6/6/2017. First Do No Harm SECTION 1 THE OPIOID CRISIS. Implementing an Opioid Stewardship Program in a HealthCare System OBJECTIVES

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1 First Do No Harm Implementing an Opioid Stewardship Program in a HealthCare System Phil Chang, MD Kristy Deep, MD Doug Oyler, PharmD June 12, 2017 OBJECTIVES Explain the role of opioid stewardship as a target intervention to combat the opioid epidemic. List key members and initiatives of an opioid stewardship program. Describe means to foster buy-in from prescribers and hospital administration to sustain an opioid stewardship program. SECTION 1 THE OPIOID CRISIS 1

2 MMWR 2016; 64: How Did This Happen? Aggressive law enforcement & stigmatization of addiction Successful pharmaceutical marketing D.A.R.E. Emphasis on pain control Opioid Epidemic Accessibility of heroin US/foreign economic factors Intractable pain laws Up to 40% of patients at risk of diversion/ dependency Inj Prev 2016; doi /injuryprev PLoS One 2013; 8: e Addiction 2010; 105: JAMA 2016; 315: Drug Alcohol Depend 2013; 132: J Hand Surg Am 2012; 37: J Urol 2011; 185: JAMA Dermatol 2013; 149: PLoS One 2016; 11: e

3 TREATMENT TREATMENT 6/6/2017 SECTION 2 PILOT PROGRAM A New Way of Thinking; A New Way of Prescribing Gabapentin, clonidine NSAIDs, acetaminophen WEAN Extended-release opioids Short-acting opioids Intravenous opioids A New Way of Thinking; A New Way of Prescribing Short-acting opioids Gabapentin, clonidine, muscle relaxants, regional techniques Non-pharmacologic, NSAIDs, acetaminophen WEAN 3

4 Milligram Morphine Equivalent 6/6/2017 Patient Engagement Set Goals & Expectations There is pain management beyond opioids Not going to get your pain to zero Educate About Risks Side effects and harms Public health campaigns SECTION 2.1 OUR RESULTS Median Discharge MME Pre- and Post-Intervention Overall* Opioid Naïve Patients* Opioid Tolerant Patients** 2013 (N=489) 2015 (N=424) *p<0.001 **p=

5 Percent 6/6/2017 Opioid Prescriptions No Opioid on Discharge ER/LA Opioid Used* *p<0.001 SECTION 3 OPIOID STEWARDSHIP: BUILDING A FOUNDATION What is Stewardship? CID 2016: 62: e

6 Antibiotics Generally effective when used appropriately Not effective for viral illness Risk of acute complications to patient (e.g., C. difficile, ADRs) Risk of MDRO in society Opioids Generally effective when used appropriately Not effective for chronic pain Risk of acute complications to patient (e.g., overdose, dependence) Risk of large-scale drug abuse & dependence in society Developing Metrics Inpatient utilization of opioids (e.g., daily MME) Discharge opioid prescriptions, MME, and quantities Naloxone prescriptions on discharge High-risk patients created (e.g., concomitant benzodiazepines) Utilization of non-opioids Pain control Patient satisfaction Building a Team Physician (lead) Pharmacist (lead) Nurse leaders Pain management Patient education Medication safety Data analysts & statisticians Information technology 6

7 Percent of Responses 6/6/2017 Opioid Stewardship: Understand Variable No. (%) Attending Physician 152 (41.9) Resident Physician 67 (18.5) Pharmacist/Resident Pharmacist 98 (27.0) Advanced Practice Provider (APRN, PA) 46 (12.7) Medicine as primary specialty 145 (39.9) Surgery as primary specialty 90 (24.8) Opioid Stewardship: Understand Variable No. (%) Opioids used too commonly at our 224 (61.7) institution Opioids are similarly effective to other 160 (44.1) analgesics Opioids are more dangerous than other 321 (88.4) analgesics Most of my patients would be receptive to 147 (40.5) using non-opioid analgesics Opioid Stewardship: Understand 70 I Feel Pressure to Prescribe Opioids to INPATIENTS from Patients Staff Senior MDs Other teams Institutional guidelines National guidelines No pressure Other 7

8 Percent of Responses Percent of Responses 6/6/2017 Opioid Stewardship: Understand 50 I Feel Pressure to Prescribe Opioids ON DISCHARGE to/because of Facilitate discharge Reduce follow up Institutional guidelines National guidelines No pressure Other Opioid Stewardship: Understand 60 I Need Help With... (No. = 358) Converting opioids Tapering opioids Using non-opioids Discussing risks of opioids Managing acute on chronic pain (inc. MAT) Question: What is the Biggest Barrier You Face? Barrier Category No. of Responses Patient satisfaction/entitlement/buy-in 74 Managing patients already on or addicted to 43 opioids/other drugs Patients inappropriately prescribed opioids by 24 other providers Lack of specialist resources 17 Lack of a unified plan between prescribers 15 within my institution Staff buy-in/lack of knowledge 15 8

9 Opioid Stewardship: Educate Discuss the dangers of opioids with prescribers and patients Discuss the role of opioids in acute & chronic pain management Evaluate alternative analgesics, including nonpharmacologic SECTION 3 OPIOID STEWARDSHIP: SUSTAINING MOMENTUM Prescribing Opioids Safely Develop plans for transition off acute opioids Avoid long-acting opioids & concomitant benzodiazepines Remind patients about safe disposal of unneeded medications Utilize PDMP data & evaluate for misuse Naloxone for high risk patients Advocate comprehensive approaches to pain management 9

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11 Keys to Success Survey the landscape Involve multiple disciplines and key stakeholders, and coordinate Provide support, not restrictions Identify low-hanging fruit early Develop metrics of interest and track routinely Impact on Institutional Goals Institutional Goal Patient satisfaction (e.g., HCAHPS) Safety/mortality Throughput Regulatory compliance Physician engagement Metric/Initiative Improve patient education regarding pain management Develop new communication tools for providers Track & reduce naloxone use inpatient Improve naloxone prescribing in compliance with CDC guidelines Improve patient education regarding medication use Reduce opioid-related complications (e.g., ileus) Align prescribing practices with new and established legislation (e.g., KY HB 333) Survey attitudes and orient goals toward responses Obtain buy-in & provide support Moving Forward: Partnerships Across the State 11

12 Summary The current opioid crisis is the result of multiple complex factors, a key one of which is liberal prescribing Multidisciplinary opioid stewardship programs can function to curb prescriptions but are one of many necessary interventions Most providers are aware of the issue, but it requires a cultural shift and more physician empowerment Stewardship is doable, but requires intentional effort to involve key stakeholders Contact Information Phillip.Chang@uky.edu KristyDeep@uky.edu Doug.Oyler@uky.edu 12