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New Strategies in Opioid StewardshipFriday, September 28th, 2018

1:30PM – 2:20PM

Christina Wiekamp, RN, MS, APRN, CNS, ACHPN

Yleana Baggenstos, PharmD, BCPS, CPE

JOIN SLIDO.COM WITH #5118

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INTRO

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Christina Wiekamp Lana Baggenstos

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CONFLICT OF INTEREST DISCLOSURE

Author’s Conflicts of interest:

• Christina, no conflict of interest

• Lana, no conflict of interest

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LEARNING OBJECTIVES

• Explain how the opioid epidemic has impacted and burdened our healthcare system

• Express how the opioid epidemic led to the demand for pain management services

and stewardship programs

• Evaluate the importance of an opioid stewardship program

• Specify the goals of an opioid stewardship program

• List the components of an opioid stewardship program

• Build an institutional specific opioid stewardship program (OSP)

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Audience Response Question #1

Do you feel comfortable in initiating or adjusting pain management pharmacotherapy in patients with medical and psychological comorbidities?

• A. Yes

• B. No

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Audience Response Question #2

Are you expected to initiate or adjust pain management pharmacotherapy in patients with medical and psychological comorbidities at your workplace?

• A. Yes

• B. No

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“Opioid abuse is a serious public health

issue, but PREVENTATIVE ACTIONS,

treatment for addiction, and proper

response to overdoses can help.” –U.S.

Dept of HHS

THE OPIOID EPIDEMIC

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"the fifth vital sign" by the American Pain Society in 1995

2000, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) introduced new pain management standards

2002 HCAPs

• 2003 landmark study of the impact of acute pain management in the hospitalized patient over a 10 yr period1

– Improvement in pain management has not kept up with other advances inhealthcare

– Reports of “any pain” and “extreme pain” are reported as higher

• 2013 surgical pain congress report4

– Inadequate pain control was the most common reason for readmission aftersame-day surgery

– Surgical pain was the leading driver of surgery patient dissatisfaction

THE PARADOX OF PAIN MANAGEMENTPain continues to be a prevalent problem for medical and surgical patients2,3

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1. Apfelbaum JL, Chen C, Mehta SS, et al. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be unmanaged. Anesth Analg. 2003;97:534-5402. Helfand M, Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. Pain Med. 2009 Oct;10(7):1183-1199.3. Kohler M, Chiu F, Gelber KM, et al. Pain Manag. 2016 Nov;6(6):591-6024. Joshi G, et al. Defining new directions for more effective management of surgical pain in the United States: Highlights of the inaugural surgical pain congress. The Amer Surg. 2014 Mar;80:219-

228.

THE DEMAND FOR PAIN MANAGEMENT SERVICES

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Hospital Accreditation Standards

• “Consult a pharmacist or pain management expert (when available) when converting from one opioid to another, or

changing the route of administration (from oral to IV or

transdermal).”

• “Create and implement policies and procedures that allow for a second level review by a pain management specialist or

pharmacist of pain management plans that include high-risk

opioids, such as methadone, fentanyl, IV hydromorphone and meperidine.”

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• Effective January 1, 2018 new and revised pain assessment and management standards will be applicable to all Joint Commission-accredited hospitals

• Opioid Stewardship is a HealthEast organization tactic for 4 out of the 6 JCstandards for pain management

Hospital Accreditation Standards

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• “If patients do not experience improvement in pain and function at >/= 90 MME/day, or if there are escalating dosage requirements, clinicians should...consider consulting a pain specialist.”

• “For patients agreeing to taper to lower opioid doses as well as for those remaining on high opioid dosages, clinicians should...consider consulting a pain specialist.”

• Because pain management in patients with substance abuse disorder can be complex, clinicians should consider consulting …pain specialists.”

• “Experts noted that naloxone co-prescribing can be facilitated …by collaborative practices models withpharmacists.”

• “Clinicians should check the PDMP for concurrent controlled medications prescribed by other clinicians and should consider involving pharmacists and pain specialists.”

• “In patients with opioid use disorder clinicians should …consider consulting a pain specialist”

Guidelines

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MAKING THE CASE

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OSPEconomic Burden

Economic Burden

HCAHPSHCAHPS

Unmanaged Pain

Unmanaged Pain

Joint Commission

Joint Commission

Opioid Epidemic

Opioid Epidemic

CDC Guidelines

CDC Guidelines

Education Gap

Education Gap

Provider ShortageProvider Shortage

Value of Pharmacy Services

Value of Pharmacy Services

Audience Response Question #3

Do you have an opioid stewardship program at your institution?

• A. Yes

• B. No

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• 7,500 employees

• 850 physicians

• 100+ primary care providers

• 4 hospitals

– Bethesda: 254 beds

– St. Joseph’s: 401 beds

– St. John’s: 184 beds

– Woodwinds: 86 beds

“To deliver optimal health and well-being for our patients, our communities and ourselves.”

HEALTHEAST CARE SYSTEM

St. Paul, MN

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St John’s

St Joseph’s

Woodwinds

Bethesda

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• Pain is common among medical patients

- 43% of medical patients experienced pain

- 12% reported unbearable pain

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OPIOID STEWARDSHIP – EXTENDING OUR REACH

Helfand M, Freeman M. Assessment and management of acute pain in adult medical inpatients: a systematic review. Pain Med. 2009 Oct;10(7):1183-1199.

• Objective

– Evaluate pharmacist interventions and patient outcomes of a pharmacist-ledoutpatient palliative care practice

• Results (March 2011 – March 2012)

– New consults were referred by an oncologist or hematologist

– 84 new and 135 follow-up visits

– A change in pain medication dose and initiation of a new medication forconstipation and N/V were the most common interventions

– Statistically significant change in pain score was observed at the 3rd visit

Published Opioid Stewardship Programs

Outpatient Palliative Care Practice – University of California

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Ma J, Tran V, Chan C, et al. Retrospective analysis of pharmacist interventions in an ambulatory palliative care practice. J Oncol Pharm Practice. 2015. DOI:10.1177/1078155215607089.

• Objective

– Described their experience with development of a opioid stewardship pharmacy service implemented in June 2010

• Pharmacist responsibilities- Admission medication reconciliation (PMP), review of pharmacy-generated reports (oral

long-acting opioids, fentanyl formulations, and methadone), monitor high-risk opioid therapy

(high dose IV opioids, multiple pain medications, PCAs, continuous infusions), providing pain management consultations for complex patient cases

• Results (June 2010 – June 2011)

– 2499 patients reviewed (16% of all admissions)

– 1099 (44%) required an intervention related to medication reconciliation, most commonly clarifying the most recent opioid use history (n=945, 86%)

– 154 consultations requested by physicians or pharmacists

Published Opioid Stewardship Programs

Academic Medical Center – University of Minnesota

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Ghafoor V.Implementation of a pain medication stewardship program.AJHP.Dec 1, 2013:70;2070-75.

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• Pharmacist responsibilities- Opioid stewardship: review of pharmacy-generated reports (patients at high-risk for

oversedation, inadequate analgesia, continuous infusions, PCAs, fentanyl patches, and methadone), and medication recommendations

- Pain Management Consultations placed by providers

- Post-discharge phone calls to patients

• Results (October 2013 – June 2014)

– 1,355 interventions (81% consultations, 19% stewardship)

– $1.6 million in estimated indirect cost avoidance ($400k from stewardship interventions)

– 59% reduction in opioid related RRT calls and Code Blues

– > 50% reduction in use of 2-4 mg IV hydromorphone dose vials

– 19% reduction in fentanyl patches

– Increase in patient satisfaction scores related to pain management

Published Opioid Stewardship Programs

Community Hospital – Kaweah Delta Medical Center, California

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Poirier R, Brown C, Garcia, Y. Implementation of a Pharmacy Directed Pain Management Service in the Inpatient Setting. Poster presented at: ASHP Midyear Clinical Meeting; Dec 7,2014; Anaheim, CA.

• Optimize pain management pharmacotherapy

– Pharmacy generated report that identifies patients are using > 6 prn opioid doses in 24 hours

• Minimize opioid associated adverse events and cost- Pharmacy generated report that identifies patients that are receiving high-risk

opioid therapy

- Epic generated patient list that ranks hospitalized patients who have received anopioid in the last 24 hours at risk for opioid induced respiratory depression

• Quality and safety improvement- Ongoing review of naloxone events/IV opioid usage/ prescribing

patterns/documentation compliance

- Findings have warranted order set reviews, practice improvements, epic prescribing thresholds, and directed education

• Enhance patient experience

OPIOID STEWARDSHIP GOALS

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METRICS

• % of recommendations accepted

• # interventions

• Decrease hospital induced naloxone events

• Decrease in IV opioid utilization

• Decrease # of opioids prescribed

• Improve RN documentation compliance with PCA policy

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• Retrospective review/activities

– Naloxone use

– Evaluate provider prescriber patterns with goal to reduce prescribing

– Decrease IV opioid utilization, optimize use of orals when appropriate

• Prospective review/activities

– Medication profile review by decentral pharmacists• Computer generated report of pain scores > 6 in the last 16 hours for opportunity to

optimize use of PRN medications (opioid and/or opioid-sparing) for uncontrolled pain

• Determine if there is a need for a Pain Team Consult

– Pilot by clinical pharmacy pain specialists on Pain Team for daily reviewof all patients meeting select criteria to reduce risk

SUMMARY OF OPIOID STEWARDSHIP IMPROVEMENT WORK

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Naloxone administrations by hospital: 2017 & 2016

Naloxone administrations by patient location: 2017 & 2016

Retrospective Review: Naloxone Use

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275

216

72

33

58

276

257

102

00

50

100

150

200

250

300

Bethesda St. John's St.Joseph's

Woodwinds Unknown

Nu

mb

er

of

Doses

Doses Per Hospital

2017

2016

279

42

91

135

338

7196

188

0

50

100

150

200

250

300

350

400

ED ICU OR Other PatientCare Areas

Doses in Different Patient Care Areas

• ConclusionsSimilar use in 2016 and 2017; however 3 interventions were implemented from2016 review by 2017

– Documentation for indication of naloxone use in MAR

– Opioid Stewardship Pilot Program implemented 8/1/2017

– Provider, RN, and Pharmacist education completed

• Goals for 2018

– Assess compliance rate with MAR documentation re: indication ofnaloxone use

– Assess order sets that contain both opioids and benzodiazepines and consider adjustment

– Ongoing opioid stewardship pilot

Next Steps: Naloxone Use

Naloxone Use Summary for 2017

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Prospective Review: Recipe for Success

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• DETERMINED BY THE MEDS OR PATIENTS YOU CHOOSE TO REVIEW

• SCREEN PATIENTS FOR OPIOID THERAPY PROBLEMS

OBTAIN COMPUTER GENERATED REPORTS

OBTAIN COMPUTER GENERATED REPORTS

•MED REC, DDI, ALLERGIES, PMH, PSH, HPI, I/O’S, CURRENT MEDICATION,OVERSEDATION RISK, COMORBIDITIES, AGE, PAIN SCORE

COMPREHENSIVE MEDICATION REVIEW

COMPREHENSIVE MEDICATION REVIEW

• OPIOID AND NON-OPIOID RECOMMENDATIONS, BOWEL MEDS, OR LAB MONITORING• RECOMMEND CONSULTATION (CHEMICAL DEPENDENCY, PSYCHIATRY, PSYCHOLOGY, ACUPUNCTURE, PM&R, ANESTHSIOLOGY, ORTHO, NEURO, PALLIATIVE CARE, HOSPICE)

• PATIENT COUNSELING

COMMUNICATE RECOMMENDATIONS

COMMUNICATE RECOMMENDATIONS

•OFFER TO WRITE THE ORDERS IF APPROVEDMODIFY ORDERSMODIFY ORDERS

•PROGRESS NOTE

•COMPUTERIZED INTERVENTION TRACKING SYSTEM OR EXCEL DATABASE (HIPAA COMPLIANT)

DOCUMENT INTERVENTIONS

DOCUMENT INTERVENTIONS

•UNTIL DISCHARGE PLAN ESTABLISHED OR AS DETERMINED BY TEAMMONITORMONITOR

•ASSESS SAFETY EVENTS, PRESRIBING PATTERNS, SATISFACTION, AND COSTREPORT OUTCOMESREPORT OUTCOMES

1. http://www.ajhp.org/content/ajhp/70/23/2070.full.pdf

2. The Joint Commission. Safe Use of Opioids in Hospitals. Sentinel Event Alert. 2012;49.

• “When I completed the specific opioids report for OS on 5/11, I noticed he was on same long acting and high dose short acting opioids at home, even though he came in with respiratory failure. I left sticky note to decrease long acting and short acting, but pt was discharged the next am. He came right back in for severe SOB, and the same provider who discharged him consulted our team the day after. The pain team did end up decreasing the opioids and patient improved.

• The win here is that the Hospitalist may order a consult more readily when they see our opioid stewardship notes for more complex cases,and maybe realize this patient would have been better served with a consult from the beginning of his first hospital visit. The hospitalized ordered a consult when he came back in, and another new consult from the day after, for a chronic opioid tolerant patient.”

Case Studies

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• ML 78 yo female, admitted 01/12/18 for community-acquired pneumonia with symptoms of dyspnea on O2 as well as AKI

• PMH includes chronic back pain, DM2, GERD, HTN and pancreatitis.

• Med Rec recorded pt taking morphine sulfate controlled-release (MS Contin)15 mgtid, and MS Contin 60 mg bid. RPh noted that the pt ran out of her morphine day prior to admission and that her last refill was 3 months ago for a 30 day supply.

• Both medications were ordered however provider ended up d/c’ing MSER 15 mgTID and continued MSER 60 mg BID with oxy IR 5-10 mg q4h prn d/t AKI

• Pt unable to wean off O2, drowsy

• Days later pt seen giving MSER to husband

• O/S pharmacist reviews case and left recommendations to resident that patient has not filled this in 3 months and diversion witnessed

• Opioids d/c’d and APAP scheduled, patient able to wean off O2

Case Studies

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Strengths of an OSP

� Simplicity and adaptability� Use of existing infrastructure (i.e. decentralized pharmacists)

� Impact on quality patient care� Individualized treatment of patients

� Medication safety� Closer review of patients deemed high risk for respiratory depression or receiving high-risk

opioid therapy

� Enhanced patient satisfaction

� Indirect cost avoidance data supporting pharmacist interventions

Challenges and barriers

� Not all patients in pain or experiencing adverse events are on high risk opioid therapy or deemed high risk for respiratory

depression

� Pain services are usually only available during business

hours leaving evening and overnight requests to be

addressed the following day

� Indirect cost savings makes it difficult to proactively budget

for additional positions to manage increased referrals and requests for policy revision and education

� Estimating the time required for services

Challenges and barriers

� Identification of patients at risk for poorly managed pain and timely communication with anticipated members of team

� Early patient education reviewing goals and setting expectations

� Timely follow-up with PCP or pain management provider

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Summary

• Over-reliance on opioid-based therapies has led to significant adverse events and nationwide epidemic of opioidmisuse and diversion

• Societal and economic costs of pain are substantial

• Opioid stewardship programs can help direct and monitor analgesic pharmacotherapy

• Opioid stewardship and pain management programs have demonstrated the ability to improve opioid prescribing, avoidcosts associated with opioid adverse effects, improve pain control and increase patient satisfaction

• Stewardship programs help ensure the safe use of opioids and improve patient care through proactively mitigatingopioid associated adverse events

• Patient experience, MD/RN satisfaction, education, intervention documentation, and cost-avoidance tracking are important to the sustainability of opioid stewardship programs

Questions ?