven by a desire for re-election to be seen as tough on crime. A new paramedic may not believe that addiction is a disease and be flabbergasted that people can’t see it’s just weak-willed people making bad choices. To help people get on board with making the changes needed, it’s helpful to start wherever they are.

Making changes happen in your community is challenging. Chances are you’ll be more successful if you work to decrease the fears associated with change and increase the motivation to move ahead.

Helping EMS providers see that helping someone who’s addicted to opioids into a treatment program is as lifesaving as good quality CPR and a quick defibrillation is likely to help with motivation. Showing data from communities that have widespread naloxone distribution that indicates a decrease in deaths without an increase in addiction can help decrease fear of lay people giving this lifesaving drug. In any case, listening, learning and really getting to know the folks you’re working with increases the chance of success.

Deming called this four-lens system that forms the foundation for the science of improvement the System of Profound Knowledge, which is an awful name. He hoped that his followers would come up with something better, but several decades after his death, the name has stuck.

It is designed to be an approach to management, particularly management of improvement. The four components cannot be separated any more than a brain, kidney and heart can function on their own without being connected to each other in a system.

References:

  1. CVS to limit Opioid drug prescriptions amid national epidemic, by Nathan Bomey, USA Today September 20, 2017
  2. the National Institute of Drug Abuse [2]. https://www.drugabuse.gov

About the author
Mike Taigman is the Improvement Guide for FirstWatch, a company which provides near-real-time monitoring and analysis of data along with performance improvement coaching for EMS agencies.

He holds a master’s degree in Organizational Systems and is an associate professor in the Emergency Health Services Management graduate program at the University of Maryland Baltimore County. He’s also the facilitator for the EMS Agenda 2050 project. He can be reached at mtaigman@firstwatch.net.

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