The Opioid Crisis in Kentucky. Doug Oyler, PharmD Director, Office of Opioid Safety UK HealthCare

Transcription

1 The Opioid Crisis in Kentucky Doug Oyler, PharmD Director, Office of Opioid Safety UK HealthCare

2 Discuss the role of opioid prescribing in creating and sustaining the crisis Describe components and initiatives of an opioid stewardship program Outline the Kentucky Statewide Opioid Stewardship key components and draft standards Objectives Physicians today are providing the leadership to help end the nation s opioidrelated overdose and death epidemic. As medical professionals, we go where the evidence leads us. page 2

3 The Opioid Crisis OVERDOSE OUD NAS WORKFORCE INFECTION ,237 Americans died from a drug overdose US Surgeon General issues public health advisory regarding naloxone million Americans with opioid use disorder (626,000 with heroin use disorder). Likely underestimated due to multiple factors per 1,000 Kentucky deliveries diagnosed with neonatal abstinence syndrome (NAS) % of labor force participation decline due to opioid overprescribing. Half of prime age men not working take prescription pain medicine of 217 US counties most susceptible to HIV outbreak located in Kentucky. Highest rate of new hepatitis C infections nationally ( ) in Kentucky. page 3

4 Prescription Opioid Misuse Agency Update, CDC Rx Summit, Atlanta. page 4

5 Understanding the Crisis Jalal, et al. Science 2018;361. page 5

6 Aggressive legislation & stigmatization of addiction Emphasis on pain control D.A.R.E. Marketing Opioid Crisis Accessibility of heroin & fentanyl US/foreign economic factors Understanding the Crisis The Role of Prescribing page 6

7 Marketing PAIN TREATMENT Pain is undertreated, and patients are suffering unnecessarily. OPIOID EFFICACY Opioids are the most effective analgesics. OPIOID SAFETY Concerns about opioid-related adverse events are unfounded. page 7

8 Marketing US GAO, page 8

9 Patients with legitimate pain won t become addicted Patients who appear addicted are suffering from untreated pain/pseudoaddiction Prescribers who do not use opioids have opiophobia Extended release preparations are safer Less than 1% of patients will become addicted based on a landmark study Opioid Safety and Efficacy Porter J. NEJM page 9

10 Risk associated with short-term use Shah A. MMWR page 10

11 Efficacy of opioid analgesics Cochrane CD002763, CD004324, CD page 11

12 Efficacy of opioid analgesics Chang AK. JAMA page 12

13 Efficacy of opioid analgesics Krebs EE. JAMA page 13

14 Opioid Stewardship page 14

15 Building a stewardship program Answering the 5 Ws WHO WHAT WHEN WHERE WHY Prescribers Nurses Pharmacists Quality/safety Patient experience Informatics Pain management Leadership What metrics are you trying to change? How retrievable is EMR data? Do you use EPCS? Can you do internal data analysis? What is actually meaningful? What is the culture at your institution? Is there a perceived need? Inpatient or outpatient? Start with a select group of motivated providers? Emergency department? Start with meeting Joint Commission standards, but set goals specific to your institution. page 15

16 Our roadmap to change UK HealthCare Optimize opioid use, dose, duration Enhance non-opioid analgesia Effective pain management with less harm Understand patient expectations & hospital culture Increase prescriber knowledge page 16

17 Our timeline for change UK HealthCare Committee Formed October 2016 Acute Pain Guidelines August 2017 KORE Partnership October 2017 State-University Partnership July 2018 KY SOS Launch May 2019 OCT JAN APR JUL OCT JAN APR JUL OCT JAN APR Provider Survey April 2017 Tableau Built October 2017 Service Pilots Launched February 2018 Nonpharm Pilot Launched October 2018 Collaboration with MCCAN January 2019 page 17

18 57% Reduction in patients receiving high-risk regimens 1,300 Opioid prescriptions avoided annually 250,000 Fewer opioid pills dispensed Data & Metrics UK HealthCare page 18

19 Building a stewardship program Identifying the right metrics GENERAL OPIOID USE Daily MME Opioid-free patients Opioid-free days Opioid continuation Opioid cessation HIGH RISK USE Opioids + benzos Over 50/90 MME New start opioids ER/LA products SAFETY Naloxone use Opioid-ADE POSS Scores Naloxone co-rx PAIN CONTROL Pain scores HCAHPS page 19

20 UK HealthCare metrics General opioid use page 20

21 UK HealthCare metrics General opioid use page 21

22 UK HealthCare metrics High risk use page 22

23 UK HealthCare metrics High risk use page 23

24 UK HealthCare metrics Safety page 24

25 UK HealthCare metrics Pain control page 25

26 Finding good information ALTO Program g/home-pagearticles/item/1908-altoalternatives-to-opioids Opioid Stewardship Program Joint Commission Revised Pain Standards g/topics/pain_management_sta ndards_hospital.aspx Guideline for Prescribing Opioids for Chronic Pain /prescribing/guideline.html NQP Opioid Stewardship Playbook nal_quality_partners_opioid_stew ardship_action_team.aspx page 26

27 Guidance regarding goals and metrics Three key interventions 1. Keep opioid-naïve patients opioid-naïve (if possible) 2. Encourage safe use and monitoring of opioids when indicated 3. Comprehensive and compassionate care for patients with OUD page 27

28 Kentucky State-Wide Opioid Stewardship Initiative page 28

29 Kentucky State-Wide Opioid Stewardship (KYSOS) Provide hospitals & health systems with guidance and incentive to implement an state-specific opioid stewardship strategy customized to their population. page 29

30 KYSOS leadership structure Program Manager Nancy Galvagni Advisory Committee Project Support Hospital CEOs CMOs & CNOs ED & Psychiatric MDs Opioid Safety Patients & Families Data Mgmt Staff Support page 30

31 KY SOS implementation timeline Phase 1 February-September 2019 Develop commitment form Finalize advisory committee Finalize metrics Begin regional training sessions Implement process measures Phase 2 October 2019-September 2020 Implement outcome measures Continued support of sites Finalize and validate reporting structure Phase 3 October 2020 & Beyond Dissemination of results Ensure sustainability Collaboration with HIIN page 31

32 Committed Community outreach Naloxone protocol Operational Committed + Guidelines for inpatient opioid use Exceptional Operational + Compliance reporting with guidelines Opioid stewardship committee Monitors metrics Provides nonpharm analgesia Guidelines for outpatient opioid use Guidelines/ ALTO in ED Guidelines/ ERAS in PACU/OR Support for DATA2000 waiver training External data reporting Drug takeback program in place Example Process Measures Patient & provider education Tapering resources available page 32

33 Baseline Assessment UK HealthCare

34 Opportunity Scores Item Not Implemented Considering Partially Implemented Fully Implemented Opportunity Score Committee presence 2 (8%) 4 (16%) 9 (36%) 10 (40%) 31 EPCS 0 (0%) 6 (24%) 7 (28%) 12 (48%) 31 Data monitoring 9 (36%) XXX 6 (24%) 10 (40%) 33 Metrics established 2 (8%) 4 (16%) 12 (48%) 7 (28%) 32 Provider education 1 (4%) 5 (20%) 15 (60%) 4 (16%) 38 ERAS 5 (20%) 5 (20%) 11 (44%) 5 (20%) 42 Outpatient guidelines 16 (64%) XXX 5 (20%) 4 (16%) 53 Community outreach 4 (16%) 8 (32%) 8 (32%) 4 (16%) 56 Nonpharmacologic pain treatment 4 (16%) 9 (36%) 10 (40%) 2 (8%) 58 Inpatient guidelines 19 (76%) XXX 3 (12%) 3 (12%) 60 ALTO 4 (16%) 13 (52%) 6 (24%) 2 (8%) 70 page 34

35 Opioid prescribing continues to contribute to the national crisis Stewardship programs can play a role in reducing inappropriate opioid use KYHA is launching a statewide opioid stewardship effort Summary page 35

36 Thank You Doug Oyler, PharmD page 36