One anesthesiologist thinks it’s high time hospitals use telemedicine to adopt opioid-as-a-last-resort pain management protocols. This Fall he’s going to help them do it.
Dr. Thomas Scott was still in medical school when one of his classmates came into the emergency room one night DOA. An opioid overdose. On another night, during Scott’s residency, a friend and fellow resident never showed up to work. Another overdose. In total, the pills have already buried four of his friends.
Scott, an anesthesiologist at George Washington Hospital in Washington, D.C., speaks passionately about pain management, and his intensity ramps up when he calls out current pain protocols and their perverse reliance on opioids. “The opioid epidemic is killing one American every 16 minutes,” he said.
He’s particularly affected by a recent study by researchers at the University of Michigan that found that, among both major and minor surgical patients, six percent of first-time opioid users went on to show new persistent opioid abuse. With approximately 50 million ambulatory surgical procedures performed in the United States in 2010, the authors’ findings suggest that more than two million individuals may transition to persistent opioid use following elective, ambulatory surgery each year.
Scott doesn’t have grand visions of ending the epidemic, but he wonders: “What if we can reduce that [six percent]by half?” he said. “Reduce it by a third? How many families can we spare that pain?”
That’s why he’s quitting his job. He intends to find a better way, and maybe he already has.
This fall, Scott will launch Nopium, his pain management practice and telemedical service that will first help hospitals develop and implement modern, evidence-based pain protocols, and then provide ongoing physician support and patient consultation via remote, HIPAA-compliant connection.
Scott, who is 40, has spent his career developing pain management systems that leverage multiple treatment modalities to achieve the greatest level of pain relief with the fewest adverse effects. In other words, effective pain management where opioids are not a first-line, but a last-line therapy.
“Telemedicine is really going to be the key to making evidence-based, non-opioid pain therapy available to the masses,” he said.
Nopium’s protocols would see hospitals tweaking the pain management algorithm to prefer generic remedies like acetaminophen, ibuprofen, regional nerve blocks, intravenous lidocaine, and low-dose ketamine. Scott is still designing the training program, but he expects it will begin with a round of phone consultations that will allow him to understand a facility’s needs and begin prepping the physicians, pharmacists, and nurses for hands-on learning. On-site training will likely last a week, longer if necessary. Physicians in the ER and the operating room can be trained in ultrasound-guided regional anesthesia. Nurses and pharmacists will learn to safely mix, dispense, administer, dispose of, and account for treatments like intravenous lidocaine and low-dose ketamine. Once the protocols have been tailored and the staff has demonstrated that they can safely and effectively administer the appropriate treatments, Scott will return to his Philadelphia practice and begin providing doctor-to-doctor telemedical support to continue training and coaching, and, when appropriate, consult with and manage patients.
“Above all else,” he said, “we have to be available.”
Say a patient with a hip fracture comes into the hospital at two in the morning. A nerve block is needed. If a physician Scott has trained in ultrasound-guided regional anesthesia isn’t yet comfortable placing a block, a headset with a front-facing camera, an earpiece, and a microphone—think Google Glass—will essentially put Scott in the room to coach the physician through the procedure (He is currently talking with various telemedical hardware manufacturers.). If a team isn’t quite comfortable managing catheter infusions, Scott can consult for these as well.
“These techniques are not known by a lot of ER docs, surgeons, and hospitalists,” he said. “But they are known by anesthesiologists and pain specialists. The problem is, we’re not out there. Right now, about 80 percent of acute care in this country is rendered in hospitals that are less than 250 beds.”
Small hospitals often can’t afford to staff a full-time acute pain specialist. Through Nopium, Scott said, hospitals could effectively employ the equivalent of .05 full-time acute pain specialists. Apart from the maintenance of relatively inexpensive telemedical hardware and software, overhead fees would nearly disappear. Contracts will be flexible.
Scott currently sees two possible business models. One sees the hospital granting Nopium telemedical privileges, and then Nopium bills for consults directly. Another sees the hospital billing for the consult and then paying Nopium an a la carte fee. Or the model may include a retainer for a specific number of consults. “There are a lot of ways to solve this contracting problem,” Scott said. “I just need a hospital that’s interested in solving it.”
Questions about educational standards will likely surround Scott’s early efforts. The Nopium model has positive aspects, said Dr. Daniel Carr, Professor of Public Health and Community Medicine at Tufts University School of Medicine and former president of the American Academy of Pain Medicine. But, he noted, subspecialty training is rigorous and exacting. Graduate medical education standards have been carefully crafted. For instance, the application proposing the standards for the Accreditation Council for Graduate Medical Education’s (ACGME) new regional anesthesiology and acute pain medicine subspecialty ran over a hundred pages. “The current approach to training is not a haphazard or poorly thought out thing,” he said.
Scott holds Nopium to the same expectations. While Nopium’s training model and standards are still being developed, he said, the requirements set by the ACGME will serve as scaffolding. The training model that allows practicing surgeons to learn and become credentialed in a new surgical technique will also likely inform the process, as will state regulatory considerations and individual hospital credentialing requirements.
“It’s not just sufficient to say, give IV lidocaine and walk away,” he said. “Intravenous lidocaine is a treatment that can result in seizures. If a dose error is made or if a seizure occurs, the cause of that seizure needs to be elucidated quickly. The treatment and support pathways need to be in place so that patient safety, above all else, is the highest priority.”
Scott is eager to prove his concept. He talks of changing the culture within acute pain management. “Pain is not an opioid deficiency in your bloodstream,” he said. He’s not against opioids—he still prescribes them when necessary—but he speaks of the opioid epidemic as if it were a personal affront. He knows that Nopium won’t end the epidemic and neither will telemedicine. But together they might chip away at that six percent of newly dependent opioid users.