Opioid Prescribing: Stemming the Tide

How One Community is Moving to Prevent New Addictions

Amy Giarrusso, MD, SFHM

Our Lady of the Lake RMC

August 16, 2018

• 66% of teens who abuse

prescription pain medication

started for free with leftover pain

medications from a friend or

relative. www.dea.gov

• 4/5 of new heroin users started

out using prescription drugs. www.aasm.org

Attacking the

Opioid Crisis

Opioids for Chronic

pain

Illegal drugs/heroin

etc

Illicit use of prescription

drugs

Opioids for Acute Pain

“Physical dependence

can develop within a

few days”www.CDC.gov/drugoverdose

American Pain Society Guidelines for

Treatment of Post-Surgical Pain (2016)

Acetaminophen and NSAIDs should be routinely used for

post-operative pain as part of multi-modal analgesia.

Site-specific regional anesthesia and spinal analgesia

encouraged when appropriate. DEVLOPMENT OF ERAS

protocols.

Oral opiates are preferred to IV opiates for post-

operative analgesia.

If IV opiates required, PCA recommended.

American Academy of Emergency

Medicine Guidelines on Treatment of

Acute Pain in the ED (2017)

EM Clinicians should make every effort to use non-opioid analgesics and non-pharmacological modalities to relieve pain in the ED.

Oral opioid administration is effective for most patients in the ED who require opioids.

Hydromorphone (dilaudid) use in the ED should be utilized with caution. Morphine is associated with less euphoria and less abuse potential.

“Base assessment of pain on overall accounting of patient status, including functional status, rather than solely on patient reported pain scores.”

American Academy of Emergency

Medicine Guidelines on Discharge

Prescriptions from the ED(2017) Discharge prescriptions should be for short duration (2-3

days in most cases).

Prescriptions for long acting opioids should not be

prescribed from ED environment.

Opioids for chronic pain or acute exacerbation of

chronic pain should not be prescribed in or from ED

setting.

Society Hospital Medicine Inpatient

Prescribing Guidelines (2018)

Use short-acting opioids in hospital for severe pain or moderate pain that has failed non-opioid therapy.

Avoid opioid use if possible/use with caution in age>65, renal/hepatic insufficiency, COPD/OSA, on other CNS depressants (benzos).

Review PMP data prior to prescribing opioids in hospital and on discharge.

Use the oral route of administration whenever possible. IV opioids should be reserved for patients who cannot take food or medication by mouth, patients with malabsorption or in emergent situations.

Pain assessment, goals of therapy should include functional assessment.

What are the common themes for

prescribing in the hospital?

Moving away from the self-reported pain scale and

towards functional pain scale.

Oral opioids preferred to IV.

Maximum of 7 days opiate at discharge; In most cases, 3

will suffice.

Review prescription monitoring program before initiation

of opioids both inpatient at at discharge.

What is Our Community Doing?

BR Health District Task Force on Opioids

Meeting to align opioid prescribing policies from the ED

Sharing information, policy, signage to provide a

consistent message to the community

Developing Non-opioid Clinical Pathways for common

pain complaints to be used city-wide – migraines,

gastroparesis, low back pain, dental pain

Leveraging EMR

Review of current order sets. Provider and nurse

education on PRN and breakthrough pain orders.

Patient info sheet for patients discharged with opiates.

Removal of standing opioid orders from all non-surgical

order sets.

Complex Patient Program - OLOL

Collaborative between ED physicians, hospitalists, social services, ethics department, EMS, insurance company to deliver appropriate, evidence-based care for patients who frequent the ED

Simple criteria = 5 or more ED visits in 6 months; high ED utilizers seem to correlate with high opioid use

Complete review of history, discussion with PCP and patient’s specialists

Send a certified letter explaining program and ask patients to come meet with team and participate in plan development

Plan is scanned into chart and flag to alert ED doc at registration

> 200 patients enrolled; 70% reduction in visits for patients in our program