OPIOID REDUCTION INITIATIVE FOR SURGICAL PATIENTS AT KAISER PERMANENTE

Transcription

1 OPIOID REDUCTION INITIATIVE FOR SURGICAL PATIENTS AT KAISER PERMANENTE DAVID PARSONS, MD NORTHWEST PERMANENTE PC MID-WILLAMETTE VALLEY PAIN SUMMIT SEPTEMBER 22, 2017

2 HOW BIG IS THIS PROBLEM? 2001 JCAHO: Pain is the fifth vital sign Almost 19,000 people die annually from prescription opioid overdose (a 4 fold increase over past 15 years). Opioid prescriptions per 100 people has quadrupled since % of prescription opioid abusers have received pills from friends or family members % of heroin abusers began by abusing prescription opioids. Post-surgical opioid prescribing is highly variable.

3 ELDERLY KAISER PATIENT S MEDICINE CABINET (17 YEAR OLD GRANDSON LIVING NEARBY)

4 WHERE TO START? MULTIDISCIPLINARY PLANNING KP Developed a progressive plan to reduce all patients to MED < 90. No new starts of long-acting opioids, including for surgical patients. Remove Opana and Oxycontin from formulary. Eliminate concurrent opioids and benzodiazepines. Set goal of initial prescribing of no more than 2 wks supply post-op opioids. Set goal of 45 day limit post-op opioids.

5 HOW TO ACHIEVE OPIOID REDUCTION? Educate surgeons about the problem Educate patients about responsible use of opioids and the risks of opioids. Change default quantities for post operative prescription orders. Use multimodality methods for pain control. Report the data Reinforce

6 POST OP OPIOID DEFAULT QUANTITIES

7 GENERAL SURGERY RECOMMENDATIONS General Surgery Laparoscopic cholecystectomy 25 0 Open cholecystectomy 35 1 Laparoscopic appendectomy 20 0 Laparoscopic Right Hemicolectomy 25 0 Laparoscopic Sigmoid colectomy 25 0 Open colectomy 30 1 Open Low anterior resection 30 1 Laparoscopic gastric bypass 30 0 Lumpectomy 15 0 Lumpectomy with sentinel node dissection 20 0 Simple mastectomy 20 1 Mastectomy with sentinel node dissection 20 1 Modified radical mastectomy 25 1 Bilateral mastectomies 30 1 Open inguinal hernia 25 1 Laparoscopic inguinal hernia 25 0 Laparoscopi Nissen 20 0 Laparoscopic PEH repair 20 0 Hemorrhoidectomy 30 1 lateral internal sphincterotomy 10 0 Fistulotomy (fistula related procedures) 20 1

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9 EXAMPLES OF ORTHOPEDIC GUIDELINES HIP THA Wean goal: 4-6 weeks Initial Rx: Oxy #75 Refill Rx: Oxy #50 KNEE TKA Wean goal: 6 weeks Possible intermittent use: 8-12 weeks Initial Rx: oxy #120 1 st refill Rx (< 6 weeks post op): Oxy #80 >3rd refill Rx (6-12 weeks post op): Oxy #50 SHOULDER Rotator Cuff Repair Wean goal: 6 weeks Possible intermittent usage: 8-12 weeks Initial Rx: Oxy #60 Refill Rx: Oxy #50

10 LONG ACTING OPIOIDS

11 45 DAY OPIOID DATA PAT_MRN_ID rx_name dispense_dt quantity surgery_dt primary_surgeon or_specialty clarity_specialty md_dispense last_md_to_dispense last_md_to_dispense_specialty last_dispense_dt days_dispensed_after_surgery xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/28/ /10/2017 Urology Urology Dermatology 02/28/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/09/ /31/2016 Anesthesiology Anesthesiology Surgery, General 02/09/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/27/ /14/2016 Ophthalmology Ophthalmology DERMATOLOGY,MOHS-Micrographic Surgery 02/27/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/20/ /22/2016 Radiology Radiology Surgery, Plastic 02/20/ xxxx-xx-xx OXYCODONE HCL 100 MG/5ML CON LUPI 02/02/ /15/2016 Radiology Radiology Surgery P.A. 02/02/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/27/ /04/2017 General Surgery Surgery, General Surgery, General 02/27/ xxxx-xx-xx OXYCODONE/ACETAMINOPHEN MG TAB AURO 02/27/ /13/2017 General Surgery Surgery, General Surgery, General 02/27/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/16/ /18/2016 Head and Neck Otolaryngology Dermatology 02/16/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/02/ /21/2016 Cardiology Cardiology Dermatology 02/02/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/23/ /12/2016 Neurosurgery Neurosurgery Dermatology 02/23/ xxxx-xx-xx FENTANYL 72HR 50 MCG/HR DIS MYLA 02/09/ /22/2016 Radiology Radiology Surgery, Colon/Rectal 02/09/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/01/ /28/2016 Spine Surgery, Neurology Neurosurgery P.A. 02/01/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/17/ /20/2016 Spine Surgery, Neurology Neurosurgery P.A. 02/17/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/02/ /07/2016 Urology Urology Dermatology 02/02/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/21/ /29/2016 General Surgery Surgery, General Surgery, Plastic 02/21/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/17/ /15/2016 General Surgery Surgery, Plastic Surgery, Colon/Rectal 02/17/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/22/ /15/2016 General Surgery Surgery, General Surgery, General 02/22/ xxxx-xx-xx FENTANYL 72HR 25 MCG/HR DIS MYLA 02/01/ /15/2016 General Surgery Surgery, General Surgery, General 02/22/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/23/ /03/2016 Ophthalmology Ophthalmology DERMATOLOGY,MOHS-Micrographic Surgery 02/23/ xxxx-xx-xx MORPHINE SULFATE 100 MG/5ML SOL MALL 02/14/ /30/2016 Radiology Radiology Cardiothoracic Surgery 02/14/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/25/ /04/2016 General Surgery Surgery, General Surgery, Plastic 02/25/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/02/ /01/2016 General Surgery Surgery, General Surgery, General 02/02/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/17/ /15/2016 Plastics Surgery, Plastic Surgery, Plastic 02/17/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/24/ /23/2016 PARSONS, DAVID PAUL General Surgery Surgery, General PARSONS,DAVID P PARSONS,DAVID P Surgery, General 02/24/ xxxx-xx-xx ACETAMINOPHEN/CODEINE MG TAB MALL 02/16/ /06/2016 Radiology Radiology, Interventional Surgery, General 02/16/ xxxx-xx-xx MORPHINE SULFATE 15 MG TAB WEST 02/23/ /30/2016 Plastics Surgery, Plastic Surgery, Plastic 02/23/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/23/ /22/2016 Plastics Surgery, Plastic Surgery, Plastic 02/23/ xxxx-xx-xx MORPHINE SULFATE 15 MG TAB WEST 02/01/ /27/2016 Urology Urology Neurosurgery P.A. 02/01/ xxxx-xx-xx OXYCODONE/ACETAMINOPHEN MG TAB AURO 02/10/ /03/2016 Ophthalmology Ophthalmology Surgery, General 02/10/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/23/ /12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/16/ /12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/09/ /12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/ xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/02/ /12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/14/ /25/2016 Cardiology Cardiology Surgery, General 02/14/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/23/ /06/2017 Neurosurgery Neurosurgery Neurosurgery 02/23/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/21/ /06/2017 Neurosurgery Neurosurgery Neurosurgery 02/23/ xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/06/ /15/2016 Neurosurgery Neurosurgery Neurosurgery P.A. 02/06/ xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN MG TAB PARP 02/19/ /22/2016 Neurosurgery Neurosurgery Neurosurgery P.A. 02/19/ xxxx-xx-xx ACETAMINOPHEN/CODEINE MG TAB MALL 02/08/ /12/2016 Orthopedics Orthopaedics Oral & Maxillofacial Surgery Dental 02/08/

12 Opioids Dispensed 45 Days After Surgery Jan 2016 Feb 2016 March 2016 April 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

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14 20000 # Pills Dispensed per 1000 Surgeries # Surgeries Pills Dispensed per 1000 Surgeries Linear (Pills Dispensed per 1000 Surgeries)

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16 QUANTITIES OF TABLETS PRESCRIBED TO SURGICAL PATIENTS AT KP January 2015: November 2016: Monthly difference: Calculated annualized reduction: Estimated overall cost reduction: 53,068 tablets prescribed 32,542 tablets prescribed 20,526 tablets 246,312 tablets per tablet)

17 WHAT NEXT? Continue to educate prescribers Continue to educate patients. Re-evaluate and modify the order sets/preferences Study opioid use rates and use data to further adjust script quantities for common operations.

18 Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures Maureen V. Hill, MD, Michelle L. McMahon, BS,y Ryland S. Stucke, MD, and Richard J. Barth Jr., MD Annals of Surgery Volume 265, Number 4, April 2017

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20 THE CHALLENGE: HOW TO MAKE THIS WORK FOR YOU?