IntroductiontotheNCEDPainManagementGuidelines

April12,2017

OurAgenda

• OverviewofOpioidEpidemic• OurCommitteeEfforts• ReviewofNCEDPainManagementGuidelines• NCHAGrantOverview

2

PollingQuestion

• DoesyourhospitalhaveEDpainmanagementguidelinesinplace?

3

TheOpioidEpidemicDonTeaterMDTeaterHealthSolutions

MeridianBehavioralHealthServicesWaynesville,NCdon@teaterhs.com

4

OpioidFacts

TheUnitedStateshas4.6%oftheworld’spopulation• Weuse80%oftheworldsopioids!1• 83%oftheworld’spopulationhasnoaccesstoanyopioids.

SeyaM-J,Gelders SFaM,Achara OU,Milani B,Scholten WK.Afirstcomparisonbetweentheconsumptionofandtheneedforopioidanalgesicsatcountry,regional,andgloballevels. JPainPalliat CarePharmacother.2011;25(1):6-18.doi:10.3109/15360288.2010.536307.

5

OpioidIncrease

Drugdistributionthroughthepharmaceuticalsupplychainwastheequivalentof96mgofmorphineperpersonin1997andapproximately700mgperpersonin2007,anincreaseof>600%.

Paulozzi LJ,BaldwinG.CDCGrandRounds:PrescriptionDrugOverdoses— aU.S.Epidemic.MMWR.2012;61(1):10-13.

6

Rates of Opioid Overdose Deaths, Sales andTreatment, Admissions,US, 1999-2010.

Year

National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS

National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS

7

https://www.cdc.gov/drugoverdose/data/prescribing.html

8

9

https://www.cdc.gov/drugoverdose/data/statedeaths.html

10

NCOpioidOverdoseDeaths

• 2013– 790• 2014– 913• 2015– 1,110

11

37

28

40

21

37

62

Ibuprofen 200 mg

Acetaminophen 500 mg

Ibuprofen 400 mg

Oxycodone 15 mg

Oxy 10 + acet 1000

Ibu 200 + acet 500

Percent with 50% pain relief

EfficacyofPainMediationsAcutePain

12

TeaterD.EvidencefortheEfficacyofPainMedications.Itasca,Illinois;2014.www.nsc.org/painmedevidence.MooreRA,DerryS,McQuayHJ,Wiffen PJ.Singledoseoralanalgesicsforacutepostoperativepaininadults.CochraneDatabaseSyst Rev.2011;9(9):CD008659.doi:10.1002/14651858.CD008659.pub2.

AcuteRxLeadstoLong-termUseDurationofacuteuse:• 1day- 6%chanceofstillusingthatdrugayearlater• 8days- 13.5%• 31days- 29.9%

13www.cdc.gov/mmwr/volumes/66/wr/mm6610a1.htm?s_cid=mm6610a1_e

14

NCStrategicPlantoReducePrescriptionDrugAbuse

I. PreventionandPublicAwareness

II. Intervention&TreatmentIII. Professionaltrainingand

coordinationIV. Identificationofcoredata

15

OurOpioidStewardshipAdvisoryCommitteeMember Affiliation

StevenJarrett,PharmD MedicationSafetyOfficerCarolinasHealthcareSystem

BridgetBridgman,PharmD,CPPS

Director,MedicationSafetyNovantHealth

ChrisGriggs,MD,MPH EmergencyRoomCarolinas HealthcareSystem

JeffGadsden,MD,FRCPC,FANZCA

Chief,DivisionofOrthopaedic,PlasticandRegionalAnesthesiologyDukeUniversity MedicalCenter

CarolLabadie,PharmD MedicationSafetyOfficerVidantMedicalCenter

BarryBunn,MD EDMedicalDirector/ChiefofStaffVidantEdgecombe Hospital

NancySchanz NCHA,NCQCPSO

DonTeaterMeridianBehavioralHealthServicesTeaterHealthSolutions

16

ReviewofNCGuidelinesforOpioidManagementintheEDChristopherGriggs,MD,MPHDepartmentofEmergencyMedicineCarolinasMedicalCenter

NCGuidelinesforOpioidManagementintheED

• Goal:Balancethedutytotreatpainanddecreasetheriskofopioiddependence,addiction,anddiversionintheemergencymedicinepopulation

• Context:Theincreaseuseofopioidsinthepasttwodecadesformanagementofacuteandchronicpainhasledtoabuse,addiction,anddeathinourcommunities.

• HospitalandEmergencyDepartmentsshouldreviewthisguidelineandcreatehospitalanddepartmentalpoliciesthatimprovepainmanagementwhiledecreasingtheuseofopioids

18

Conceptsrequiredtointerprettheseguidelines:

• Acutepain:Paincausedbytissueinjuryorinflammationthatlastslessthan3months.

• Chronicpain:Painwithoutidentifiabletissueinjuryorlastingpastthetimeofnormaltissuehealing,usuallygreaterthan3months.

• Malignant/Cancerpain:Painresultingfromchronicinflammatoryortissuedestroyingprocess.Examples:Metastaticcancer,sicklecelldisease,cripplingrheumatoidcondition

19

1. Onemedicalprovidershouldprescribeallopioidpainmedicinestotreatapatient’schronicpain.

• Chronicpainisdefinedaspainlastinglongerthan3months

• AccordingtotheCDCguidelinesandmedicalliterature,thereispoorevidencefortheeffectivenessofopioidsintreatingchronicpain.

• Incaseswhereopioidsareusedtotreatchronicpain,onemedicalproviderwithanongoingrelationshipwiththepatientisrequired,whichisnotpossibleintheemergencymedicinesetting.

20

2. EmergencyProvidersshouldusetheirjudgmentandotherresourcestoprovidethebestandsafestcaretopatients.HospitalsshouldsupporttheEP’sdecisionwhenitistheirclinicaljudgmentthatanopioidshouldnotbeprescribedevenifapatienthasrequestedaprescription.

• Thetreatmentofpaindoesnotrequireopioidmedications

• EPsshouldprovidetheirpatientsaplanandstrategiesformanagingpain

21

3. Prescriptionsforacutepain/injuriesshouldbewrittenfortheshortestdurationandlowesteffectivedoseappropriate– nomorethan3daysonaverage.CDCguidelinesrecommendlessthan3daysassufficientformostacutepainandrarelywillmorethan5to7daysofopioidsberequired.

• Acutepainisdefinedbypainrelatedtoinjuredorinflamedtissue.Inmostcasesitlastsdaystoweeksandisexpectedtoresolvebefore3months.

• IfEPsdecidetogiveanopioidprescription,a3dayprescriptionisrecommendedastheaveragestandardprescriptions

22

4. HospitalsandEDsshoulddeveloppoliciestointegratetheuseoftheNCControlledSubstanceReportingSystem(NCCSRS)intoproviderworkflowswhenopioidsareprescribed.Additionally,hospitalsshouldworktointegratetheNCCSRSintocurrenthospitalelectronicmedicalrecordstoprovideefficientreviewofpatientprofileswithouttheneedtorepeatedlyaccessawebportal.

23

5. TheNCCSRSreportshouldbeinterpretedwithintheclinicalcontextofthepatientpresentation.Ultimately,thedecisiontoprescribeopioidsrequirestheprofessionaljudgmentoftheEP,weighingtherisksofabuse,diversion,oraddictionwiththeriskoffailingtotreatseverepain.

24

6. Non-opioidtherapiesshouldbeprioritizedoveropioidanalgesicsinthereliefofacuteandchronicpain.ThisincludestheuseofNSAIDS,acetaminophen,heat/coldtherapy,positionsofcomfort,physicaltherapy,andothermultimodaltherapies.

• Hospitalsandemergencydepartmentsshouldincreaseaccesstoandprioritizeopioidsparingpainmanagementstrategies.

• Theabovelistareexamplesandisnotanexhaustivelistofpossibletherapies.

25

7. Onlyinrarecircumstancesshouldashortprescription(<3days)beprovidedforapatientonchronicopioidtherapyforchronicnon-cancerpain.Thedecisiontoprescribeforthesepatientsshouldoccurincoordinationwiththeprimaryprescriberandinformationregardingtheencountershouldbecommunicatedtotheprimaryprescriberwhenpossible.

• Ideally,patientsinchronicpainshouldnotbeintroducedtoopioidsintheemergencydepartment.

• Shouldapatientmanagedonchronicopioidforchronicpainhaveanexacerbationofpain,ashortcourseofopioidsmayberequiredinrarecircumstances.

26

8. LongactingorextendedreleasenarcoticagentssuchasOxyContin,extendedreleasemorphineorfentanylpatchesshouldonlybeprescribedinconsultationwiththeprimaryopioidprescriber.

• Longactingagentscarryahigherriskofoverdoseandshouldnotbeprescribedfromtheemergencydepartmentwithoutcoordinationoccurringwithaprimaryprescriber.

27

9. Controlledsubstanceprescriptionsthatwerelost,stolen,destroyedorfinishedprematurelyshouldnotbereplaced.EDprovidersshouldnotprovidereplacementdosesofmethadoneorbuprenorphineforpatientsparticipatinginatreatmentprogramwithoutconsultingthetreatmentprogramorprimaryopioidprescriber.

• Replacementdosesofmethadoneshouldonlyoccurinconsultationwithprescribingclinicorprimaryprescriber

• Buprenorphinemaybeusedtostabilizepatientsinacuteopioidwithdrawalintheemergencydepartment.Prescriptionsforoutpatientbuprenorphineshouldonlybeprovidedinconcertwithanoutpatienttreatmentprogramandareplacementdoseshouldonlyoccurwithcommunicationtothepatient’soutpatienttreatingprovider. 28

10. AdministrationofIMorIVopioidsforthereliefofacuteexacerbationsofchronicnon-cancerpainisnotinthepatient’sbestinterestandshouldbediscouraged.

• IMandIVopioidsactfasterthanoralopioidsandcausegreatereuphoriaanddopaminereleaseinthelimbicsystem.Startingwithoralopioidsinpatientsthatrequirefurtheropioidtherapyforchronicpainshouldbeprioritized.

29

11. Patientswhoareidentifiedwithasubstanceusedisorderoratriskforsubstanceusedisordershouldbereferredtoanaddictionprogramorprimarycareproviderforevaluationandtreatment.

• Routinescreeningfortobacco,alcohol,andillicitsubstanceabuseshouldoccurinpatientsyouareconsideringtreatingwithopioids.

• Theabuseofothersubstancesincreasestheriskoflongertermopioiddependenceandabuse.Consideralternativepainmanagementstrategiesinthesespatientsorshortercoursesofopioidsifyoufeeltheyarerequired.

• Allthosewhoscreenpositiveforasubstanceabusedisordershouldbereferredtotreatment. 30

12. Hospitalsandout-patientnetworksshoulddeveloppoliciestocoordinatethecareofpatientswhofrequentlyvisittheEDforevaluationsofacuteexacerbationsofchronicpain.ApatientspecificcareplaninvolvingtheED,hospital,andprovidertreatingthepatient’spain-inducingconditionshouldbedevelopedthatincludespatient-specificpoliciesortreatmentplans,includingreferralsforpatientswithsuspectedprescriptionopioidabuseproblems.

31

13. Patientsprescribedopioidsshouldbecounseledto:a.Knowrisks,sideeffectsandbenefitsofopioiduse,b.Storemedicationssecurely,notsharethemwithothersanddisposeofthemproperlywhentheirpainisresolved,

c.Usethemedicationsasdirectedformedicalpurposesonly,and

d.Avoidusingopioidswithalcohol,sedatives,musclerelaxantsorhypnoticsduetotheriskofoverdose.

• HighriskopioidusersshouldreceiveeducationaboutnaloxoneandaprescriptionfornasalorIMnaloxone.

32

AnotherPollingQuestion…

Whichbestpracticeswillbemostchallengingtoyourfacility?1. Developingfacilitypoliciestointegratethesebestpractices.2. Offeringnon-opioidmulti-modaltherapiestopatients.3. IntegratingtheuseofNCCSRSintoproviderworkflowwhenopioids

areprescribed.4. Referringhighriskpatientsorthosewithsubstanceusedisordersto

theirPCPortreatmentprograms.5. CoordinatingthecareofpatientswhofrequentlyvisittheEDfor

evaluationsofacuteexacerbationsofchronicpain.

33

Resources

34

TheInjuryandViolencePreventionBranchattheDivisionofPublicHealthinpartnershipwiththeNorthCarolinaHospitalAssociationislookingathowtoimprovecarepathwaystopreventpatientsfrom

succumbingtoOpioidAddictionandforthosesufferingwithOpioidUseDisorderatahospitalandhealthsystemlevel.

35

TheCoalitionforModelOpioidPracticesinHealthSystems

Phase1 • CurrentStateAnalysis

Phase2 • ProtocolAlignment

Phase3 • ResourceMapping

Phase4 • ImplementationSupport

36

WhatWillbeInvolved?

Prevention:

• PrescribingPractices

Response:

• Overdose/SubstanceUseDisorderResponse

Diversion:

• Preventionofdiversionbyhealthsystempractitionersandemployees

Systems:

• Hospitalleadership/in-housesystemstomakealloftheabovehappen

37

YourThoughtsandQuestions?

38