The Role of the Pharmacist in Postoperative Pain Management: Strategies to Help Combat the Epidemic

The Role of the Pharmacist in Postoperative Pain Management: Strategies to Help Combat the Epidemic Presented By: Cheryl Genord, R.Ph. B.S.Pharm Clinical Pharmacy Specialist

Learning Objectives Describe how opioids prescribe for acute postoperative pain has contributed to the opioid epidemic. Identify strategies used for successful and safe discontinuation of prescription opioid following surgery. 2015 2

The Opioid Epidemic 3

SOURCE: National Center for Health Statistics, National Vital Statistics System, mortality data (http://www.cdc.gov/nchs/deaths.htm). SUGGESTED CITATION: Rossen LM, Bastian B, Warner M, Khan D, Chong Y. Drug poisoning mortality: United States, 1999 2016. National Center for Health Statistics. 2017. (Available from: https://www.cdc.gov/nchs/data-visualization/drug-poisoning-mortality/).

Opioid Use Disorders in Michigan 2015 Overdose Deaths In Michigan 1257

Michigan 2016 County RX per 100 pts. 2016 RX per 100 pts. 2006 RX % Increase since 2006 Calhoun 120.4 105.24 14% Grand Traverse 103 136.87-25% Ingham 71.7 69.47 1% Iosco 153.4 115.61 31% Kalamazoo 72.4 83.62-14% Kent 75.5 72.8 3% Mason 124.5 127.79-3% Muskegon 126.7 120.28 5% Newaygo 116 87.8 32% Ostego 150.2 114.1 31% Van Burren 112.8 75.92 48% In 2016, 11 million RX written for opioid 1.1 RX or 84 pills for every Michigan resident.

How did post-operative prescribing help fuel the opioid epidemic 13

Discharge Prescriptions Pain control is essential to recovery Decrease Length of Stay and effort to accelerate post op recovery Increase in Ambulatory Surgeries Pharmaceutical companies marketing opioids for surgical pain with little concern for addiction or persistent opioid use Maximize patient satisfaction/ Decrease work for office staff / physician OVER PRESCRIBING 2015 14

Overprescribing & No guidance on opioids New Persistent opioid use Increase opioids in reservoir Possibility of withdrawal after use of opioids for acute pain Substance Use Disorders 16

From: Incidence of and Risk Factors for Chronic Opioid Use Among Opioid-Naive Patients in the Postoperative Period JAMA Intern Med. 2016;176(9):1286-1293. doi:10.1001/jamainternmed.2016.3298 Date of download: 4/11/2018 Copyright 2016 American Medical Association. All rights reserved.

Risk factors associated with persistent opioid use Preoperative tobacco use Alcohol or Substance Use Disorder Mood disorders Anxiety Preoperative pain disorder: Back pain Neck pain Arthritis Centralized pain 19

Overprescribing & No guidance on opioids New Persistent opioid use Increase opioids in reservoir Possibility of withdrawal after use of opioids for acute pain Substance Use Disorders 21

Systemic review of 6 studies 810 patients Surgeries: orthopedic, thoracic, obstetric, and general surgical procedures 67-92% Pts reported unused opioids 42-71% Opioid tablets that went unused 75% Did not store opioids safely 4-30% Plan to dispose of opioids 2015 22

Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults From: Medication Sharing, Storage, and Disposal Practices for Opioid Medications Among US Adults JAMA Intern Med. 2016;176(7):1027-1029. Copyright 2016 American Medical Association. All rights reserved. JAMA Intern Med. Published online June 13, 2016. doi:10.1001/jamainternmed.2016.2543

In the US, 5.3M young adults had SUDs in 2015; 15.3% or 1 in 7 young adults Source: 2015 National Surgery on Drug Use and Abuse

Survey 1151 young adults -2015 Results obtained were statistically valid (95% confidence level) to +/- 2.8%

70 Source of prescription Opioids Among Past-Year Non-Medical Users Chart Title 60 50 40 30 20 10 0 Any 1-29 30-99 100-199 200-365 Given by a friend or relative for free Prescribed by physician(s) Stolen from a friend or relative Bought from a friend or relative Bought from a drug dealer or other stranger Other Jones JAMA Internal Medicine May 2014 Volume 174, Number 5

Overprescribing & No guidance on opioids New Persistent opioid use Increase opioids in reservoir Possibility of withdrawal after use of opioids for acute pain Substance Use Disorders 27

Patient on epidural Fentanyl infusion after surgery at 24mcg/hr. PS>3 4 hr after DC pt experienced agitation, restlessness, profuse sweating, muscle aches BP 170/110 and HR was 105 Pt receive fentanyl 50mcg IVx2 - signs of withdrawal improved Epidural was tapered down gradually over 12 hours by reducing rate 6 mcg/hr every 3 hours. Symptoms did not return. 2015 28

68 year old consulting firm president had 9 hour back surgery. Outpatient RX: Hydromorphone 2 tab q4hprn- which she took close to full dose for 2 weeks about 28mg/day = about 75mg oxycodone/day Received no guidance on tapering off Hydromorphone. She tapered off herself and went into withdrawal nervousness, nausea, diarrhea, vomiting, muscle pains, headache, Surgeon and PCP did not recognize her symptoms as withdrawals 2015 29

Downward Spiral of not recognizing withdrawal after hospital discharge Patient has surgery and discharged with oxycodone Patient has significant pain and uses oxycodone After the pain began to subside and non-opioid are sufficient. Stops using the oxycodone. But after discontinuing the oxycodone, patient reports feeling terrible, experiencing body aches, restlessness, and insomnia. Takes another oxycodone and feels better. Continued treating withdrawal systems with oxycodone, versus using it for pain. Don t want to stop taking opioids, even after pain subsides. 2015 30

Overprescribing & No guidance on opioids New Persistent opioid use Increase opioids in reservoir Possibility of withdrawal after use of opioids for acute pain Substance Use Disorders 31

Michigan-OPEN (Opioid prescribing engagement network) 32

Chronic Opioid Use/Opioid Diversion DECREASE RESERVOIR Decrease the amount of opioids dispensed. Decrease the amount of opioids consumed. Increase the amount of opioids destroyed 33

Strategies used for opioid de-escalation Provider Based Multimodal analgesia Guidelines Patient Based Education on Tailor prescribing to individualized patient s utilization Procedure Based Evidence based prescribing by surgery 34

Multi-modal Strategies Pre-op Intra-op Post-op Decrease/minimize preop opioids Ketorolac, Ketamine, etc. Cryotherapyice, cooler, wrap Set Expectations Pain is part of recovery process Brief opioid education Field block or regional block Cognitive Behavioral Therapy, Meditation Offer self-management strategies: Meditation, Music, Aromatherapy, Personal coping strategies 2015 CAM music, aroma, distraction, healing touch Weaning strategy Discharge instructions, wean by MME 35

Multimodal Therapy Short Acting Opioids NSAIDs and APAP Anticonvulsants NO Sedatives hypnotics Least amount of weeks possible Most surgeries 1 week To Pain Management or Addiction Specialist if can t ween NO Extended Release/Long Acting Opioids Order as scheduled not prn Administer 4 times daily and give at same time. For Neuropathic pain Benzos, Ambien 36

Probability of Opioid Prescription Refilling After Surgery: Does Initial Prescription Dose Matter? Refills: Quantity does not predict Refills N=26,520 Optum Insight Clims data Sekhri S, Arora NS, Cottrell H, Baerg T, Duncan A, Hu HM, Englesbe MJ, Brummett C, Waljee JF, Ann Surg 2017 2015 37

Probability of Opioid Prescription Refilling After Surgery: Does Initial Prescription Dose Matter? No, then what did matter? Patient factors correlated with the probability of refill: tobacco use [odds ratio (OR) 1.42, 95% confidence interval (CI) 1.23-1.57] anxiety (OR 1.30, 95% CI 1.15-1.47) mood disorders (OR 1.28. 95% CI 1.13-1.44) alcohol or SUD (OR 1.43, 95% CI 1.12-1.84) arthritis (OR 1.21, 95% CI 1.10-1.34) 2015 38

Patient Satisfaction: HCAHPS Prescribing Lee JS, Hu HM, Brummett CM, Syrjamaki JD, Dupree JM, Englesbe MJ, Waljee JF. JAMA May 16, 2017

Pharmacy Initiatives on Provider-Based Strategies Develop multimodal pain management in the hospital AND when patients are discharge Education of Clinicians on multimodal therapy and opioids reductions

Department of defense military health system opioid naïve patient for 8 common surgeries Over 200,000 patients mean prescription length 2005-2014 Surgery Appendectomy and cholecystectomy Inguinal Hernia Repair Hysterectomy Mastectomy ACL repair and Rotator Cuff repair Discectomy Median Presciption Length 4 days 5 days 4 days 5 days 5 days 7 days 2015 42

Laparoscopic Cholecystectomy 43

Michigan-OPEN recommendations 46

N=51 Received education about expected pain, treatment options and adverse effects of options. Patients decided how many oxycodone tablets they wanted 0-40 tablets 47

Pharmacy Initiatives on Procedure-Based Strategies Help standardize opioid amount prescribed Share Decision Making Intervention

Strategies used for opioid de-escalation Provider Based Multimodal analgesia Guidelines Patient Based Education on tailor prescribing to individualized patient s utilization Procedure Based Evidence based prescribing by surgery Add Shared Decision Making 49

Development/Counseling on a Opioid Exit Plan Multimodal FIRST non opioids and nonpharmacologics Opioid Taper Physician support and commitment Side Effects and treatment Safe Storage and Disposal of opioids

2015 52

2015 53

Opioid Taper Regimens - Standard Taper for specific surgery GYN Laparoscopic Hysterectomy #15 oxycodone for 4 days Multimodal base - Schedule: APAP; NSAIDs etc. Non medication: Ice, heat, rest, exercise, etc. Oxycodone taper: Day 1: 1-2 tabs q6hprn no more than 6 tab per day Day 2: 1 tabs q6hprn no more than 4 tab per day Day 3: 1 tabs q6hprn no more than 3 tab per day Day 4: 1 tabs q6hprn no more than 2 tab per day 54

Standard GYN Exit Plan 2015 55

Opioid Taper Regimen Individualize taper for more complicated patient and/or surgery Multimodal base scheduled non-opioids APAP, NSAIDS, Adjuvants, Muscle Relaxants, etc. Non medication: Ice, heat, rest, exercise, etc. Calculate last 24 hours opioid requirement prior to discharge. Base the drug, dose, and amount of opioids prescribed at discharge on this requirement. Individualize a taper from this prescription based on how long the pain usually last from this surgery. 56

Individualized Taper: Neurosurgery expected to have pain requiring opioids for 10 days Opioid requirement in last 24 hours prior to discharge: 40mg of oxycodone, administered as 10mg four times. Oxycodone 5mg 1-2 tabs q6h prn #50 Day 1-2 Day 3-4 2 tabs q6h prn up to 8 tabs per day 1-2 tab q6h prn up to 6 tabs per day Day 5-7 1 tab q6h prn - up to 4 tabs per day Day 8-10 1 tab q6h prn - up to 2 tabs per day 57

Individualized Exit Plan 2015 58

Post discharge ambulatory clinic Assessment Pain Dehydration Ileus Surgical Site Infection Goals: Decrease readmits Decrease ER visits Adherence to Opioid Exit plan 2015 59

Encourage Opioid Disposal Police Stations and Big Red Barrel National Take Back Days April and October Opioid Disposal Systems 60

Opioid Disposal System Program Given free to every St. Joseph Ann Arbor, Chelsea, and Livingston patient who has an acute pain opioid prescription. 61

Pharmacy Initiatives on Patient Based Strategies Development of Post-surgical pain discharge plan Patient education of the Post surgical discharge plan Multimodal pain management Opioid exit plan Involvement in Ambulatory Post discharge clinic Encourage opioid disposal

Questions? 63