Newsletter I N T H I S I S S U E

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1 V O L U M E 1 1. I S S U E NEWS THAT MATTERS TO HOSPICE Making Management of Opioid-Induced Constipation a Smooth Move Heidi Trautwein, RPh, PharmD, CGP, FASCP, Clinical Pharmacist, HospiScript Constipation can be one of the most distressing symptoms for a hospice patient, and with approximately 50% of patients experiencing constipation, this symptom should not be overlooked. 1 Have you noticed the multitude of prescription medications for opioid-induced constipation? Ever wonder what to use first? Let s review opioid-induced constipation and explore the role of laxatives in hospice symptom management. Constipation can contribute to delirium, abdominal pain and distension, and embarrassment. Frequent assessment of bowel function and use of preventative interventions is imperative for patients receiving hospice care. Assess the patient s normal bowel habits and any complications of constipation such as agitation, anorexia, confusion, nausea, pain, and urinary dysfunction on admission and regularly throughout care. 1,2 Patients with constipation may present with abdominal tenderness, bloating, flatulence, and the feeling of incomplete evacuation. 1,2 In addition to discussing symptoms and normal bowel habits with a patient, a physical assessment including listening to bowel sounds, palpating the abdomen, and examining the rectal vault are also important assessment tools in managing constipation. 1,2 The Bristol Stool Scale describes seven types of feces and is a tool for assessing intestinal transit time and changes in stool consistency. 3 This scale can be used to assess severity of constipation. Several factors contribute to constipation including dehydration, immobility, reduced food and fluid intake, and medications (Table 2). 4 Opioids are likely the most prevalent medication-related cause of constipation in the hospice setting. To understand how to treat opioid-induced constipation (OIC), we must first understand how opioids cause constipation. Opioids provide analgesia through activation of the µ-opioid receptors in the central nervous system (CNS) which is comprised of the brain and spinal cord; however, they also exert their effects on peripheral µ-opioid receptors including those in the gastrointestinal (GI) tract. Activation of µ-opioid receptors in the GI tract reduces fluid secretion and H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 1. I S S U E increases water absorption from the colon resulting in hardened stool. Large intestine µ-opioid receptor activation also leads to reduced peristalsis of the bowel. 5 Reduction in GI motility results in hardened stool in up to 90% of patients taking opioids. 1 Prophylactic treatment for OIC should start at initiation of opioid therapy and continue throughout treatment with opioids. Fiber supplements such as psyllium (Metamucil ), polycarbophil (FiberCon ), methylcellulose (Citrucel ) are not recommended for use in patients with OIC. Avoid fiber supplements in OIC due to increased risk of fecal impaction. Other over-the-counter (OTC) medications for constipation are effective and the first step in managing constipation. The gold standard for treating OIC is a combination of stimulant laxative and stool softener such as Senna-S. Senna-S may be titrated to a max dose of 8 tablets per day to manage symptoms. 1 The least invasive route of administration (oral) is recommended however, if swallowing is impaired; bisacodyl rectal suppositories can be an effective alternative to oral stimulant laxatives. For a patient who desires a chewable product, chocolate sennoside tablets (Ex-Lax Chocolate) may be useful in managing symptoms. Once stimulant laxatives are optimized, the addition of an osmotic laxative may be effective in managing symptoms. Osmotic laxatives cause water retention in the stool resulting in increased frequency of bowel movements. Of the osmotic laxatives, sorbitol is more cost effective than lactulose; however, patients may not find either of these palatable in higher doses. Polyethylene glycol 3350 (Miralax ) is a flavorless osmotic laxative, that is mixed in 4-8 ounces of juice, tea or other fluids of patient preference. 6 The fluid Table 1: Bristol Stool Scale 3 STOOL TYPE STOOL DESCRIPTION Continued on page 2 1 Separate hard lumps, like nuts.* 2 Sausage shaped but lumpy.* 3 Like a sausage or snake but with cracks on its surface. 4 Like a sausage or snake, smooth and soft. 5 Soft blobs with clear cut edges. 6 Fluffy pieces with ragged edges, a mushy stool. 7 Watery, no solid pieces. * Type 1 and 2 may indicate constipation EMPOWERING HOSPICE CARE THROUGH INNOVATION TM Newsletter I N T H I S I S S U E Making Management of Opioid-Induced Constipation a Smooth Move Clinical Case Study: Opioid-Induced Constipation In The Spotlight It s Here: 4th Edition Palliative Care Consultant HospiMobile TM 2.0 HospiScript Regional Conference Savannah, GA May 14-15, 2015 Lunch & Learn Teleconferences Register Online! Clinician s Corner: Hospice Item Set (HIS): NQF 1617 Patients Treated with an Opioid who are Given a Bowel Regimen On a Lighter Note Ask HospiScript Sharing information and updates about the HospiScript program The HospiScript Newsletter is a quarterly publication for the clients of HospiScript Services. Articles for publication consideration may be submitted to the attention of the Managing Editor, Kim Konczal (kkonczal@hospiscript.com). The clinical information contained in this newsletter is not medical advice. Health care providers should exercise independent clinical judgment. Some information cites the use of a product in a manner or for an indication other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.

2 Continued from page 1 volume required for use of polyethylene glycol may be difficult for patients to manage. Table 2: Medications Causing Constipation 4 When stimulant and osmotic laxatives have been optimized without sufficient results, medications for refractory constipation should be considered. Table 3 lists the available prescription-only laxative medications. Methylnaltrexone (Relistor ) and naloxegol (Movantik ) are peripherally-acting µ-opioid receptor antagonists (PAMORA) that may be effective if first line agents have been exhausted. 7,8 PAMORA drugs work by blocking the activation of the µ-opioid receptors in the gastrointestinal tract while preserving the activation of µ-opioid receptors in the CNS, maintaining analgesia. 5-7 Consideration of goals of care and current swallowing status is important in determining which µ-opioid receptor antagonist to choose. Methylnaltrexone is given subcutaneously; while naloxegol s oral formulation may be desirable for some. Both methylnaltrexone and naloxegol have an onset of action of under 2 hours. 6-9 Both methylnaltrexone and naloxegol are contraindicated in patients with known or suspected bowel obstruction or for those with an increased risk of recurrent obstruction. 6 Neither will be effective if the patient is not taking opioids. Lubiprostone (Amitiza ) is a chloride channel activator that recently received FDA-approval for OIC in patients with chronic noncancer pain. Lubiprostone acts by enhancing intestinal fluid secretion and motility. 5 Results from clinical trials studying lubiprostone have been somewhat inconsistent. Improvement in constipation in the trials was measured as an increase of at least 1 spontaneous bowel movement over baseline. 9 Patients tend to report higher incidence of nausea with the higher dose of lubiprostone needed for OIC. 6 If patients cannot tolerate the 24mcg twice daily dose, the 8mcg dose is not likely to be effective for OIC and therapy should be changed. When evaluating improvement in OIC related symptoms or quality of life, at least one study found no significant difference between senna and lubiprostone. 10 Finally, Vaseline balls may be effective if a high impaction is suspected. Vaseline balls are pea-sized balls of petrolatum that are rolled in confectioner sugar, or any preferred flavored powder, and swallowed whole. 11 Because docusate is a surfactant that can emulsify mineral oil or petrolatum, discontinue all docusate containing preparations prior to use due to the risk of systemic absorption and toxicity. 11 Oral mineral oil is not recommended due to high risk of aspiration and aspiration pneumonia. 11 Opioid-induced constipation is a distressing symptom frequently experienced by hospice patients. Assessing the patient at initiation of therapy and throughout the course of treatment is imperative in early detection and treatment. Stimulant laxatives plus stool softeners remain the gold standard of treatment and doses should be maximized before adding second line therapies or other adjuvants. Newer agents, such as µ-opioid receptor antagonists, should be reserved for the management of refractory constipation. Analgesics Opioids NSAIDs Antihypertensives Calcium channel blockers Diuretics Clonidine Miscellaneous Amiodarone Cholestyramine Ondansetron Table 3: Drug Initial Dose Route Formulation Osmotic Laxatives Lactulose (Chronulac ) Methylnaltrexone (Relistor ) Naloxegol (Movantik ) Lubiprostone (Amitiza ) Prescription Medications for Constipation 30mL Daily PRN 12mg Daily PRN 25mg QAM on empty stomach Oral solution: 10g/15 ml Clinical Considerations More costly than stimulants with no improved efficacy Associated with increased cramping & flatulence Onset of action, hours Sorbitol is more cost effective, OTC equivalent product with same dosing recommendations P A G E 2 PO Anticholinergics Tricyclic antidepressants Antihistamines Antispasmodics Antipsychotics Chlorpromazine Olanzapine Prochlorperazine Quetiapine Risperidone Peripherally-acting mu-opioid receptor antagonists (PAMORA) Miscellaneous Linaclotide (Linzess ) *AWP=average wholesale price per day based on initial dosage listed. Antiepileptics Phenytoin Carbamazepine Valproate Cation-containing agents Aluminum, Calcium antacids Bismuth subsalicylate Iron supplements AWP/Day* REFERENCES: 1) Davis L. Constipation. In Protus BM, Kimbrel JM, Grauer PA, eds. Palliative Care Consultant: A Reference Guide for Palliative Care. 4th ed. Dublin, OH:HospiScript Services, ) Librach SL, Bouvette M, DeAngelis C, et al. Consensus recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom Manage 2010;40(5): ) O Donnell L, Virjee J, Heaton K. Detection of pseudodiarrhoea by simple clinical assessment of intestinal transit rate. BMJ 1990;300: ) Deepak P, Ehrenpreis E. Constipation. Dis Month 2011;57(9): ) Sharma A, Jamal M. Opioid induced bowel disease: a twenty -first century physicians dilemma. Curr Gastroenterol Rep. 2013;15:334. 6) Lexi-Comp Online. Lexi-Drugs Online. Hudson (OH): Lexi-Comp, Inc. February 18, ) Leonard J, Baker D. Naloxegol: treatment for opioid-induced constipation in chronic non-cancer pain. Ann Pharmacother. 2015;49(3): ) Rhiner M, Ferrell B, Yudin J. Opioid-induced constipation (OIC) in advanced illness patients receiving palliative care when response to laxative therapy has not been sufficient. Home Healthcare Nurse. 2009;27(1): ) Siemens W, Gaertner J, Becker G. Advances in pharmacotherapy for opioid-induced constipation: a systematic review. Expert Opin Pharmacother. 2015;16(4): ) Marciniak C, Toledo S, Lee J, et al. Lubiprostone vs senna in postoperative orthopedic surgery patients with opioid-induced constipation: a double-blind, active comparative trial. World J Gastroenterol. 2014;20(43): ) Tavares C, Kimbrel J, Protus BM, Grauer P. Petroleum jelly (Vaseline balls) for the treatment of constipation: a survey of hospice and palliative care practitioners. Am J Hosp Palliat Med. 2014;31(8): $2.30 SC Injection: 8mg/0.4mL, 12mg/0.6mL Indicated for second line treatment of OIC, after oral stimulant laxatives and suppositories have failed Weight based dosing 0.15mg/kg Onset of action, minutes $86.50 PO Tablets: 12.5mg, 25mg Indicated for treatment of OIC in patients with chronic noncancer pain Drug interactions with CYP3A4 inducers/inhibitors Take on empty stomach at least 1 hour before or 2 hours after meal Do not crush or chew tablets Avoid grapefruit, grapefruit juice $ mcg BID PO Capsules: 8mcg, 24mcg Efficacy may be reduced by methadone Take with food to decrease nausea Indicated for chronic idiopathic constipation or OIC in chronic noncancer pain Do not chew or open capsules $ mcg Daily PO Capsules: 145mcg, 290mcg Take with food to decrease nausea Indicated only for constipation predominant IBS or chronic idiopathic constipation Do not open or chew capsules $11.10

3 Clinical Case Study: Opioid-Induced Constipation Molly Sinert, RPh, PharmD, Clinical Pharmacist, HospiScript Patient: SD, male, age 71 Hospice Diagnosis: Lung cancer, with metastases to bone Chief Complaint: Severe constipation Functional Status: Palliative Performance Scale (PPS) 40% Past Medical History: Benign Prostatic Hyperplasia (BPH), hypertension, anemia History of Present Illness: SD resides in a nursing home. He has gone 6 days without a bowel movement. He received doses of PRN milk of magnesia, followed by PRN bisacodyl (Dulcolax ) suppository 2 days ago. Manual disimpaction today was unsuccessful. SD has reduced oral intake of foods and fluids, but has been compliant with all routine medications, including his bowel regimen, linaclotide (Linzess ) and senna (Senokot ). The nursing home physician has discontinued linaclotide and senna with new orders for methylnaltrexone (Relistor ) 12mg subcutaneous daily until the patient has a bowel movement, then start lubiprostone (Amitiza ) 24mcg PO BID for opioid-induced constipation. Allergies: Penicillin (hives) Current Medications: Acetaminophen (Tylenol ) 325mg 1-2 tablets PO q4h prn mild pain or fever Acetaminophen/Codeine (Tylenol #3 ) mg 1 tablet PO q4h prn moderate to severe pain Bisacodyl (Dulcolax ) 10mg 1 suppository rectally as needed if no result from milk of magnesia Esomeprazole magnesium (Nexium 24 HR ) 22.3mg PO every morning Ferrous sulfate 325mg 1 tablet PO BID Finasteride (Proscar ) 5mg 1 tablet PO daily Hydrochlorothiazide (Microzide ) 25mg 1 tablet PO daily Linaclotide (Linzess ) 145mcg 1 capsule PO daily Lisinopril (Zestril ) 5mg 1 tablet PO daily Milk of magnesia 400mg/5mL, take 30mL PO daily prn constipation Morphine ER (MS Contin ) 15mg 1 tablet PO q12h Naproxen (Naprosyn ) 250mg 1 tablet PO q8h ATC Promethazine (Phenergan ) 25mg 1 tablet PO q6h prn nausea/vomiting Senna (Senokot ) 8.6mg 1 tablet PO BID Tamsulosin (Flomax ) 0.4mg 1 capsule Po daily Pharmacist consultation with the nurse revealed the following: Patient is mainly bed bound and has no trouble swallowing pills BP 136/78 mmhg, pulse 86; no signs of edema Bowel sounds hypoactive Disimpaction was unsuccessful, as RN was only able to scrape off some stool Patient denies nausea/vomiting, but states his belly feels full and that is why he does not eat or drink as much There is recent evidence of dehydration (skin is dry and pulse is higher than normal) Pain has increased all over, so the patient started using more PRN acetaminophen/codeine about 2 weeks ago; prior to that he required only one dose a week on average Linaclotide was started 3 weeks ago, because the patient has had ongoing trouble with constipation Patient has been on Senna 1 tablet PO BID since he started Morphine ER (before hospice admission) Patient refuses enema due to past use resulting in residual diarrhea; type of enema unknown Medication points of discussion: Review all potential causes of constipation, including medications for this patient. Evaluate risk vs benefit of medications that may be contributing to constipation to guide decision-making about the need to continue these medications. Although opioids cause constipation, most patients continue opioid therapy for pain and dyspnea management. In order to provide analgesic effects, codeine requires metabolism to morphine. Some patients may have reduced ability to metabolize codeine, impairing efficacy but still exposing them to side effects like constipation. 1 Optimizing adjuvant analgesics may reduce total opioid intake, thus reducing risk of constipation. Oral corticosteroids can help manage pain related to the patient s bone metastases. 2 Ferrous sulfate is associated with constipation, dark stools, and GI upset, and does not offer palliative benefit making it easy to discontinue without sacrificing comfort. 3 Blood pressure, edema, and hydration status should be regularly assessed, with prompt discontinuation of diuretics when clinically indicated (i.e. hypotensive, no edema present, dehydration). Immobility and dehydration can lead to fecal impaction and bowel obstruction, especially in elderly patients. 4,5 Patient has denied nausea and vomiting; there was no mention of new or significant abdominal pain or cramping, therefore low suspicion of bowel obstruction. Fecal impaction is likely high in the rectum or in the colon based on difficulty reaching stool for manual disimpaction. High impactions can be treated with Vaseline balls. 6 Vaseline balls are frozen pea-sized balls of white petrolatum coated with a powder for taste (cocoa powder, fruit juice powder, powdered sugar). They function to lubricate the lower GI passageway and soften the stool. Discontinue docusate-containing products during therapy with Vaseline balls. Although methylnaltrexone and lubiprostone are approved to treat opioid induced constipation, they are not first-line options 3 Stimulant laxatives can overcome reduced intestinal motility caused by opioids, and the addition of a stool softener can make it easier for stool to pass. 7 Senna (stimulant) and docusate (stool softener) is the preferred first-line regimen to manage opioid-induced constipation. 8 Consider osmotic laxatives if additional therapy is needed once senna and docusate are optimized. Sorbitol is more cost effective than lactulose although palatability may be difficult with either sorbitol or lactulose. 8 Reserve methylnaltrexone or lubiprostone as second-line therapy if the patient has not responded to preferred treatments and all causative factors have been addressed. 8 Pharmacist and case manager agreed on the following plan to discuss with the attending physician: 1) Discontinue linaclotide as per patient s attending physician. 2) Discontinue medications contributing to constipation: ferrous sulfate, hydrochlorothiazide, and acetaminophen/codeine. 3) Non-pharmacological management: a) Encourage oral hydration and/or foods with high water content as tolerated (e.g., fruits, soups, yogurt). b) Encourage low-impact exercise as tolerated in bed or chair, or abdominal massage. 4) Acute impaction (recommend the following in place of methylnaltrexone): a) Increase plain senna to 2 tablets PO BID, then increase by 1 tablet per dose every day there is no bowel movement (maximum 4 tablets PO BID). b) Initiate Vaseline balls 3-6 balls swallowed whole daily until a bowel movement occurs. 5) Chronic prevention (recommend the following in place of lubiprostone): a) Once patient has the first bowel movement, discontinue plain senna and Vaseline balls. b) Initiate senna-docusate 2 tablets PO BID, may titrate gradually up to 4 tablets PO BID if necessary. c) If senna-docusate is not effective alone to prevent opioid-induced constipation, add sorbitol 15mL PO daily and titrate as necessary. 6) Pain management a) Replace acetaminophen/codeine with morphine immediate release (20mg/mL) 5mg PO/SL q2h prn pain or dyspnea. b) Replace naproxen with dexamethasone 4mg PO QAM to improve pain and breathing, and reduce overall opioid needs. REFERENCES: 1) Smith, HS. Opioid Metabolism. Mayo Clin Proc. 2009;84(7): ) Weinstein E, Arnold R. Steroids in the treatment of bone pain #129. J Palliat Med. 2010;13(7): ) Lexi-Comp Online. Lexi-Drugs Online. Hudson (OH): Lexi-Comp, Inc. March 12, ) Librach SL, Bouvette M, DeAngelis C, et al. Consensus recommendations for the management of constipation in patients with advanced, progressive illness. J Pain Symptom Manage. 2010;40(5): ) National Cancer Institute. Gastrointestinal Complications: Impaction. National Institutes of Health. HealthProfessional/page3. March 12, ) Tavares CN, Kimbrel JM, Protus BM, Grauer PA. Petroleum jelly (Vaseline balls) for the treatment of constipation: a survey of hospice and palliative care practitioners. Am J Hosp Palliat Med. 2014;31(8): ) Thomas J. Opioid-induced bowel dysfunction. J Pain Symptom Manage. 2008;35: ) Davis L. Constipation. In Protus BM, Kimbrel JM, Grauer PA, eds. Palliative Care Consultant: A Reference Guide for Palliative Care. 4th ed. Dublin, OH:HospiScript Services, H O S P I S C R I P T N E W S L E T T E R V O L U M E 1 1. I S S U E P A G E 3 EMPOWERING HOSPICE CARE THROUGH INNOVATION TM

4 IN THE SPOTLIGHT Palliative Care Consultant 4th Edition The 4th Edition It s here! Order the Palliative Care Consultant 4th Edition online today, and have it shipped directly to your door. ORDER AT HospiScript.com/books REGISTER TODAY! REGISTRATION INCLUDES BOOK CHOICE Retail Price $69.99 Regional Conference VISIT FOR DETAILS Retail Price $79.99 Retail Price $24.99 May 14-15, 2015 Historic Savannah, Georgia Marriott Savannah Riverfront Special thanks to Patron Sponsor Hands of Hope, a Division of Hospice Care of South Carolina Free for HospiScript Clients Free Publication Choice PCC 4th Edition, Pediatric PCC or Wound Care Adult & Pediatric Sessions Free Continuing Education Credits P A G E 4

5 Lunch & Learn Teleconference Programs Schedule Enhancing Patient Care through Education Register Online Today! HospiScript strives to meet your educational needs. Every month, HospiScript hosts teleconferences on topics of special interest to hospice staff. All HospiScript clients are encouraged to participate free of charge. Continuing Education Credits are also available for a nominal processing fee. To register, please visit and click on the Educate, Event Registration link. MAY 2015 JUNE 2015 JULY 2015 Navigating the Market: New Medications & Implications for Hospice & Palliative Care Stacey Rexrode, PharmD, CGP; HospiScript Wednesday 05/06/15 3:00 PM ET Thursday 05/07/15 10:00 AM ET Don t Lose Sleep Over It! Medication Management in Sleep Disturbances in End of Life Care Elizabeth Miles, PharmD; HospiScript Wednesday 06/03/15 3:00 PM ET Thursday 06/04/15 10:00 AM ET Don t Let the Management of Depression at the End of Life Get You Down Marliese Gibson, PharmD; HospiScript Wednesday 07/01/15 3:00 PM ET Thursday 07/02/15 10:00 AM ET Caring Across Cultures: Providing Healthcare to Diverse Patients & Families Donna Skurzak, MA, LSW, CDP; Cleveland Clinic Wednesday 05/20/15 3:00 PM ET Thursday 05/21/15 10:00 AM ET Live Discharges: The Regulations with Case Studies Jennifer Kennedy, RN, MA, BSN, CHC; National Hospice & Palliative Care Organization (NHPCO) Wednesday 06/17/15 3:00 PM ET Thursday 06/18/15 10:00 AM ET My Brother s Keeper: Caring for Vulnerable Patients at the End of Life Jean O Leary-Pyles, BASW, MSW, LISW-S; OhioHealth Hospice Wednesday 07/22/15 3:00 PM ET Thursday 07/23/15 10:00 AM ET CLINICIAN S CORNER: Hospice Item Set (HIS): NQF 1617 Patients Treated with an Opioid who are Given a Bowel Regimen Bridget McCrate Protus, RPh, PharmD, MLIS, CGP, CDP, Director of Drug Information, HospiScript Opioids are commonly used for management of moderate to severe pain; constipation is a common opioid adverse effect. Clinical studies demonstrate that opioid-related constipation is a significant problem in adults of all ages using opioids for cancer-related pain or chronic non-cancer pain. 1 Severe constipation may cause patients to access hospital emergency departments even in the last 6 months of life. 2 Tolerance to the constipating effects of opioids is not developed; therefore, preventive laxative therapy is necessary for most patients. 1 Additionally, patients in hospice care frequently have limited mobility and dehydration, further contributing to the risk of constipation. Centers for Medicare & Medicaid Services (CMS) and the National Quality Forum (NQF), as well as other patient advocacy organizations, consider effective symptom management to be a hallmark of quality hospice care. Hospices are now required to report data for patient admissions for 7 quality measures, also known as the Hospice Item Set (HIS). These include measures on screening and assessment of pain and dyspnea, preferences for life sustaining treatment, discussion of religious/spiritual concerns, and patients treated with opioids who are prescribed a bowel regimen. The quality measure concerning opioids and bowel regimens (NQF 1617) describes the percentage of adult hospice patients treated with an opioid that are offered or prescribed a bowel regimen. 3,4 To meet this quality measure, when opioids are initiated, orders for a bowel regimen should be in place unless there is documentation in the patient s chart that a bowel regimen is not needed. CMS has clarified that comfort care kits including opioids, delivered to the patient s home, are considered on standby and not initiated until the hospice instructs the patient or caregiver to begin using the treatment for the relevant symptom. 5 Patients with standby orders for opioids are not included in the NQF 1617 measure; in other words, orders for a bowel regimen are not required until the patient actually begins using the opioid. CMS has not yet determined what the benchmark percentage indicator will be for NQF Based on patient medication profiles, just over 77% of patients cared for by HospiScript partners have both an opioid and a laxative in place. We recommend incorporating the HospiRxMonitor report, Opioids No Laxatives into your patient discussions during your interdisciplinary group meetings. Contact your account manager for assistance in accessing HospiRxMonitor. For more information on HIS requirements, please visit the Hospice Item Set (HIS) portion of the CMS Hospice Quality Reporting Program website at Instruments/Hospice-Quality-Reporting/. REFERENCES: 1) McNicol E, Horowicz-Mehler N, Fisk R, et al. Management of opioid side effects in cancer-related and chronic noncancer pain: a systematic review. J Pain. 2003;4(5): ) Barbera L, Taylor C, Dudgeon D. Why do patients with cancer visit the emergency department near the end of life? CMAJ 2010;186(2): Available at pmc/articles/pmc /pdf/ pdf. 3) Centers for Medicare & Medicaid Services (CMS). Hospice Quality Reporting. Hospice Item Set (HIS). Current Measures. Baltimore, MD: CMS, 03/09/2015. Available at Reporting/Current-Measures.html. Accessed March 16, ) National Quality Forum (NQF). Patients treated with an opioid who are given a bowel regimen (Rand). Washington, DC: National Quality Forum, 04/17/2014. Available at forum.org/qps/qpstool.aspx. Accessed March 16, ) Centers for Medicare & Medicaid Services (CMS). Hospice Item Set (HIS): Quarterly Questions and Answers. October Baltimore, MD: CMS, 02/18/2015. Available at Quality-Reporting/Hospice-Item-Set-HIS.html. P A G E 5

6 Communications is a key element in how HospiScript informs you about educational information, special programs and important news alerts. We want to hear from you! You can take the survey by visiting Ask HospiScript The Ask HospiScript column shares information and updates about the HospiScript program for our clients. Please forward your comments or questions to info@hospiscript.com. Does HospiScript provide an e-prescribing solution? e-prescribing Solution Yes. HospiScript has teamed up with DrFirst to offer their state-of-theart e-prescribing solution to HospiScript clients. DrFirst and HospiDirect allow nurses to notify physicians of prescription needs while allowing physicians the convenience of prescribing from anywhere! No more emergency fills. No more locating a fax machine in the middle of the night. The efficiency of electronic medication orders streamlines the processes saving time and money. HospiScript understands the unique challenges our hospice clients face with ever changing regulations and, the having to do more with less reality. We are delighted to offer this easy to use, award winning software to our hospice clients at a reduced rate. Please contact your Account Manager for more information. P A G E 6