The Opioid Crisis in Kentucky Doug Oyler, PharmD Director, Office of Opioid Safety UK HealthCare
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
The Opioid Crisis OVERDOSE OUD NAS WORKFORCE INFECTION 2017 70,237 Americans died from a drug overdose. 2018 US Surgeon General issues public health advisory regarding naloxone 2016 2.1 million Americans with opioid use disorder (626,000 with heroin use disorder). Likely underestimated due to multiple factors. 2017 19.3 per 1,000 Kentucky deliveries diagnosed with neonatal abstinence syndrome (NAS). 2017 25% of labor force participation decline due to opioid overprescribing. Half of prime age men not working take prescription pain medicine. 2017 54 of 217 US counties most susceptible to HIV outbreak located in Kentucky. Highest rate of new hepatitis C infections nationally (2008-2015) in Kentucky. page 3
Prescription Opioid Misuse Agency Update, CDC. 2018 Rx Summit, Atlanta. page 4
Understanding the Crisis Jalal, et al. Science 2018;361. page 5
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
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
Marketing US GAO, 2003. page 8
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 1980. page 9
Risk associated with short-term use Shah A. MMWR 2017. page 10
Efficacy of opioid analgesics Cochrane CD002763, CD004324, CD010210. page 11
Efficacy of opioid analgesics Chang AK. JAMA 2017. page 12
Efficacy of opioid analgesics Krebs EE. JAMA 2018. page 13
Opioid Stewardship page 14
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
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
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 2016 2017 2018 2019 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
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
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
UK HealthCare metrics General opioid use page 20
UK HealthCare metrics General opioid use page 21
UK HealthCare metrics High risk use page 22
UK HealthCare metrics High risk use page 23
UK HealthCare metrics Safety page 24
UK HealthCare metrics Pain control page 25
Finding good information ALTO Program https://www.stjosephshealth.or g/home-pagearticles/item/1908-altoalternatives-to-opioids Opioid Stewardship Program Joint Commission Revised Pain Standards https://www.jointcommission.or g/topics/pain_management_sta ndards_hospital.aspx Guideline for Prescribing Opioids for Chronic Pain https://www.cdc.gov/drugoverdose /prescribing/guideline.html NQP Opioid Stewardship Playbook https://www.qualityforum.org/natio nal_quality_partners_opioid_stew ardship_action_team.aspx page 26
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 https://www.jointcommissionjournal.com/article/s1553-7250(18)30088-6/fulltext page 27
Kentucky State-Wide Opioid Stewardship Initiative page 28
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
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
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
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
Baseline Assessment UK HealthCare
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
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
Thank You Doug Oyler, PharmD doug.oyler@uky.edu https://ukhealthcare.uky.edu/opioid-safety page 36