Opioid Stewardship Committee: A Multimodal ApproachKYLE E ICHELBERGER, PHARMD, BCPS

LAWRENCE MEMORIAL HOSPITAL

LAWRENCE, KANSAS A partner for lifelong health

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Objectives:Identify leading strategies for developing an opioid stewardship committee

Review opioid stewardship goals and recommendations

Establish and evaluate metrics to measure opioid stewardship

Share LMH Health’s opioid stewardship committee initiatives

Review of use of multimodal pain management

Discuss factors that help/hinder an Opioid Stewardship Program

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Opioid Stewardship Program Overview:•March 2018: LMH joined Vizient’s Opioid Stewardship Collaborative

•May 2018: Attended Mid-America Improvement Leader Network in St. Louis

•May 2018: Created Opioid Stewardship Committee

•Resources:◦ Joint Commission Standards◦ National Quality Partners Playbook: Opioid

Stewardship◦ CDC Opioid Prescribing Guidelines

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LMH Opioid Stewardship Goals•Optimize pain management pharmacotherapy

•Minimize opioid associated adverse events and cost

•Promote education on safe opioid prescribing, administration, and patient monitoring

•Develop opioid stewardship metrics for assessment

•Enhance patient experience regarding opioid utilization and understanding

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NQP Opioid Stewardship PlaybookFundamental Actions:

1. Leadership Commitment and Culture2. Organizational Policies3. Clinical Knowledge, Expertise, and Practice4. Patient and Family Caregiver Education and

Engagement5. Tracking, Monitoring, and Reporting6. Accountability7. Community Collaboration

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Vizient Collaborative Project Focus Distribution

Source: Lichauer, Jim. Implementation of an Opioid Stewardship Program Collaborative Knowledge Transfer Webinar. Presented March 4, 2019. https://amc.vizientinc.com/pages/35362. Accessed on April 24, 2019.

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1. Leadership Commitment and Culture

Create the infrastructure for formal opioid stewardship program

Receive buy-in from the board of directors

Include opioid stewardship in the annual operating plan

Integrate opioid stewardship into organizational patient safety plan

Establish new ways to assess and treat pain

Disconnect opioid prescribing and patient satisfaction

Destigmatize substance abuse disorder

ACTION Established Opioid Stewardship Committee Executive sponsor Chair members Physician champions

Reported OSC projects to administration and board members

Devoted time and resources to OSC goals IT/Data Analyst New technology/tools Physician representation

RECOMMENDATIONS

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Opioid Stewardship Committee Composition

•Pharmacy

•Orthopedic Physician

•Pain Management Physician

•Primary Care Physician

•Anesthesiologist

•Hospitalist

•Pelvic Health Specialist

•Emergency Medicine Physician

•Emergency Department Director

•Data Analytics

•Pain Team Chair/OB Clinical Coordinator

•Executive Representative: Clinical Excellence Vice President

•Clinical Excellence Manager

•Application Integration Director (IT)

•Integration Engineering Manager (IT )

•Pain Clinic Nurse

•Pain/Palliative Care Nurse Practitioner

•Risk Management

•Director of Primary Care

•Care Coordination Director

•Outpatient Social Worker

•Director of Integrated Crisis Team

•PACU Director

•PACU Nursing Manager

•Operational Excellence

•Primary Care Nurse Practitioner

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2. Organizational PoliciesRECOMMENDATIONS

Promote current pain management services

Implement a functional pain scale and opioid risk tools

Standardize the use of the state’s PDMP

Implement naloxone dispensing policy targeting specific patient populations

Establish a formal partnership with local treatment facilities for MAT

ACTION

ED Opioid Prescribing Policy New Opioid Risk Tool (ORT) New Pain Assessment CAPA replaced Numeric Pain Scale

Utilizing Cerner’s Opioid Toolkit Tracking Recommendations

Pain Management Services Drug Take-back options Naloxone Recommendations

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3. Clinical Knowledge, Expertise, and Practice

Implement inpatient pain orders for opioid naive pain and opioid tolerant patients Expand non-pharmacologic pain management modalities Develop core competencies for pain management Standardize pain assessment tools Develop a pain comfort menu Implement a respiratory suppression scale Create alerts to identify high-risk patients, identify high-dose prescribing and high-risk combinations

Create a tiered-system guideline of discharge opioid prescriptions

Educate prescribers about multimodal analgesia

Support consistent use of PDMP for all prescribers

Develop standardized risk assessment tool and referral network for OUD

Establish a standardized naloxone program for high risk patients

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3. Clinical Knowledge, Expertise, and Practice

Multimodal Pain Management Total Joint Replacement Hysterectomy C-sections Spinal fusions Laminectomies ALTO in ED Universal Multimodal order-set

Integration of PDMP (KTRACs) in EHR

Screening and referral for OUD

Naloxone recommendation

Clinical Training/Education: Opioid stewardship Pain Management Communication techniques Tapering Psychosocial aspects of pain (stress, anxiety,

depression)

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Medical Staff Education•Provided information about UDS drug screens available at LMH and send-out options for pain agreement patients

•Developed computer-based learning program for physicians using CDC guidelines

•Palliative care and pain specialist helping to developing CME lecture

•Wrote MedStaff Newsletter detailing recent restrictions to opioid prescribing• Including Medicaid, Wal-Mart, BCBS,

UnitedHealthCare

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Multimodal Pain Management: Purpose

To examine the safety and efficacy of a multimodal pain

management strategy for total joint replacement

patients

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Multimodal Pain Management: Background•With current opioid epidemic, providers and healthcare agencies have searched for alternatives to opioids to manage pain and reduce patient harm

•2012 ASIPP:• Opioid use accompanied by increasing fatalities and

adverse consequences, and a lack of evidence regarding effectiveness and safety

•2016 American Pain Society:• recommend acetaminophen and/or NSAIDs as part

of multimodal analgesia for management of postoperative pain

• recommend use of gabapentin or pregabalin as a component of multimodal analgesia

•2018 AANA:• Pre-medicating patients with acetaminophen,

gabapentinoids, NSAIDs, and corticosteroids decreased postoperative pain, length of stay, and opioid use

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Multimodal Pain Management: Objectives◦ Primary Outcome:

◦ Measure morphine milligram equivalent (opioid use) use at 12hr, 24hr, 48hr

◦ Secondary Outcomes:◦ Incidence of intolerable pain at 12hr, 24hr, 48hr◦ Opioid adverse effects:

◦ Nausea◦ Constipation◦ Itching◦ Overdose

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Multimodal Pain Management: MethodsPre-operative Medications

Intra-operativeMedications

Post-Operative Medications

Pre-Multimodal(Control Group)

None Interarticular Joint Compound: • Ropivacaine• Epinephrine• Clonidine• Ketorolac

• Mild: APAP 650mg q4hr PRN• Moderate: hydrocodone/APAP 7.5/325mg q4hr PRN• Moderate 2nd: ketorolac 30mg q6hr PRN x 2 doses• Severe: Oxycodone 10mg q4hr PRN• Severe 2nd: Morphine IV 2mg q2hr PRN

Post-Multimodal (Multimodal Group)

• Gabapentin 600mg x 1 dose

• Celecoxib 400mg x 1 dose

• Acetaminophen 1000mg PO x 1 dose

Interarticular Joint Compound: • Ropivacaine• Epinephrine• Clonidine• Ketorolac

Scheduled APAP 1000mg three times dailyScheduled celecoxib 200mg twice dailyModerate: Oxycodone 5mg q4hr PRN Severe: Oxycodone 10mg q4hr PRNSevere 2nd: Ketorolac 15mg PRN x 1 doseSevere 3rd: Morphine IV 2mg q2hr PRN

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Multimodal Pain Management: DemographicsParameter Pre-MM Post-MM P ValueAge: Avg (range) 63.3 (47-87) 64.6 (41-86) 0.304145Sex:Male: n (%) 12 (40%) 20 (45%) 0.641925Female: n (%) 18 (60%) 24 (55%)LOS in days: Avg (range) 2.7 (1-4) 2.15 (1-6) 0.062251BMI: Avg (range) 30.9 (22.2-40.4) 29.8 (19.4-39.4) 0.254934Surgery:Knee: n (%) 12 (40%) 20 (45%) 0.641925Hip: n (%) 18 (60%) 24 (55%)

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Multimodal Pain Management: Results

PRIMARY OUTCOME: Measure and compare cumulative morphine milligram equivalent between pre-implementation and post-implementation of a multimodal pain management strategy at 12 hours, 24 hours, and 48 hours postoperatively.

12 H Post-op Cumulative 24 H Post-op Cumulative 48 H Post-opPre-Multimodal 65.38 111.25 172.67Post-Multimodal 55.39 93.44 131.13

65.38

111.25

172.67

55.39

93.44

131.13

0.0020.0040.0060.0080.00

100.00120.00140.00160.00180.00200.00

MM

E

Average Morphine Milligram Equivant Use

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Multimodal Pain Management: Results

SECONDARY OUTCOME: Measure and compare the incidence of patients not reporting intolerable pain (NPS ≥7 or CAPA=intolerable) between pre-implementation and post-implementation of a multimodal pain management strategy at 12 hours, 24 hours, and 48 hours postoperatively.

No Intolerable Pain at 12 H No Intolerable Pain at 24 H No Intolerable Pain at 48 HPre-Multimodal 30.0% 23.3% 20.0%Post-Multimodal 52.3% 47.7% 45.5%

30.0%23.3% 20.0%

52.3%47.7% 45.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Patie

nts

Number of patients not reporting intolerable pain

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Multimodal Pain Management: Results

SECONDARY OUTCOME: Measure and compare incidence of nausea, constipation, itching and overdose between pre-implementation and post-implementation of a multimodal pain management strategy.

50%

30%

3%

0

31%

16%

4%

0

0% 10% 20% 30% 40% 50% 60%

Nausea

Constipation

Itching

Overdose

Nausea Constipation Itching OverdosePost-MM 31% 16% 4% 0Pre-MM 50% 30% 3% 0

Side Effect Profile

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Multimodal Pain Management: DiscussionPrimary Outcome:

•Opioid use• Trend toward reduced opioid use

• Particularly at 48 hours post-operatively

Secondary Outcomes:•Incidence of intolerable pain

• Significant reduction of intolerable pain at 24 and 48 hours after surgery

•Side effect profile• Trend toward reduced incidence of nausea and

constipation

Limitations:

•Retrospective

•Pre-Implementation sample size

•Allergies/Intolerances/Age/Renal function limited use of celecoxib and gabapentin

•Pain Assessment Challenges• NPS vs. CAPA• Subjectivity of pain assessment

•Assessment of medication use for nausea, constipation, itching

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Multimodal Pain Management: Conclusion

Use of a multimodal pain management strategy, that

incorporates use of preoperative gabapentin, scheduled

acetaminophen and scheduled celecoxib, appears to reduce opioid

use, incidence of intolerable pain and common opioid side effects.

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4. Patient and Family Caregiver Education and Engagement

Utilize Cerner’s opioid use agreement forms

Nonpharmacologic Options LMH Comfort Menu

Limit risk of opioid abuse: Limit prescribed quantity at discharge Utilize ORT Naloxone co-prescribing criteria

Update Opioid Discharge Education Drug interactions Side effects (withdrawal and overdose) Safe drug storage/disposal Risk of dependence Naloxone availability and use Tapering

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Pain Management Agreement•Standardized Pain Management Agreement document

•Work with IT, HIMS and physicians to utilize Cerner’s Closed-looped Opioid Treatment Agreement Program• Alerts a provider who begins to order an opioid if the

patient is part of an Opioid Treatment Agreement with another provider

• Notifying the primary prescriber of an expiring agreement 30 days prior to the expiration

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5. Tracking, Monitoring, and Reporting: Data Sources/Metrics LMH Discharge Opioid Data Douglas County Health Dept. Overdose Data Cerner’s Lights-On Data CollectionMedicare Opioid Prescribing Data Great Plains QIN Prescribing Data

Handouts

ICD 10 Codes for Opioid Poisoning and Non-Poisoning for inpatient and outpatient (Vizient Data) Inpatient naloxone use

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Opioid Data Collection•Working with IT to develop a report to collect data on discharge opioid prescriptions throughout health system

1. Percentage of patients discharged from the hospital with opioid discharge prescription

2. Percentage of opioid discharge prescriptions exceeding 7 days

3. Use of multimodal order-set 4. Percentage of patients from the ER

discharged with opioid prescriptions

5. Percentage of patients discharged on opioids who receive discharge education on opioids

•Future Goal:• Inpatient MMED (available and

administered)• Comparable data to support

outpatient prescriptions• Establish clinic opioid data collection

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Douglas County Health Department CollaborationDee Vernberg, PhD, MPH

Syndromic Surveillance◦ Analysis platform developed by Johns Hopkins

that uses EMR data to detect outbreaks

Opioid project goals ◦ To validate an opioid overdose syndrome query ◦ To develop relationships with other community

partners for prevention and treatment of overdoses

◦ To enhance opioid overdose preparedness efforts in Douglas County and develop public health’s role in this effort

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Monthly LMH Overdose 2016-2019

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Weekly LMH Overdose: 2017-2018

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Douglas County Opioid Prescribing (Medicare Data)

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LMH Health Opioid Prescribing Rate

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6. AccountabilityEstablished Opioid Stewardship CommitteeAddressing community pain management needs

by adding new Pain ClinicMeeting Joint Commission StandardsEstablishing a Diversion CommitteeReviewing policy/procedures surround controlled

substance waste Share prescribing data so providers can see how

they compare with their peers

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Diversion CommitteeCreate a Diversion Oversight Committee

Create a Diversion Response Team

Update Policies and Procedures

Improve tracking and reporting

Develop Diversion Risk Rounds to identify potential areas of diversion

Educate staff on proper disposal and identifying potential diversion

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7. Community Collaboration Douglas County Health Department Data Drug Take-Back Programs

Public messaging about pain management strategies and opioid use: Radio Newspaper

Public Library Pain Management Education

Bert Nash Community Mental Health Center

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Drug Take-Back Options: Deterra™ •Safely dispose of unused medications at home with the Deterra™ Drug Deactivation System

•The only patented technology that deactivates prescription drugs, rendering them ineffective for abuse and safe for the environment.• Free of charge • Simple 3-step process• Works with pills, liquids and patches

•Provided by Douglas County Health Department/DCCCA Grant

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Drug Take-Back Options: MedSafe™ •Drop off unused controlled substances at Lawrence Pain Specialist Clinic

•MedSafe is an ultimate-user medication collection and disposal solution• Easy-to-operate system accepts controlled (Schedules II-V), non-

controlled, and over-the-counter medicines• Cost-effective and easy-to-manage system that meets DEA

regulations• Inner liners transferred by a common carrier• Controlled drugs destroyed using incineration, meeting the DEA's

destruction standard of non-retrievability

•Provided by Douglas County Health Department/DCCCA Grant

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Opioid Stewardship FactorsHELPED

Prioritization as a community crisis

Hospital and medical staff leadership support

A strong committee with a charter

Organizational patient safety goals for opioid stewardship

Inclusion of opioid stewardship as part of the annual operating plan

Taking advantage of current climate and regulatory standards Structure and support

IT support and dedicated time

Protected time for patient care providers to attend meetings

HINDERED

Agreeing on appropriate and meaningful metrics

Obtaining and identifying necessary data

Competing time commitments and not having dedicated personnel

Communicating with key stakeholders, structural and cultural barriers

Sharing provider prescribing data and the potential repercussions of sharing un-blinded data

Lacking a good process to disseminate important information/education

Lacking pain management clinicians in the acute care setting

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Current Opioid Stewardship InitiativesCompleted In Process Planned

• Physician UDS Education (7/15/18)• Med Staff Newsletter detailing

insurance/pharmacy opioid restrictions (7/20/19)

• Deterra Controlled Substance Disposal Bags Available (9/19/18)

• C-Section and Hysterectomy Multimodal Orders (11/16/18)

• Stull’s Total Shoulder Multimodal Orders (10/2/18)

• Multi-Modal Pain Management in Total Joint Replacements and data collection (11/22/18)

• ED Opioid Policy (12/6/18)• Create Diversion Committee and policy

(12/2018)• Update Discharge Opioid Education (3/2019)• Health Dept: Overdose Data Collection

(4/2019)• LMH Prescribing Data from KFMC (5/2019)• Discharge Opioid Data Collection (5/2019)

• Pain Agreement Notification-Janelle/Cerner/Dr.Harper/Pain clinic

• Universal multimodal orders• Update opioid prescription

sentences to reflect <50MMED/7 day supply

• Double Opioid Sentences to reduce amount filled.

• Community Opioid Disposal Program at the hospital

• Provider use of KTRACS Data• Inpatient Opioid Data Collection• Multimodal Orders for Spine Surgery• Hospital Controlled Substance

Disposal Dropbox• Addition and documentation of non-

pharmaceutical options• Community Collaborative- Public

Education- Newspaper/Radio

• Opioid Tapering• Opioid + Benzo Warning• High Dose Opiates Warning (>90MMED)• Naloxone Prescribing Guideline• Hospital Opioid Policy- include methadone

policy• Improve treatment access to

buprenorphine for OUD• HealthTracksRX (deferred until 2019)• Opioid Stewardship Newsletter• ED ALTO orderset- Dr. Dahl

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Collaborative: Key LearningCreate a formal and embedded infrastructure for the opioid stewardship program A leader or leadership team is required by Joint Commission Develop charter

Develop a simple and balanced set of metrics, covering the domains of opioid stewardship Track a short list of meaningful measures to monitor the impact of opioid stewardship and pain management

initiatives

Establish a formal communication process to relay performance and policy updates to practitioners and front-line workforce Formalized way to communicate measures and changes in policies, guideline and regulations. Establish criteria for reporting data

Realize that opioid stewardship is one step on the path to improve the patient’s pain management Joint Commission states that hospitals must assess and manage the patient’s pain and minimize risks

associated with treatments

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Opioid Stewardship Committee: Future• Reevaluate committee involvement using TJC Standards and CDC Recommendations

• Solidify Data Collection/Analysis Process

• Physician Involvement

• Implement Cerner Opioid Toolkit update• Morphine Milligram Equivalent Tracking

• Implement multimodal pain management and ERAS

• Update surgical and ED order sets

• Expand Community Collaboration

• Controlled Substance Disposal Program

• Expand treatment options for Opioid Use Disorder

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References:1. Mikosz C, Conlon P, et al. National Quality Partners Playbook: Opioid Stewardship. National

Quality Forum 2018.

2. Williams SN, Wolford ML, Bercovitz A. Hospitalization for total knee replacement among inpatients aged 45 and over: United States, 2000–2010. NCHS data brief, no 210. Hyattsville, MD: National Center for Health Statistics. 2015

3. Chou R, Gordon DB, Leon-Casasola OA, 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 administrative council. J Pain. 2016;17(2):131-157.

4. Oseka L, Pecka, S. Anesthetic Management in Early Recovery After Surgery Protocols for Total Knee and Total Hip Arthroplasty. American Association of Nurse Anesthetists Journal. 2018;86:32

5. Clarke H, Pereira S, Kennedy D, et al. Gabapentin decreases morphine consumption and improves functional recovery following total knee arthroplasty. Pain Res Manag. 2009;14(3):217-212.

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Opioid Stewardship Committee: A Multimodal ApproachKYLE EICHELBERGER, PHARMD, BCPS

KYLE.EICHELBERGER@LMH.ORG A partner for lifelong health

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