Opioid & Pain Management in the In-Patient Setting J. L. Epps, - PowerPoint PPT Presentation

Opioid & Pain Management in the In-Patient Setting J. L. Epps, MD Chief Medical Officer 1

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Why Do Physicians Overprescribe? • How Physicians Were Trained • Lack of knowledge – How many pills most patients actually take to relieve postoperative pain – Percentage of opioid naïve patients who remain on narcotics 1 year after surgery • Inconvenience – Patient – Provider 4

Doctor’s Do Not Treat Pain Effectively A Lost Middle Ground: Pain Management Has Evolved From Undertreatment to Overreliance and Overtreatment 1980s 1998 2016 Pain is established as a “fifth “Today, more Americans die Published studies and letters vital sign.” Consistent pain posit that opioids do not carry because of drug overdoses than significant risks for adverse management guidelines that because of car crashes, and most events or addiction 1,2 rely on opioids are created 3,4 of these overdoses involve some form of opioid” 5 -US Surgeon General References: 1. Porter J et al. N Engl J Med . 1980;302(2):123. 2. Portenoy RK et al. Pain . 1986;25(2):171-186. 3. Pain as the 5th Vital Sign Toolkit . Washington, DC: Dept of Veterans Affairs; 2000. 4. Federation of State Medical Boards of the United States, Inc. http://www.fsmb.org/Media/Default/PDF/FSMB/ Advocacy/pain_policy_july2013.pdf. Accessed March 3, 2017. 5. Murthy VH. Public Health Reports. 2016;131:387-388.. 5

Common Surgeries Create a Surplus of Opioids That Flood the “Market” Proportion of patients taking half or less of prescribed opioid pills 1 Outpatient upper extremity surgery 2 C-SECTION THORACIC SURGERY ► ~ 300 patients, with 92% reporting adequate pain control ► Usually received 30 narcotic pills ► >50% took pain pills for 2 days or less ► Consumed an average of 11 pills per patient 83% 71% Almost 5000 leftover tablets Initiation of short-term opioid therapy may lead to long-term use References: 1 . Bartels K et al. PLoS ONE . 2016;11(1):e0147972 . 2. Rodgers J et al. J Hand Surg Am . 2012;37(4):645-650. 6

Postsurgical Opioid Utilization Can Lead to Chronic Use Patient aged ≥65 years with an opioid Patients 1 year after surgery 1 prescription 7 days postsurgery 2 18% 44% 33% 10% of opioid-naïve increased chance of all patients remained on patients were of becoming a were still opioids still using long-term using opioids 1 year later narcotics opioid user Postsurgical Opioid Utilization Can Lead to Chronic Use 7 References: 1 . Wang M et al. Spine J. 2013; 13(9):S6-S7. 2. Alam A et al. Arch Intern Med . 2012;172(5):425-430.

Drug Source 8

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Pain Management: Standardization in the Midst of an Opioid Epidemic Pain Scale Use of Sedation Scales – Emphasis on function Escalation of Nursing or Patient Concerns –“Something’s not right!” Pathways: Impact in Cerner – For pain orders imbedded in Mandatory Attending Evaluation Disease/Procedural Pathway: Minimal Morphine Milligram Equivalents Change – Common language of “how much” – Guidance established for inexperienced On-Site Drug Disposal Receptacle clinicians via two new Pain Pathways – Secure and Responsible Drug Disposal Act 2014 – Experienced Clinicians (Hospitalists) using Decreasing the Number of Opioid Pills General Medicine Pathways essentially Prescribed unaffected Standardized Management of IV Drug Use – – Multi-modal (Non-narcotic Options) easier Associated Infections to access in Computerized Physician – Plan of Care Order Entry – Withdrawal Management – Pain Flow Sheet – Addiction treatment “3 Strikes…You’re Out (Evaluate)” – Guidance for expected responses for both nursing and physicians established Red Flags – Prompt to identify the Accurate Diagnosis and treat the CAUSE of the pain 12

Expected Pain Level: Pathway Orders in CPOE 1. Pain Non-Narcotic Pathway 2. Pain Low Narcotic Pathway 3. Pain High Narcotic Pathway 4. Pain Individualized Pathway 5. Pain Orders in Procedural / Disease Pathways 13

Pathway: Pain Meds Summary Common language for how much narcotics are administered! 14

Standardization of Pain Control Drug 2016 2018 %Decrease Lortab 8.2 7.4 10% Percocet 13.5 11.9 12% Morphine IV 48.2 31.3 35% Dilaudid IV 4.0 2.8 30% * Opioid Doses per patient • Believed to be result of multi-modal analgesia & increased use of regional anesthesia • Use of Ofirmev has decreased 15

Unexpected Financial Benefit: IV Acetaminophen (Ofirmev) • UTMC received a 35% Year Drug Spend 2017 Ofirmev $1,259,826 volume discount 2018 Ofirmev $603,100 • 2019 projected use based 2019 Ofirmev $318,088 upon July – Dec 2018 (Projected) data • 2019 volume discount decreased to 33% 16

IV Lidocaine • Multiple studies have confirmed the benefits of perioperative IV lidocaine infusions including decreases in pain scores, analgesic consumption, and side-effects with improvements in ERAS outcomes • Common practice at UTMC in specific patient populations e.g. colectomy & renal colic 17

TN Together Impact Percentage of Opioid Prescriptions Exceeding 7 Day Supply vs Equal to 3 Days or Less 2018 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 18

19 Pain Scale • The Pain Scale incorporates patient functional abilities • This will ideally help the patient to score their pain more accurately with a reference point 19

Pain Scale • Previous process mandated nursing reassessment if pain scale was < 4 • In patients with chronic pain and scores, the pain assessment flow sheet would sometimes show the pain score going from 8 to 0 in patients whose baseline pain was never less than 6 • Pain assessment process was revamped to a baseline based upon function 20

Sedation Scale: UTOSS • Prevention of respiratory arrest from excessive opioid administration or patient sensitivity is best predicted by the degree of sedation Level State Guideline S Sleeping, easy to arouse No action; increase opioid if needed 1 Awake & alert No action; increase opioid if needed 2 Drowsy, easy to arouse No action; increase opioid if needed Unacceptable; Decrease opioid 25 – 50%; notify 3 Frequently drowsy MD; consider non-narcotics until SS improves 4 Somnolent; minimal Unacceptable; stop opioid; consider naloxone; response to stimuli notify MD 21

UTOSS Impact • No adverse or sentinel events due to opioid induced respiratory depression since UTOSS instituted on our medical or surgical floors 22

Red-Flags • If pain management therapies are unsuccessful, there may be an underlying complication which is resulting in their pain • Don’t just treat the pain score, treat the CAUSE of the pain • Consider the following questions (Red-Flags) when evaluating the patient’s pain Is pain outside the expected location? Is pain out of proportion to the diagnosis? Is something ‘just not right?’ 23

Three Strikes!!!: An Example 72 y.o. female with a fractured femur awaiting surgery tomorrow morning after a fall following admission for syncope evaluation • Provider selects Drug and Dose from Pathway • Nurse tries Prescribed Therapy • Not Effective (no PAIN RED FLAG present) = STRIKE 1 → RETRY • Nurse re-tries next available ordered dose • Not Effective (or PAIN RED FLAG present) = STRIKE 2 → ESCALATE • Nurse escalates to provider • Provide pain score UTOSS and vital signs • Provider determines proper escalation strategy • Not Effective (or PAIN RED FLAG present) = STRIKE 3 → EVALUATE • Nurse calls provider to evaluate using script • Provider further evaluates the situation – Additional Hx, repeat PE, review or order new Dx Testing 24

25 Communication Script The communication script outlines the information the provider will need in order to determine an appropriate escalation strategy for the patient in the event previous therapies have been unsuccessful. 1. This is [45 y.o. male] admitted with [kidney stones]. 2. Now complaining of [abdominal pain]. 3. Pain score is [7] 4. He has received [Lyrica] and [4 mg morphine] with [no] relief. 5. Sedation score is [2]. Vital Signs are [xxxxx] 6. Has [no or 1-3] Red Flags . 7. How would you like me to proceed? 25

PACT At The University of Tennessee Medical Center, patient safety and quality care are our top priorities. If you have concerns about your care or the care of your loved one, the PACT offers an additional safety net to ensure you receive compassionate and excellent care. 26

TJC 2018 Guidelines • “Kick Start Your Hospital’s Program To Reduce Opioid-Induced Ventilatory Impairment ” – Ongoing assessment of pain should not solely be based on numeric (1 – 10) scales & should include functional criteria – Every patient receiving opioids should have regular nursing assessments of the level of sedation at appropriate intervals including after dosing of an opioid – Standardized handoffs & communicate 27

Drug Use Associated Infections 28