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 1
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. 2
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” 3 https://www.youtube.com/watch?v=Er78Dj5hyeI
“This study was NOT evaluating the impact of chronic opioid therapy for chronic pain; their observation had little bearing on the risk of developing addiction with chronic use.” Daniel Tobin, MD 4 NEJM March 14, 1980
Pain? No addiction risk? Go get the opioids!! 5
Uh oh… • Free love, free opioids…. • Increased opioid-induced deaths • From inappropriate prescribing? • From prescription misuse/abuse? • From illicit opioids such as fentanyl? 6
…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) 7 Webmd.com/special-reports/opioids-pain/20180314/opioids-pain?print=true
Finding Middle Ground (black, white, gray?) Is this the responsibility of the palliative care team? 8
These are strategies?? • “We’re an opioid-free practice” • DEA cuts manufacturing limits on opioids • CDC releases guidelines on opioids and chronic pain • When to initiative or continue opioids for chronic pain • Opioid selection, dosage, duration, follow up and discontinuation • Assessing risk, addressing harm with opioid use 9
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 10
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12 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 National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx
13 Promote Leadership Commitment and Culture • Clear direction and support for high-quality pain care, and opioid • Framing as a patient safety issue stewardship • Avoid stigmatizing language Basic • Provide support and resources for • opioid stewardship • Staff education • development of comprehensive, • System point of contact Intermediate evidence-based pain management programs • System metrics and integrated goals • Promote a culture of best practice • Improving EHR for clinical decision opioid prescribing Advanced support • Discourage the stigma of opioid use disorder (OUD) 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 of “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
15 Organizational Policies • Should support the • Interdisciplinary teams (IDT) implementation of multimodal pain • Integrate guidelines management based on the best Basic available evidence • PDMP, risk assessment strategies • Core competencies for IDT • Mitigate risks and harms and tools, patient/ Intermediate family/caregiver/clinician education, support access to • Guidance for types of specialty procedures substance abuse treatment Advanced • Default opioid doses in EHR 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
19 Clinical Knowledge, Expertise, Practice • Develop and promote core • Use activity and function based pain intensity scale competencies in evidence-based • Specify dx, drug, dose, duration and de-escalation for every opioid Rx pain management, including: Basic • Knowledge of nonpharmacologic and nonopioid strategies • Standard risk assessment process • Referral needs • Promote referral network for OUD services Intermediate • Risk assessment • Clinicians should be well-versed in • Develop IDT pain service patient communication techniques. • Standardized naloxone program Advanced 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 0 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% Alarm Symptoms Unarousable 29 23% Shallow breathing 5 4%
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 22 Gourlay DL, Heit HA, Almahrezi A. Pain Medicine 2005
23 Patient and Family Caregiver Education and Engagement • Patient education materials (written, video, • Risks and benefits of therapy; virtual) realistic goal-setting; safe opioid • Informed consent and/or opioid use agreements Basic use; signs drug misuse • Education on co-prescribing of naloxone • Support groups Intermediate • Engage PFACs and peer recovery coaches • Telemedicine consults to improve access Advanced National Quality Partners Playbook: Opioid Stewardship: https://www.qualityforum.org/NQF_Store.aspx
Who is educating the informal caregivers (family members)?
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