The Opioid Crisis in Black and white (with some grey)

Christina Wiekamp APRN, CNS, ACHPN

Melissa Mueller RN, MSN, AGCNS-BC

OBJECTIVES▪ Identify the impact and factors that contributed to the opioid epidemic in the US.

▪ Correlate effects of pain to statistical outcomes

▪ Compare and contrast pain campaign/initiatives over the last two decades

▪ Review the 2018 Joint Commission Pain Standards.

▪ Review the role of an opioid stewardship program (OSP) in decreasing adverse outcomes

DISCLOSURES▪ None

WHY IS PAIN IMPORTANT?

WHO DOES PAIN AFFECT? COMPLEXITY OF SPINE PATIENTS

$$$$

Disability

Surgery

PAINConservative Management

Psychological and Social

Impact

ECONOMIC BURDEN

$635 billion• PAIN

$309 billion• Heart Disease

$243 billion• Cancer

$188 billion• Diabetes

Institute of Medicine. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press; 2011.

BEYOND SPINE…EQUAL OPPORTUNITY▪ Case study

National Inshttps://www.drugabuse.gov/publications/drugfacts/understanding-drug-use-addiction

ADDICTION…THE DISEASETHE OPIOID EPIDEMIC

“Opioid abuse is a serious public

health issue, but PREVENATIVE

ACTIONS,

treatment for addiction, and

proper response to overdoses

can help.” – U.S. Dept of HHS

STATISTICS ▪ 16,000 deaths per year from

prescription opioids▪ 50-78 deaths per day (2 deaths

every hour)▪ People in the U.S. consume

opioid pain relievers at a greater rate than any other nation -- twice as much per capita as the second ranking nation, Canada. (CDC)

▪ Approximately 60% of opioid overdose fatalities originate from opioids prescribed within medical guidelines.7

Emailed for permission on 6/9CDC images used freely without permission given part of public domain

HOW, WHY, AND WHEN?

2002 HCAPs

"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

SOURCE WHERE PAIN RELIEVERS WEREOBTAINED FOR MOST RECENT NONMEDICAL USE

Source: 2011 and 2012 data from the 2012 National Survey on Drug Use and Health, Substance Abuse and Mental Health Services Administration, 2013.

Florence, C. S., Chao, Z., Feijun, L., Likang, X., Zhou, C., Luo, F., & Xu, L. (2016). The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care, 54(10), 901-906.

REIMBURSEMENT LINKED TO PATIENT PERSPECTIVE

NEW GUIDELINES

“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 with pharmacists.”

“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”

WHAT IS AN OPIOID STEWARDSHIP?

PROCESS▪ Opioid stewardship pharmacist review daily computer generated reports of all active orders for

oral long-acting opioids, fentanyl formulations and methadone and reconcile orders with state PDMP database

▪ EPIC report review M- F▪ Leave notes or call ▪ Looking at medications (methadone, Duragesic), pain scores (>6), OSA history, obesity,

respiratory hx, renal/hepatic alterations, similar to antibiotic stewardship

PURPOSE AND GOALSOptimize pain management pharmacotherapy

Minimize opioid associated adverse events and cost Through surveillance and prevention strategies (i.e. monitoring high risk opioid practices - PCAs, continuous infusions, fentanyl formulations, and methadone)

Quality and safety improvement i.e. collaboration with pharmacists, physicians, and nurses to improve the use of standard order sets, policies and procedures for opioid administration, smart-pump technology, capnography, staff education, and formulary managementReview respiratory depression cases requiring naloxone reversal that are reported in the hospital’s adverse-event database

Enhance patient experience

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

RECIPE FOR SUCCESSOBTAIN COMPUTER GENERATED REPORTS• DETERMINED BY THE MEDS OR PATIENTS YOU CHOOSE TO REVIEW• SCREEN PATIENTS FOR OPIOID THERAPY PROBLEMS

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

COMMUNICATE RECOMMENDATIONS• 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

MODIFY ORDERS• OFFER TO WRITE THE ORDERS IF APPROVED

DOCUMENT INTERVENTIONS• PROGRESS NOTE• COMPUTERIZED INTERVENTION TRACKING SYSTEM OR EXCEL DATABASE (HIPAA COMPLIANT)

MONITOR• UNTIL DISCHARGE PLAN ESTABLISHED OR AS DETERMINED BY TEAM

REPORT OUTCOMES• ASSESS SAFETY EVENTS, PRESRIBING PATTERNS, SATISFACTION, AND COST

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.

WHY IS THIS IMPORTANT?

▪The Joint Commission (TJC) revised its pain assessment and management standards as part of a national effort to address the opioid crisis.▪New elements include standards specific to:▪ Leadership (LD)▪ Medical Staff (MS)▪ Provisions of Care, Treatment and Services (PC)▪ Performance Improvement (PI)

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HOW DO YOU MEET THE STANDARDS?

Pain Assessment• Pain Management

Policies• Documentation

Patient Goals• Discuss Treatment Goals

with Patient• Offer Integrative

Therapies

Safe Opioid Use• Staff Education and

Resources • Access to the Prescription

Drug Monitoring Database

Adverse Event Prevention & Detection

• Identify Patients at High Risk for Adverse Outcomes

Quality Improvement

• EPIC Enhancements for Opioid Prescribing

• Patient and Caregiver Education

• Quality Improvement Metrics

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Evidence based order sets

Document assessment & management of opioid side effects

! Many parts of the problem not just one!! ! Naloxone

! Stewardship

! Overprescribing

! Governmental guidelines

! Chronic pain

! Function

! Disability

FIRST, DO NO HARM. WILL NALOXONE SOLVE THE PROBLEM?

▪ Not exactly… ▪ Reducing total number of

excess prescriptions▪ Reducing diversion ▪ Avoiding opioids for

certain conditions▪ Caution with high risk

populations ▪ Avoiding co-prescribing of

opioids and benzodiazepines

▪ Avoiding doses greater than 90 MME/day

▪ Determining when to initiate or continue opioids for chronic pain ▪ Selection of non-pharmacologic therapy, non-opioid pharmacologic

therapy, opioid therapy▪ Establishment of treatment goals▪ Discussion of risks and benefits of therapy with patients

▪ Opioid selection, dosage, duration, follow-up and discontinuation ▪ Selection of immediate-release or extended-release and long-acting

opioids▪ Dosage considerations▪ Duration of treatment▪ Considerations for follow-up and discontinuation of opioid therapy

▪ Assessing risk and addressing harms of opioid use ▪ Evaluation of risk factors for opioid-related harms and ways to mitigate/

reduce patient risk▪ Review of prescription drug monitoring program (PDMP) data▪ Use of urine drug testing▪ Considerations for co-prescribing benzodiazepines▪ Arrangement of treatment for opioid use disorder

CHANGES … SUMMARY▪ Over-reliance on opioid-based therapies has led to significant adverse events and nationwide epidemic of

opioid misuse and diversion

▪ Societal and economic costs of pain are substantial

▪ RNs are uniquely positioned to help direct and monitor analgesic pharmacotherapy

▪ Opioid stewardship and pain management consultations have demonstrated the ability to improve opioid prescribing, avoid costs 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 mitigating opioid associated adverse events

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

MORE RESOURCES? YES PLEASE!▪ CDC webcasts

▪ https://www.cdc.gov/drugoverdose/prescribing/providers.html

▪ MN Medical association series on Pain ▪ http://www.mnmed.org/advocacy/Key-Issues/prescription-opioids-lecture-series

▪ Everyone can!!▪ Consider non-opioid options for pain management.▪ Store prescription opioids in a secure place, out of reach of others (including children, family,

friends, and visitors).▪ Dispose of medications properly as soon as the course of treatment is done. For more

information, visit FDA at: http://www.fda.gov/Drugs/ResourcesForYou.▪ Get help if you’re having trouble controlling your opioid use, SAMHSA’s National Helpline:

1-800-662-HELP

▪ Healthcare providers can!!!▪ Follow the CDC Guideline for Prescribing Opioids for Chronic Pain, which includes

recommendations such as: ▪ Use opioids only when benefits are likely to outweigh risks.▪ Start with the lowest effective dose of immediate-release opioids. For acute pain, prescribe

only the number of days that the pain is expected to be severe enough to require opioids.▪ Reassess benefits and risks if considering dose increases.▪ Use state-based PDMPs which help identify patients at risk of addiction or overdose.

QUESTIONS?

REFERENCES▪ 1. Florence, C. S., Chao, Z., Feijun, L., Likang, X., Zhou, C., Luo, F., & Xu, L. (2016). The

Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Medical Care, 54(10), 901-906.

▪ 2. National Center for Injury Prevention and Control, Division of Bacterial Diseases▪ 3. National Institute on Drug Abuse retrieved on 1/8/2018 from https://www.drugabuse.gov/

publications/drugfacts/understanding-drug-use-addiction▪ 4. The Burden of Musculoskeletal Diseases in the United States retrieved on 1/8/2018 from

http://www.boneandjointburden.org/

CONTACT ▪ Please feel free to contact us directly:

▪ CMWiekamp@healtheast.org651-232-7163

▪ Mmmueller@healtheast.org651-232-7954