One Size May NOT Fit All: The Role of Opioid Stewardship for - - PowerPoint PPT Presentation

One Size May NOT Fit All: The Role of Opioid Stewardship for Patients with Serious Illness

Mary Lynn McPherson, PharmD, MA, MDE, BCPS Professor, University of Maryland School of Pharmacy Executive Director, Advanced Post-Graduate Education in Palliative Care mmcphers@rx.umaryland.edu | graduate.umaryland.edu/palliative

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Learning Objectives

• At the conclusion of this presentation the participant will

be able to:

• Define the term “opioid stewardship.”
• Describe the impact of inappropriate opioid utilization on the

care of patients with serious illness.

• Develop a “best practice” approach to developing opioid

utilization policies for health care systems.

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What the heck happened?

• In the 1980’s the HIV epidemic drew

attention to the under-treatment of pain

• In 1996 the American Pain Society

declared pain “the fifth vital sign” (and VA)

• 1996 Purdue Pharma released

OxyContin

• In 1998 Purdue released video “I

Got My Life Back”

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https://www.youtube.com/watch?v=Er78Dj5hyeI

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NEJM March 14, 1980 “This study was NOT evaluating the impact of chronic opioid therapy for chronic pain; their observation had little bearing

• n the risk of

developing addiction with chronic use.” Daniel Tobin, MD

Pain? No addiction risk?

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Go get the

• pioids!!

Uh oh…

• Free love, free opioids….
• Increased opioid-induced deaths
• From inappropriate prescribing?
• From prescription misuse/abuse?
• From illicit opioids such as fentanyl?

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…unintended consequences

• “The increase in opioid-related mortality fueled by injudicious prescribing

and increasing illicit use of both prescription and illegal opioids has led some clinicians to simplify their lives by discontinuing prescribing of opioid analgesics.” (NEJM)

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Webmd.com/special-reports/opioids-pain/20180314/opioids-pain?print=true

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Finding Middle Ground (black, white, gray?) Is this the responsibility of the palliative care team?

These are strategies??

• “We’re an opioid-free practice”
• DEA cuts manufacturing limits on opioids
• CDC releases guidelines on opioids and chronic pain

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• When to initiative or continue
• pioids for chronic pain
• Opioid selection, dosage, duration,

follow up and discontinuation

• Assessing risk, addressing harm

with opioid use

These are strategies??

• The Joint Commission
• Pain management is identified as an organizational priority for the hospital
• Medical staff are actively involved
• Hospital manages patient’s pain based on clinical practice guidelines
• Monitor indicators of safe opioid use
• Reduced use of opioids post-operatively, in oncology practice, primary

care

• Patient suffering, increased use of heroin, suicide

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NQP Playbook: Opioid Stewardship

• Provides concrete strategies and implementation

examples for healthcare organizations and clinicians committed to effective pain management and opioid stewardship.

• Aligns with CDC guidance
• 7 fundamental activities
• Basic, intermediate, advanced strategies

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National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

Promote Leadership Commitment and Culture

• Clear direction and support for

high-quality pain care, and opioid stewardship

• Provide support and resources for
• opioid stewardship
• development of comprehensive,

evidence-based pain management programs

• Promote a culture of best practice
• pioid prescribing
• Discourage the stigma of opioid use

disorder (OUD)

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Basic

• Framing as a patient safety issue
• Avoid stigmatizing language

Intermediate

• Staff education
• System point of contact

Advanced

• System metrics and integrated goals
• Improving EHR for clinical decision

support

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

Cultural Issues- Language Matters

• Committee charters with language to

“decrease opioid prescribing” instead

• f “appropriate opioid use”
• Narcotics instead of opioids
• “Opioid Reporting”
• Relying on guidelines (e.g., CDC) as

ultimate source of truth

• CDC guidelines does not specifically

consider palliative, hospice, sickle cell, active ca tx

http://freepdfhosting.com/0dc0977cdd.pdf

• Should support the

implementation of multimodal pain management based on the best available evidence

• PDMP, risk assessment strategies

and tools, patient/ family/caregiver/clinician education, support access to substance abuse treatment

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Basic

• Interdisciplinary teams (IDT)
• Integrate guidelines

Intermediate

• Core competencies for IDT
• Mitigate risks and harms

Advanced

• Guidance for types of specialty

procedures

• Default opioid doses in EHR

Organizational Policies

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

Organizational Policies

• Standard treatment agreements
• Policy on threshold dosage levels for patient populations
• Prescription refill or renewal policies
• Frequency of monitoring patients on long term opioid therapy
• Frequency of urine drug testing
• Checking PDMP procedures

CDC toolkit for Chronic Pain Prescribing: https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf

Implementing Considerations from CDC

CDC toolkit for Chronic Pain Prescribing: https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf

Pain Management Program Development

Areas of Focus

Consolidation of pain physicians under MMG Anesthesiology in order to facilitate movement and coverage during both growth and maintenance of the program Uniform delineation of privileges across MedStar Standard APS practice guidelines, including catheters, ketamine and lidocaine infusions on the hospital floor and pain order sets Review and optimization of documentation and billing practices for nerve blocks Establish cross-specialty opioid prescribing assistance including guidelines for assisting primary care physicians, post-op surgical management of opioids, and opioid take-back programs Coordinate acute and chronic pain services with Palliative Care APS training program: 4 weeks (or more as needed) at Georgetown, with Palliative Care pain certification, and 2 weeks with Palliative Care at institution where they will practice

• Develop and promote core

competencies in evidence-based pain management, including:

• Knowledge of nonpharmacologic and

nonopioid strategies

• Referral needs
• Risk assessment
• Clinicians should be well-versed in

patient communication techniques.

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Basic

• Use activity and function based pain intensity scale
• Specify dx, drug, dose, duration and de-escalation for

every opioid Rx Intermediate

• Standard risk assessment process
• Promote referral network for OUD services

Advanced

• Develop IDT pain service
• Standardized naloxone program

Clinical Knowledge, Expertise, Practice

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

Survey of hospice RNs – Starter Kit Medications

• What are the three most common adverse effects with morphine?
• Constipation
• Nausea
• Drowsiness
• What percentage of experienced

hospice nurses should know all three?

Morphine Common Side Effects

# Correct out of Three Number of Staff % of Staff 5 4% 1 25 20% 2 64 52% 3 30 24% TOTAL 124 100% # Correct out of Three Number of Staff % of Staff Slowed respirations 55 44% Unarousable 29 23% Shallow breathing 5 4%

Alarm Symptoms

Ten Steps of Universal Precautions in Pain Medicine

• 1. Make a diagnosis with appropriate differential
• 2. Psychological assessment including risk of addictive disorders
• 3. Informed consent
• 4. Treatment agreement
• 5. Pre- and Post-intervention assessment of pain level and function
• 6. Appropriate trial of opioid therapy +/- adjunctive medicine
• 7. Reassessment of pain score and level of function
• 8. Regularly assess the “Four A’s” of pain medicine (analgesia, activity, adverse

effects, aberrant behavior, [affect])

• 9. Periodically review pain diagnosis and comorbid conditions, including addictive

disorders

• 10. Documentation

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Gourlay DL, Heit HA, Almahrezi A. Pain Medicine 2005

• Risks and benefits of therapy;

realistic goal-setting; safe opioid use; signs drug misuse

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Basic

• Patient education materials (written, video,

virtual)

• Informed consent and/or opioid use agreements

Intermediate

• Education on co-prescribing of naloxone
• Support groups

Advanced

• Engage PFACs and peer recovery coaches
• Telemedicine consults to improve access

Patient and Family Caregiver Education and Engagement

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

Who is educating the informal caregivers (family members)?

• Key quality metrics:
• identify opportunities for

improvement

• assess the impact of opioid

stewardship efforts

• Opioid prescribing data, patient-

reported outcomes, adverse events, PDMP

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Basic

• Engage entire IDT in process (not just prescribers)
• Create a positive (not punitive” culture to embrace

feedback Intermediate

• Ongoing, real-time data sharing
• E-prescribing to track patterns and minimize

variation Advanced

• Integration of PDMP data into EHR
• Stratify patients by risk factors

Tracking, Monitoring, Reporting

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

CDC toolkit for Chronic Pain Prescribing: https://www.cdc.gov/drugoverdose/pdf/prescribing/CDC-DUIP-QualityImprovementAndCareCoordination-508.pdf

MedStar Health

• Revised the order sentences in EHR for discharge prescriptions to populate

quantity dispensed = three days of therapy

• There are alerts/reminders to:
• prescribe naloxone at discharge/in ambulatory setting for patients at high risk

for opioid overdose

• dispense naloxone (at no charge) from the ED to patients at risk
• Provide information via discharge instructions about safe storage and disposal to

patients who are prescribed opioids.

• Now providing to our patients an easy-to-use method to safely dispose of

unneeded medications with opioid prescriptions delivered to our discharge patients via bedside delivery.

• Installing “take-back” units in hospital lobbies for opioids and other medications

for safe disposal.

MedStar Health

• New post-op discharge opioid rx went live 9-14-2018; limits to 3 days and 20

pills

8/15/2019

MedStar Health

• ED data similar with number of doses per rx going down (not as dramatic as the new

default for post-op opioids)

8/15/2019

Categories of Daily Opioid Dosage

Opioid Regular Doses (mg/day) Elevated Dose (mg/day) Low Moderate High Very High Morphine < 59 60-299 300-599 > 600 Hydrocodone < 59 60-299 300-599 > 600 Oxycodone < 49 50-249 250-499 > 500 Hydromorphone < 11 12-59 60-119 > 120 Oxymorphone < 24 25-124 125-249 > 250 TD Fentanyl < 25 mcg/h 50-125 mcg/h 150-275 mcg/h > 300 mcg/h

Adapted from: Bercovitch and Adunsky. Cancer 2004;101:1473-1477.

Morphine

Total # Rx’s Low (mg/d) Moderate (mg/d) High (mg/d) Very High (mg/d) Morphine Total 21,456 (46.2%) < 59 60-299 300-599 > 600 Morphine SA 14,194 (66.2%) 8,010 Rx’s 5,936 Rx’s 253 Rx’s 126 Rx’s Morphine LA 7,262 (33.6%) 3,421 Rx’s 3,554 Rx’s 228 Rx’s 59 Rx’s Dosage Range Number Prescriptions Mean (SD) Median (IQR) Low - < 59 mg/day 11,314 27.0 (10.1) 30 (20-30) Moderate – 60-299 mg/day 9,482 99.3 (51.6) 80 (60-120) High – 300-599 mg/day 471 3984.6 (75.2) 360 (300-480) Very High - > 600 mg/day 179 1,468.3 (2,458.9) 800 (600-1200)

Oxycodone

Total # Rx’s Low (mg/d) Moderate (mg/d) High (mg/d) Very High (mg/d) Oxycodone Total 3,188 (6.8) < 49 50-249 250-499 > 500 Oxycodone SA 1,691 (53.0) 1,085 417 273 116 Oxycodone LA 1,497 (47.0) 1,011 457 24 5 Dosage Range Number Prescriptions Mean (SD) Median (IQR) Low - < 49 mg/day 2,096 22.8 (11.6) 20 (15-30) Moderate – 50-249 mg/day 874 103.1(51.0) 60 (60-80) High – 250-499 mg/day 97 363.7 (63.4) 360 (300-400) Very High - > 500 mg/day 121 680 (202.5) 600 (600-600)

Tablet Strength Number Rx’s % TDF Rx’s 12 mcg/h 2,182 22.4 25 mcg/h 3,180 32.6 37.5 mcg/h 31 0.3 50 mcg/h 2,183 22.4 62.5 mcg/h 3 0.03 75 mcg/h 980 10.0 100 mcg/h 1,197 12.2 Transdermal Fentanyl Prescriptions, n = 9,755

Even though almost 25% of all TDF prescriptions are the higher strengths, ALL TDF prescriptions are in low or moderate dosage range.

• Board of directors, C-Suite,

department leaders and team leaders

• Set measurable goals for

promoting, establishing and maintaining a culture of opioid stewardship

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Basic

• Stewardship measures reported to board
• Framing opioid stewardship with emphasis on pt

safety, pain mgmt. and pt centered outcomes Intermediate

• Develop process to address outlier prescribing
• IDT accountability for stewardship goals

Advanced

• Align incentives to support opioid stewardship goals
• Requirements for credentialing privileges (e.g.,

enrollment in PDMP and access)

Accountability

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

• Work with community partners to

promote appropriate opioid use, safe storage and disposal of opioids

• Home-based care, pharmacies,

rehabilitation providers, dental clinics, veterinary clinics, EDs, first responders, law enforcement, injury prevention centers, schools, faith communities, health insurers, government agencies

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Basic

• Designate a leader to act as integrator for community

resources

• Develop shared goals and accountability with cmty

partners

Intermediate

• Encourage use of standard, nonstigmatizing terminology
• Facilitate education on naloxone use and distribution

Advanced

• Public education events
• Measure effectiveness of collaboration through data and
• utcomes (e.g., OD rates, ED visits)

Community Collaboration

National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx

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Good communication skills

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Risks and benefits; roles and responsibilities

Opioid not working? Could be…

Opioid poorly-responsive pain Type of pain; temporal pattern of pain (breakthrough) Opioid-induced tolerance / Disease progression Opioid-induced hyperalgesia Poorly managed opioid therapy (conversions) Non-physical pain

Opioid Math (oh my!)

Understanding opioid potency Understanding opioid TDD Opioid conversion calculations Tapering opioid doses (up/down)

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Spectrum of OUD

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• Role of methadone and

buprenorphine for pain management

• Co-managing patients with
• ther professionals
• Setting boundaries on

patients/families

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Case 1 - Joan

• 42 year old woman admitted to hospice with end-stage cervical cancer.
• Pain had been well-controlled of long-acting oral morphine tablets twice

daily, but pain control deteriorated.

• After several dose escalations, the team decided to switch her to

methadone oral solution.

• The oral methadone solution was delivered late Tuesday evening, and the

RN was scheduled to visit early Wednesday to start therapy.

• Patient had a significant pain crisis Tuesday night, and the decision was

made to bring her to the hospice inpatient unit.

Case 1 - Joan

• After five days in the IPU, Joan’s pain was well controlled on oral

methadone, with oral morphine for breakthrough pain.

• She was discharged from the IPU, and the RN followed the ambulance

home to commence methadone education.

• When patient and RN arrived at the house, the completely full bottle of
• ral methadone solution was missing.
• The husband tearfully admitted that he drank the whole bottle

immediately after his wife was admitted to the IPU the previous week.

Case 1 - Joan

• “Any opioid solution you bring in this house I’ll probably drink.

I mix it with Coke, and it’s awesome. But the tablets are pretty tempting too.”

• The husband further tearfully admitted “Any controlled substances

you bring into this home I will take and use for myself. I love my wife, but I just can’t help myself.”

• You encourage Joan to be admitted to a facility.
• Joan refuses because she knows she has limited time, and wants to

spend her remaining days with her three children (ages 4, 8 and 10).

• Great. What do you do now?

Drug Abuse and Diversion in Home Hospice

• Survey of 371 hospice programs in USA
• A minority of hospices screen family members for risk
• However, they are the most common diverters (80% of cases)
• Nearly half of hospices report med shortages
• When adjusting for agency size, smaller hospices have much higher rates of

diversion

• Lack of opioid disposal in 1/3 of home deaths is a concern
• Our estimates are that annually:
• Opioid medications are left in over 150,000 homes in the U.S. after a hospice death (among

463K hospice home deaths)

• There are 14,193 confirmed cases of drug diversion (among 1.4 million hospice recipients)
• There are 26,713 suspected cases of drug diversion (among 1.4 million hospice recipients)

Case 2 – Dr. Jekyll and Dr. Hyde

• Podunk Memorial Hospital has decided to track opioid prescribing among

their physicians (NPs, PAs)

• Two physicians in particular are outliers in prescribing quantities.
• Dr. Jekyll is the palliative care physician for the hospital.
• “Of course I prescribe a lot of opioids – I’m dealing with seriously ill and dying
• patients. They all have pain and it’s sure not going to get any better!”
• Dr. Hyde is a very busy cardiothoracic surgeon
• “I’m not letting the government [CDC] tell me how to prescribe opioids. Post-

thoracotomy pain is the worst pain imaginable. I stand by my practice and I’m not changing!”

• Awesome. Now what?

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Questions?