NYSPFP Kickoff. Reducing Adverse Drug Events from Opioids. April 6, 2017

Transcription

1 NYSPFP Kickoff Reducing Adverse Drug Events from Opioids April 6, 2017

2 I have no financial relationships with drug companies, durable medical equipment companies or other for profit entities related to pain therapy. I did create this presentation using data collected with a grant from the Society of Hospital Medicine. I have collaborated with physicians at the Society of Hospital Medicine on some of the slides and continue to mentor other hospitals as a representative of the Society of Hospital Medicine.

3 Learning Objectives Recognize patients at high risk for adverse events Identify common adverse events of opioid medications Review best practices of pain treatment in the hospital Review alternative and emerging treatments for pain

4 Reducing Adverse Drug Events from Opioids Opioid related adverse events, including death: 47% wrong dose medication errors 29% related to improper monitoring 11% related to excessive dosing, drug interactions and adverse drug reactions Joint Commission Sentinel Event Database

5 Identify High Risk Patients Obstructive Sleep Apnea Peri-operative patient Chronic pain Obesity Pulmonary Disease Cardiac Disease Renal Disease Hepatic Disease Substance Abuse Number one risk factor for opioid-induced respiratory depression and failure Increased risk of respiratory depression and hypercarbia/hypoxia due to sedating medications General Anesthesia Opioids Benzodiazepines Others Prevalence is about 7 to 22% About 75% of these patients are undiagnosed

6 Identify High Risk Patients Obstructive Sleep Apnea Peri-operative patient Chronic pain Obesity Pulmonary Disease Cardiac Disease Renal Disease Hepatic Disease Substance Abuse Increased sedation and respiratory depression from opioids Patients with severe hepatic impairment have slower opioid metabolism and accumulation can occur Reduced opioid doses and increasing the interval Patients with a history of ETOH abuse, ascites and evidence of hepatic failure have been shown to have a higher risk of developing respiratory failure in the hospital, adding opioids will compound the risk

7 Identify High Risk Patients Obstructive Sleep Apnea Peri-operative patient Chronic pain Obesity Pulmonary Disease Cardiac Disease Renal Disease Hepatic Disease Substance Abuse Substance Abuse Obtain history of current or past legitimate and illicit substance use Have the right to have pain management Patients with substance abuse currently or history present a pain management challenge Tolerance, withdrawal and addiction behavior complicate the acute pain management Hospital policies needed to help guide treatment of such patients Confirm home dosing, continue home doses unless high risk Examine skin for fentanyl patches

8 Common Adverse Events Adverse Events Constipation Nausea/vomiting Respiratory depression Respiratory arrest Delirium Clinical syndrome marked by a fluctuating acute decline in cognitive function Typical are Hallucinations Disorientation Agitation and/or somnolence Many causes including disease processes, medications including opioids, pain, urinary retention, constipation Treatment is symptomatic and removing insults Doubles mortality Patients often do not return to baseline

9 Common Adverse Events Adverse Events Constipation Nausea/vomiting Respiratory depression Respiratory arrest Delirium Most common side-effect Bowel habits are variable making assessment difficult Necessary to involve the patient in prevention

10 Common Adverse Events Respiratory Depression Aggravation of other disease process (CHF, PNA, PE) CO2 Narcosis Arousal Failure (OSA) Risk of Alarm Fatigue

11 Why is Pain so Painful? High incidence, multiple etiologies Subjective assessments that are patient dependent Varied presentation, varied response to therapy High risk of dependency, often after short term use Manipulation common in dependent patients EHRs and hospital protocols often rigid and unable to adapt More flexible evaluation and response patterns needed Nursing, Physicians, Pharmacy and Patient communication key

12 Reducing Adverse Drug Events from Opioids Goals Always Safe Supportive Culture for staff and physicians Actual number of events in trials is higher than reported Clear communication Scripting/Standing orders/know when to call Re-education for all medical staff regularly

13 What s the Expectation Assess, monitor and treat pain Identify potential and real risks Patient history Medication interactions Monitor for and treat adverse reactions Partner with hospital and system and quality improvement organizations to improve patient safety

14 Respiratory Depression Interventions: Reduce Polypharmacy High Risk Patient Identification Sedation Assessments and Monitoring POSS, EWS, Neuro function SA, 1, 2 are safe 3 or 4 are high risk

15 Pasero Opioid-Induced Sedation Scale 5-point nursing assessment of opioidrelated sedation S = Asleep but easy to arouse Level 1 = Awake and alert Level 2 = Slightly drowsy, easily aroused Level 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Level 4 = Somnolent, minimal or no response to verbal or physical stimulation

16 Pasero Opioid-Induced Sedation Scale S = Asleep but easy to arouse Acceptable; no action necessary; may increase opioid dose if needed Level 1 = Awake and alert Acceptable; no action necessary; may increase opioid dose if needed Level 2 = Slightly drowsy, easily aroused Acceptable; no action necessary; may increase opioid dose if needed Level 3 = Frequently drowsy, arousable, drifts off to sleep during conversation Unacceptable; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory; decrease opioid dose 25 percent to 50 percent or notify prescriber or anesthesiologist for orders; consider administering a non-sedating, opioid-sparing non-opioid, such as acetaminophen or an NSAID, if not contraindicated. Level 4 = Somnolent, minimal or no response to verbal or physical stimulation Unacceptable; stop opioid; consider administering naloxone; notify prescriber or anesthesiologist; monitor respiratory status and sedation level closely until sedation level is stable at less than 3 and respiratory status is satisfactory.

17 Obstructive Sleep Apnea Screening can guide in-hospital pain management and monitoring needs Tools STOP-Bang - highest sensitivity at 96%, but has a low specificity at 16% Over estimates the likelihood of OSA The most widely used screening tool in the pre-operative area System wide screening instituted by SSM in Sept Berlin Questionnaire has better specificity of 35%, lower sensitivity Epworth Sleepiness Scale has lower sensitivity 50% but better specificity at 67%

18 STOP-Bang Screening Test 1. Snoring do you snore loudly? 2. Tired do you often have daytime tiredness, fatigue or sleepiness? 3. Observed has anyone observed you stop breathing while you sleep? 4. Blood Pressure do you have or are you being treated for high blood pressure? 5. BMI > 35 kg/m 2? 6. Age > 50 years? 7. Neck Circumference > 17 in or 40 cm? 8. Gender Male? Three or more of 8 is a positive screen

19 Opioid Classification Phenanthrenes Morphine, codeine, oxycodone, hydrocodone, and hydromorphone Phenylpiperidine Fentanyl and meperidine Diphenylheptanes Methadone Patients with and allergy or metabolism deficiency may benefit from medications in other classes

20 Multimodal Treatment Plans Alternatives Non-opioid pain medications Regional anesthesia Local injection and possibly repeat injection around incision Nerve blocks Gabapentin, pregabalin SNRIs, TCA Muscle Relaxers Capsaicin/Lidocaine cream Physical therapy With therapist and on own in room Mobility is linked to pain relief and decreased risk of adverse events Manipulation Heat/cold packs TENS unit Acupuncture Music therapy

21 Multimodal Treatment Plans Avoid Opioids when: Pelvic pain Fibromyalgia Chronic pain treatment Headaches, migraine Low back pain TMJ disease Irritable Bowel disease Potential presentation for secondary gain or diversion Avoid using in the Hospital Codeine Toxicity a problem. Tramadol Lowers Seizure threshold, drugdrug interactions Meperidine Seizure threshold reduced; accumulates if renal injury Fentanyl Patch Not for acute pain Check patient skin on arrival

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23 Multi-modal Therapy

24 Opioids in the Literature Pain Apr;158(4): Anti-nerve growth factor helpful in mouse models increasing post orthopedic surgery mobility. J Neurosurg Mar 3:1-8 IV ibuprofen reduces pain scores in postsphenoidal surgery by 43% and led to 58% reduction in rescue opioid use. J Surg Res May 1;195(1):61-6 Trend toward less use of morphine in PCA after surgery with Transversus abdominis plane block bilaterally after laparoscopic colectomy. (Overlapping confidence intervals on all interval measures) Nature Sep 8;537(7619): New structurally similar protein that mimics opioid function on μ-opioid-receptor causing analgesia without respiratory depression or dependency Curr Med Res Opin Mar 15:1-8 To evaluate the relative clinical efficacy, safety, and tolerability associated with two noninvasive patient-controlled analgesia (PCA) treatments, sufentanil sublingual tablet system (SSTS) and fentanyl iontophoretic patient-controlled transdermal system (PCTS). These two treatments have recently been approved in the EU for the management of acute moderate-to-severe post-operative pain in adult patients. In the absence of direct head-to-head data, the combination of promising phase III trial results compared to IV morphine PCA, a SLR comparison against other opioid treatments, and the results of this exploratory analysis present a strong rationale in support of SSTS as a key option for management of postoperative pain.

25 Overview of Upcoming Seminars Identify, plan intervention and reduce complication rates for high risk patients Evaluating and Intervene for adverse events early Alternative therapies, reducing provider opioid dependence Safe Opioid Use in the hospital Patient education and Care Transitions

26 Nisbet AT, Mooney-Cotter F. Comparison of selected sedation scales for reporting opioid-induced sedation assessment. Pain Manag Nurs Sep;10(3): Kobelt P, Burke K, Renker P. Evaluation of a standardized sedation assessment for opioid administration in the post anesthesia care unit. Pain Manag Nurs Sep;15(3): Pasero C. Assessment of sedation during opioid administration for pain management. J PeriAnesthesia Nurs Jun;24(3): Chung F, Abdullah H, Liao P. STOP-Bang Questionnaire: A practical Approach to Screen for Obstructive Sleep Apnea. Chest. 2016, 149 (3): * Prescribers Letter. Appropriate Opioid Use. 2016, August 2012 Pasero C, Pain Manag Nurs. 2012;13(2): * Original article published in Anesthesiology, 2008