cf fshp slide template oscar santalo - read-only ... · oscar santalo, pharmd, mba, mha, bcps...

9/27/2019

1

Developing An Opioid & Pain Stewardship Program: A Health‐System Pharmacy Approach

Oscar Santalo, PharmD, MBA, MHA, BCPSPharmacy Operations and Compliance CoordinatorAdventHealth OrlandoOctober 5th, 2019

www.fshp.org

Disclosure

• Oscar Santalo, PharmD, MBA, MHA, BCPS has disclosed that he has no relevant financial disclosures. No one else in a position to control content has any financial relationships to disclose.

2

Objectives

• Review and analyze current literature and guideline recommendations related to pain management

• Describe the responsibilities and opportunities for pharmacy leaders in developing an opioid and pain stewardship program

• Evaluate key components for an effective opioid and pain stewardship team

• Assess current practices for opioid & pain stewardship at other health systems (inpatient)

3

Abbreviations• Acetaminophen (APAP)

• Benzodiazepines (BZs)

• Management (Mgmt)

• Opioid & Pain Stewardship (OPS)

• Patient Controlled Anesthesia (PCA)

• Pharmacist (RPh)

• Transcutaneous Electrical Nerve Stimulation (TENS)

• United States (U.S.)

4

Why Stewardship

5

Martin L, Laderman M, Hyatt J, Krueger J. Addressing the Opioid Crisis in the United States. IHI InnovationReport. Cambridge, Massachusetts: Institute for Healthcare Improvement; April 2016

2009

• # of opioid prescriptions increased by 68 percent

• Reaching 202 million

2010

• Hydrocodone/APAP was the most commonly prescribed drug in the U.S.

• U.S. uses 99% of the world’s supply

2011

• Providers wrote 259 million prescriptions for opioid medications

Why Stewardship

6

2012

• Estimated that >420K ED visits related to the abuse of narcotic pain relievers

2013

Increased number of deaths that year from heroin, cocaine, and bzs combined

2014

• Opioids were involved in 61% of all drug overdose deaths


1 2

3 4

5 6

9/27/2019

2

Why Stewardship

7

Why Stewardship

• Opioid crisis is not improving

• Pain management is complicated

• When treating pain must consider:

• Pain classifications (acute, chronic, cancer) and pathology

• Pain treatment options

• Risk and addiction

• OPS programs must define pain indications, reduce the risk of addiction, and target best practices

8

Opioid & Pain Stewardship Definition

• The standardization of best practices to identify the best treatment options for pain mgmt to limit the use & supply of opioids

• Evaluates risk of opioid addiction

• Improve quality of overall pain mgmt

9


Government & Regulatory Organizations: Pain Mgmt Recommendations/Updates

• Florida Law

• CDC

• Centers for Medicare & Medicaid (CMS)

• The Joint Commission (TJC)

• Det Norske Veritas (DNV)

10

US House Passes 12 Bills Combating Opioid Crisis

• Establishes prescribing limits

• Requires continuing education on controlled substance prescribing

• Maintains current CE requirement for pharmacists

• Expands required use of Florida’s Prescription Drug Monitoring Program, EFORCSE

11

House Passes 12 Bills Aimed at Combating Opioid Crisis. DEA Chronicles. https://deachronicles.quarles.com/2018/06/house-passes-12-bills-aimed-at-combating-opioid-crisis/. . Published June 18, 2018. Accessed November 15, 2018

HB21 (FL Law)

• H.R. 4275 Empowering Pharmacists in the Fight Against Opioid Abuse Act

• H.R. 5197 Alternatives to Opioids (ALTO) Act

• H.R. 5327 Comprehensive Opioid Recovery Centers Act

• H.R. 5041 Safe Disposal of Unused Medication Act

• H.R. 5473 Better Pain Management Through Better Data Act

• H.R. 5009 Jessie’s Law

• H.R. 5812 Creating Opportunities that Necessitate New & Enhanced Connections that Improve Opioid Navigation Strategies Act

• H.R. 4284 Indexing Narcotics, Fentanyl and Opioids (INFO) Act

• H.R. 5483 Special Registration for Telemedicine Clarification Act

• H.R. 5353 Eliminating Opioid Related Infectious Diseases Act

• H.R. 5582 Abuse Deterrent Access Act of 2018

12

House Passes 12 Bills Aimed at Combating Opioid Crisis. DEA Chronicles. https://deachronicles.quarles.com/2018/06/house-passes-12-bills-aimed-at-combating-opioid-crisis/. . Published June 18, 2018. Accessed November 15, 2018

7 8

9 10

11 12

9/27/2019

3

FL Law Updates: Acute Prescriptions

• Prescribing practitioner may prescribe or dispense up to a 3‐day supply of a Schedule II opioid to alleviate acute pain

• Exception: May prescribe up to 7 day supply for acute pain

• if the physician determines more than a three‐day supply is needed

• Writes "acute pain exception" on the Rx

• Documents exception in patient’s medical record

13

Statutes & Constitution :View Statutes : Online Sunshine. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400‐0499/0456/Sections/0456.44.html. Date Accessed November 15, 2018.

FL Law Update: Non Acute Prescriptions

• The prescriber must indicate "Non‐acute Pain“ on the prescription

• Pain related to cancer, terminal conditions, pain treated with palliative care, or traumatic injuries with an Injury Severity Score of 9 or greater

• An injury severity score of 9 or greater, a prescriber issuing a schedule II controlled substance must concurrently prescribe an emergency opioid antagonist

14

Statutes & Constitution :View Statutes : Online Sunshine. http://www.leg.state.fl.us/Statutes/index.cfm?App_mode=Display_Statute&Search_String=&URL=0400‐0499/0456/Sections/0456.44.html. Date Accessed November 15, 2018.

15

Injury Severity Score. OrthoTips. http://orthotips.com/16-injury-severity-score. Published November 4, 2015. Accessed November 15, 2018


• Florida Law

• CDC




16

CDC Recommendations

• Clinicians and patients consider safer and more effective treatment

• Improve patient outcomes

• Reduced pain, increased function

• Reduce number who develop opioid use disorder, overdose or other adverse events related to opioids

17

Morbidity and Mortality Weekly Report (MMWR). Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/wr/mm6518a10.htm. Published May 12, 2016. Accessed November 15, 2018

CDC Recommendations (Cont)

• Integrated, collaborative pain management and practice models that include pharmacists

• Determining when to initiate or continue opioids for chronic pain

• Opioid selection, dosage, duration, follow‐up and discontinuation

• Assessing risk and addressing harms of opioid use

18

Morbidity and Mortality Weekly Report (MMWR). Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/65/wr/mm6518a10.htm. Published May 12, 2016. Accessed November 15, 2018

13 14

15 16

17 18

9/27/2019

4


• Florida Law

• CDC




1920

Implement more effective person-

centered and population based

strategies

Expand naloxone use, distribution, and

access, when clinically appropriate

Expand screening, diagnosis, and

treatment of opioid use disorders

Increase the use of evidence based

practices for acute and chronic pain management

Lutz, J. (2018). CMS Announces New Guidelines on High-Dose Opioids. [online] Affirmhealth.com. Available at: https://www.affirmhealth.com/blog/medicare-announces-new-guidelines-on-high-dose-opioids [Accessed 15 Nov. 2018].

CMS


• Florida Law

• CDC




21

TJC: Hospital Standards

• Identify a team that is responsible for pain mgmt

• Involve patients in developing their treatment plans

• Promote safe opioid use by identifying & monitoring high‐risk patients

• Conduct performance improvement activities focusing on pain assessment/mgmt to increase safety & quality

22

The Joint Commission. Pain assessment and management standards for hospitals. R3 report. August 2017;37:Issue 11.Available at: https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_2_9_18_REV_FINAL.pdf.Accessed April 7, 2018.The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert; 2012;49.

TJC: Hospital Responsibilities

Institution

• Provide Nonpharmacologic pain treatments

• Offer educational resources and programs on pain and safe prescribing

• Give information on consultation/referral for complex pain needs

Leadership/Staff

• Facilitate clinician access to prescription drug monitoring databases (PDMP) access and use

• Staff is actively involved in pain assessment and ability to reach treatment goals

• Monitor high‐risk patients for opioid adverse outcomes

23

The Joint Commission. Pain assessment and management standards for hospitals. R3 report. August 2017;37:Issue 11.Available at: https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_2_9_18_REV_FINAL.pdf.Accessed April 7, 2018.The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert; 2012;49.


• Florida Law

• CDC




24

19 20

21 22

23 24

9/27/2019

5

DNV Requirement

• Pain mgmt is a right provided in the care of the patient

• Provide assessment and plan of care for pain mgmt.

• Pain mgmt must be incorporated in Anesthesia services

• Appropriate doses of analgesic medication ordered for pain management

25

NIAHO Critical Access Hospitals Accreditation Requirements. DNV Healthcare. http://www.bonnergeneral.org/wp-content/uploads/2015/04/DNVHC_CAH_Accreditation_Requirements_and_Interpretive_Guidelines.pdf. Updated October 1, 2018. Accessed November 15, 2018

Government & Regulatory Organizations: Pain Mgmt Recommendations Summary

26

FL Law/CDC CMS TJC/DNV

• Prescriptions must contain Pain Condition “notation”

• Integrated, collaborative pain management and practice models that include pharmacists

• Expand naloxone use, distribution, and access

• Increase the use of evidence based practices for acute and chronic pain management

• Identify a team that is responsible for pain management

• Conduct performance improvement activities focusing on pain mgmt.

• Pain mgmt assessment and plan of care

Self Assessment 1

• Which pain related indication would NOT be an appropriate for a “Non‐acute Pain” notation on a prescription?

A. Cancer pain

B. Terminal care/palliative conditions

C. Traumatic injuries with an Injury Severity Score of 9 or greater

D. Patient with a history of substance abuse

27

Self Assessment

• Which pain related indication would NOT be an appropriate for a “Non‐acute Pain” notation on a prescription?

A. Cancer pain

B. Terminal care/palliative conditions

C. Traumatic injuries with an Injury Severity Score of 9 or greater

D. Patient with a history of substance abuse

28

Self Assessment 2

• The DNV has a hospital standard that an institution must “Identify a team that is responsible for pain management and safe opioid prescribing”

– True

– False

29

Self Assessment 2

• The DNV has a hospital standard that an institution must “Identify a team that is responsible for pain management and safe opioid prescribing”

– True

– False

30

TJC

25 26

27 28

29 30

9/27/2019

6

Professional Organizations:Pain Mgmt Recommendations/Updates

• American Pain Society (APS)

• National Comprehensive Cancer Network (NCCN) Adult Cancer Pain

• Pharmacy Quality Alliance (PQA)

• American Society for Pain Management Nursing (ASPMN) Position Statement & Opioid Monitoring

31

American Pain Society (APS) Recommendations

32

Preoperative Education, Pain Management, and Methods of Assessment

Provide tailored education on treatment options for postoperative pain

Offer multimodalAnalgesia or

nonpharmacological interventions

Use IV PCA be used for postoperative analgesia when IV route is needed

Provide counseling of proper instruction for assessing pain

Consider (TENS) as adjunctive therapy

Discourage routine basal infusion of IV PCA in opioid‐

naïve adults

Conduct preoperativeevaluation

Neither recommend nor discourage acupuncture,

massage, or coldtherapy as adjuncts

Monitor sedation, respiratory status, and other AEs in patients who receive

systemic opioids

Chou R, et al. Management of Postoperative Pain: A Clinical Practice Guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’Committee on Regional Anesthesia, Executive Committee, and Administration Council. The Journal of Pain, 2016;17(2):131-157.

American Pain Society (APS) Recommendations (Cont.)

33

Preoperative Education, Pain Management, and Methods of Assessment

Make interventions based on adequacy of pain relief

and adverse events

Consider cognitive‐behavioral modalities as a multimodal approach

Provide APAP and/or NSAIDs as part of

multimodal analgesia

Use validated painassessment tool to track

responses

Use PO over IV opioids if patients can tolerate

oral medications

Avoid IM administration ofanalgesics for

postoperative pain


APS: Clinician Recommendation

• IV ketamine as part of multimodal analgesia

• IV lidocaine infusions for open and laparoscopic Abdominal surgery if no contraindications

• Preoperative dose of celecoxib if no contraindications

• Gabapentin or pregabalin for multimodal analgesia

34







35

NCCN Guidelines

Moderate to severe pain ≥ 4 or patient goals not met

Opioid Naïve• PO morphine sulfate 5-15 mg or

equivalent• IV morphine sulfate 2-5 mg or

equivalent

Opioid Tolerant• PO opioid equivalent to 10-20% of

total dose used in last 24h• IV opioid dose equivalent to 10-

20% of total opioid used in last 24h

If pain unchanged or increased, increase dose by 50-100%

If pain improved and well controlled,

continue current dose PRN over initial 24h

If pain decreased butInadequately

controlled, repeatsame dose

Pain Outcome

Swarm, RA, Kamal, AH, Portman, DG, et al. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Published 2014

31 32

33 34

35 36

9/27/2019

7






37

PQA Opioid Core Measure

38

Concurrent Use of Opioids

and BZ

Opioids at High Dosage

Opioids from Multiple Providers

Initial Opioid Prescribing

Schmitz, R. . Opioid Core Measure Set. [online] Pqaalliance.org. Available at: https://www.pqaalliance.org/opioid-core-measure-set [Accessed 15 Nov. 2018].






39

ASPMN

• Opioid Doses based solely on Pain Intensity Should be Prohibited

• Monitoring Opioid‐Induced Sedation and Respiratory Depression

• Perform comprehensive preadmission, admission, and preoperative therapy assessments

• Organizations should develop and implement policies/procedures

• Mechanisms for oversight and surveillance of practice outcomes

40

American Society for Pain Management Nursing Guidelines on Monitoring forOpioid-Induced Sedation and Respiratory Depression. Pain Management Nursing, Vol 12, No 3 (September), 2011: pp118-45.

Professional Organizations:Pain Mgmt Recommendations Summary

41

APS/ NCCN Guidelines PQA ASPMN

• Offer multimodal Analgesia or nonpharmacological interventions

• Provide treatment algorithm for opioid naïve or tolerant patients

• Concurrent Use of Opioids & BZ

• Opioids at High Dosage in pts w/o cancer

• Opioids from Multiple Providers

• Initial Opioid Prescribing

• Organizations should develop and implement policies/procedures

Self Assessment 3

• This governing body or agency recommends to “Expand naloxone use, distribution, and access, when clinically appropriate”

A. CDC

B. NCCN

C. CMS

D. PQA

42

37 38

39 40

41 42

9/27/2019

8

Self Assessment 3

• This governing body or agency recommends to “Expand naloxone use, distribution, and access, when clinically appropriate”

A. CDC

B. NCCN

C. CMS

D. PQA

43

Program and Literature Examples

• Intermountain Healthcare

• Veteran Affairs (VA) Review of Pain Mgmt Services

• “Pain Stewardship Program” in a Tertiary Children’s Hospital

44

45

Intermountain Healthcare Acute Pain Management

Stop • Avoid prescribing long‐acting or extended‐release opioids for acute conditions

• Opioids in doses > 50mg morphine equivalents/day (MME)

Caution • For elderly patients and those at risk for opioid induced respiratory distress, reduce dose and frequency when opioid unavoidable

Go • Prescribe the lowest effective dose• Integrate non‐opioid therapies (multimodal)• Re‐evaluate severe acute pain that continues beyond the anticipated

duration• Follow‐up with primary care within 3‐5 days of discharge• Educate patient and caregiver• Consider prescribing naloxone for all patients at risk for opioid‐induced

respiratory depression if discharged on opioids

Acute Pain Opioid Prescribing Guidelines. Intermountain Healthcare Clinical Guideline. https://intermountainphysician.org/Documents/AcutePainOpioidPrescribing_FINAL.pdfPublished January 2017. Accessed November 15, 2018

Intermountain Healthcare AlgorithmAcute or Anticipated Post‐Operative Pain

46

Common acute pain conditionsrarely indicated for opioids

• Fibromyalgia/Neuropathic pain• Headache• Self-limited illness, i.e., sore throat• Uncomplicated back and neck pain• Uncomplicated musculoskeletal pain

Acute Pain Opioid Prescribing Guidelines. Intermountain Healthcare Clinical Guideline. https://intermountainphysician.org/Documents/AcutePainOpioidPrescribing_FINAL.pdfPublished January 2017. Accessed November 15, 2018

VA Emergency Department Opioid Prescribing Guidelines

• Administration of IV/IM in the ED for acute exacerbation of chronic pain

• Discharge CS prescriptions should be written for the shortest duration appropriate (no more than 3 days)

• Policy that screens for substance misuse

47

Review of Pain Management Services in Veterans Health Administration Facilities. VETERANS HEALTH ADMINISTRATION. Office of Healthcare Inspections. https://www.va.gov/oig/pubs/VAOIG-16-00538-282.pdf. Published September 17, 2018. Accessed November 15, 2018

VA Emergency Department Opioid Prescribing Guidelines

• ED providers should

– use caution when prescribing CS to patients without proper photo ID

– Encourage to consult pain management

– Not prescribe replacement doses of methadone or buprenorphine for patients in opioid treatment programs

– Not prescribe long‐acting or controlled release opioids

48

Review of Pain Management Services in Veterans Health Administration Facilities. VETERANS HEALTH ADMINISTRATION. Office of Healthcare Inspections. https://www.va.gov/oig/pubs/VAOIG-16-00538-282.pdf. Published September 17, 2018. Accessed November 15, 2018

43 44

45 46

47 48

9/27/2019

9

“Pain Stewardship Program”in a Tertiary Children’s Hospital

• Pain scores are recorded every 4 hours in the hospital electronic health record

• Report was constructed to find all patients with an average pain score > 7 in the preceding 12 hours

• Reviewed by our anesthesia pain service

49

Patient Groupings

No action required Telephone call to the patient’s attending physician

One‐time consultation Consultation with ongoing management

Patient was already on the anesthesia pain service

Brenn BR, Choudhry DK, Sacks K, et al. The Development of a “Pain Stewardship Program” in a Tertiary Children’s Hospital. Hospital Pediatrics 2016;6(9): 520-8.

“Pain Stewardship Program”in a Tertiary Children’s Hospital

• 1 month duration

50


What Play Do Health‐System Pharmacies Call?

51

https://tenor.com/search/playbook-gifs

National Quality Partners Playbook

52

Promoting leadership

commitment and culture change

Implementing policies that support

evidence-based multimodal approaches

Advancing the clinical knowledge,

expertise, and practice

of clinicians

Enhancing patient and family caregiver

education andengagement

Tracking, monitoring, and

reporting performance data

Establishing accountability for a

culture of opioid stewardship

Supporting collaboration with community leaders

andstakeholders

APTA Contributes to New 'Playbook' on Pain Management and Opioid Stewardship. APTA. http://www.apta.org/PTinMotion/News/2018/03/12/NQFOpioidPlaybook/. Accessed November 15, 2018.

Implementation Strategies

Selecting Physician champion

Engage executive leaders for support

Establish an interdisciplinary opioid and pain stewardship committee

Create an RPhled pain mgmt

team

53

Selecting A Physician Champion

• Initiates collaboration and inclusiveness

• Serves as a bridge to the executives and other providers to the program

• Physician Champions provide

– Team leadership and Direction

– Policy development and implementation strategy

– Multidisciplinary involvement

– High risk case reviews, gap analyses, metric oversight

– Academic detailing

54

Bentley E.D. Pain Management Stewardship. ASHP Leadership Conference. Dallas, Tx. October 14, 2018. APTA Contributes to New 'Playbook' on Pain Management and Opioid Stewardship. APTA. http://www.apta.org/PTinMotion/News/2018/03/12/NQFOpioidPlaybook/. Accessed November 15, 2018.

49 50

51 52

53 54

9/27/2019

10

Engaging Executive Leaders For Support

• Support provides funds or resources

• Goal of engaging the hospital and health system executives

– Interdisciplinary OPSP supports the institution’s mission

– Improve patient outcomes

• The pharmacy leader and physician champion need to match both valuable and scarce resources

55

APTA Contributes to New 'Playbook' on Pain Management and Opioid Stewardship. APTA. http://www.apta.org/PTinMotion/News/2018/03/12/NQFOpioidPlaybook/. Accessed November 15, 2018.

Opioid And Pain Stewardship Committee Implementation

• Goals of the program

• Identify stakeholders

• Recognizing the team essentials

• Focus areas

• Implementation components

• Create policies and procedures

56

Bentley E.D. Pain Management Stewardship. ASHP Leadership Conference. Dallas, Tx. October 14, 2018.

Goals of Health Systems in Opioid Stewardship

• Implementing clinician education about appropriate prescribing practices

• Oversight and auditing of appropriate prescribing practices

• Patient & family education

• Offering referrals or treatment for patients with substance abuse disorder

57


Key Stakeholders

• Anesthesiologists

• Education

• Informatics

• Patient/caregiver

• Med Safety

• Primary care

• Pharmacy

• Surgeons

• Acute care Providers

• Leadership

• Mental health

• Primary care

• Community

• Pain specialist

58


Program‐Team Essentials

59

Leadership

Communication

CollaborationMulti‐

disciplinary

Organization Support


Committee Focus Areas

• Regulatory compliance and implementation

• Pain mgmt treatment options, multi‐modal

• Community collaboration and partnerships

• Addiction awareness and treatment

• Opioid safety initiative metrics and risk mitigation strategies

• Patient education

• Ambulatory and acute care focus

60


55 56

57 58

59 60

9/27/2019

11

Implementation Components

61


Retraining the physicians

Development of treatment algorithms

Coordinate interdisciplinary rounding teams

Create a role for pharmacists

Create Policies and Procedures

• Professional organizations like the APS, ASIPP, NCCN, PQA, and ASPMN, provide evidence‐based best practice strategies

• Incorporate these practice techniques into policy

– Patients can be assured that the institution is using the most efficacious strategies for patients receiving opioids

62

Role of a Pharmacy Led Opioid and Pain Stewardship Team

63

ComplianceMaking

interventions

Rounding on interdisciplinary

teams

Education to patients and

family members

Pharmacist Reporting Tool Examples

• Patients receiving > 4 doses w/in 24 hrs

• Patients receiving opioids and benzodiazepines

• High dose opioids in patients without cancer

• Home opioid use from multiple providers

• Elderly patients and those at risk for opioid induced respiratory distress

• Pain score monitoring

• Patients receiving methadone, opioid infusions, and PCAs

• Opioid naïve patients receiving long‐acting or extended release opioids

64

Self Assessment 4

• What are the program team essentials for opioid and pain stewardship?

A. Leadership

B. Communication

C. Organization Support/Collaboration

D. Multi‐disciplinary

E. All of the above

65

Self Assessment 4

• What are the program team essentials for opioid and pain stewardship?

A. Leadership

B. Communication

C. Organization Support/Collaboration

D. Multi‐disciplinary

E. All of the above

66

61 62

63 64

65 66

9/27/2019

12

Unintended Consequences

• Drug shortages

• Abrupt opioid discontinuation vs tapering

• Lack of chronic pain treatment

• Lack of community infrastructure or support

• Influence on palliative or hospice care

67


Institutional Challenges

• Knowledge about pain management

– Large teams

– Multiple disciplines with different levels of training

• Lack of understanding about appropriate use and limitations

• Absence of pain mgmt experts

• Limited funding and resources

• Policies promote intensity scores as most important part of assessment

68Brenn BR, Choudhry DK, Sacks K, et al. The Development of a “Pain Stewardship Program” in a Tertiary Children’s Hospital. Hospital Pediatrics 2016;6(9): 520-8.

Advocacy for Pharmacist Integration

• Pharmacist described as critical to the opioid epidemic in prevention and treatment of opioid use disorder and overdose

• CDC promotes integrated, collaborative pain management and practice models that include pharmacists

• NQP Opioid Stewardship action team has pharmacy involvement

69

Establishing an opioid stewardship program in your health system. jointcommission.org. https://www.jointcommission.org/webinar_establishing_an_opioid_stewardship_program_in_your_health_system/. Accessed November 15, 2018.

Advocacy for Pharmacist Integration

• ASHP advocates for the roles of pharmacist in the opioid crisis

– Pharmacist with unique knowledge, skills, responsibilities in substance abuse prevention, education and assistance, including in the hospital setting, are involved in reducing negative effects of substance abuse

70


AdventHealth Orlando

• No Opioid & Stewardship Team at AHS level

• PRN Duplicate report

• Utilization of Theradoc

• Multidisciplinary rounding

71

Kaweah Delta Medical Center

• Pharmacist received pain mgmt consults

• Pharmacist ran daily reports

72

High Risk Opioids High Risk PRNs High Risk Patients

Patients that were on methadone, opioid infusions, PCAs

use > 4 prn doses in a 24 hour period

age>60, BMI>=35, hx of respiratory failure, OSA and/or fibromyalgia, currently on opioids, CNS Depressants

Knocking out pain: Hospital pharmacists launch new approach to pain management. Pharmacist.com. https://www.pharmacist.com/article/knocking-out-pain-hospital-pharmacists-launch-new-approach-pain-management. Published 2018. Accessed November 15, 2018.

67 68

69 70

71 72

9/27/2019

13

Kaweah Delta Medical Center

• From 2013‐2015

– Pharmacists have made 2,267 interventions, which

– Estimated an indirect cost avoidance of $2.7 million

• Initially executing 16 consults per month 45 consults per month

• 59% reduction in opioid‐associated rapid response calls and code blues

• Overall reduction in the use of high‐risk medications on patients

73


Program Example Key Takeaways

• Standardize opioid dosing strategies

• Integrate non‐opioid therapies (multimodal, opioid sparing)

• Policy that screens for substance misuse

• Utilization of naloxone

• Pharmacist led opioid stewardship programs with executive and interdisciplinary “buy in” is important!

74

Conclusion

• Limited evidence on the structure of opioid and pain stewardship models for health‐systems

• Pooling recommendations from accrediting and professional organizations

• Implementing a pain stewardship committee and a pharmacist led program

• Standardize the best treatment options for pain management while limiting the use and supply of opioids

75

Developing An Opioid & Pain Stewardship Program: A Health‐System Pharmacy Approach

Oscar Santalo, PharmD, MBA, MHA, BCPSPharmacy Operations and Compliance CoordinatorAdventHealth OrlandoOctober 5th, 2019

www.fshp.org

77 78

73 74

75 76

77 78

9/27/2019

14

79

OUD Screening

• SCREENING — A multispecialty expert panel recommended in 2018 that all patients receiving a medical evaluation for endocarditis, bacteremia, skin abscesses, vertebral osteomyelitis, HIV infection, and/or HCV infection be screened for opioid use disorder

• Assessment‐ hx, consumption

• Signs of intoxication pinpoint pupils, drowsiness, slurred speech, and impaired cognition

• Signs of acute opioid withdrawal syndrome include watering eyes, runny nose, yawning, muscle twitching, hyperactive bowel sounds, and piloerection

• DSM 5 criteria:

80

DSM V Criteria

• A problematic pattern of opioid use leading to clinically significant impairment or distress is manifested by two or more of the following within a 12‐month period:

• Opioids are often taken in larger amounts or over a longer period than was intended A persistent desire or unsuccessful efforts to cut down or control opioid use A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects ●Craving, or a strong desire or urge to use opioids ●Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home ●Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids●Important social, occupational, or recreational activities are given up or reduced because of opioid use ●Recurrent opioid use in situations in which it is physically hazardous ●Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance ●Tolerance* ●Withdrawal* * Experiencing these symptoms while taking opioids solely under appropriate medical supervision is an exception to (does not meet) these criteria for OUD. Specifiers for the diagnosis include:

81

82

79 80

81 82