OPIOID REDUCTION INITIATIVE FOR SURGICAL PATIENTS AT KAISER PERMANENTEDAVID PARSONS, MD

NORTHWEST PERMANENTE PC

MID-WILLAMETTE VALLEY PAIN SUMMIT

SEPTEMBER 22, 2017

HOW BIG IS THIS PROBLEM?

• 2001 JCAHO: Pain is the “fifth vital sign”

• Almost 19,000 people die annually from prescription opioid overdose (a 4 fold

increase over past 15 years).

• Opioid prescriptions per 100 people has quadrupled since 1999.

• 55% of prescription opioid abusers have received pills from friends or family

members.

• 50-85% of heroin abusers began by abusing prescription opioids.

• Post-surgical opioid prescribing is highly variable.

ELDERLY KAISER PATIENT’S MEDICINE CABINET(17 YEAR OLD GRANDSON LIVING NEARBY)

WHERE TO START? MULTIDISCIPLINARY PLANNING SESSION @ KP

• Developed a progressive plan to reduce all patients to MED < 90.

• No new starts of long-acting opioids, including for surgical patients.

• Remove Opana and Oxycontin from formulary.

• Eliminate concurrent opioids and benzodiazepines.

• Set goal of initial prescribing of no more than 2 wks supply post-op opioids.

• Set goal of 45 day limit post-op opioids.

HOW TO ACHIEVE OPIOID REDUCTION?

• Educate surgeons about the problem

• Educate patients about responsible use of opioids and the risks of opioids.

• Change default quantities for post operative prescription orders.

• Use multimodality methods for pain control.

• Report the data

• Reinforce

POST OP OPIOID DEFAULT QUANTITIES

GENERAL SURGERY RECOMMENDATIONSGeneral Surgery Laparoscopic cholecystectomy 25 0

Open cholecystectomy 35 1

Laparoscopic appendectomy 20 0

Laparoscopic Right Hemicolectomy 25 0

Laparoscopic Sigmoid colectomy 25 0

Open colectomy 30 1

Open Low anterior resection 30 1

Laparoscopic gastric bypass 30 0

Lumpectomy 15 0

Lumpectomy with sentinel node dissection 20 0

Simple mastectomy 20 1

Mastectomy with sentinel node dissection 20 1

Modified radical mastectomy 25 1

Bilateral mastectomies 30 1

Open inguinal hernia 25 1

Laparoscopic inguinal hernia 25 0

Laparoscopi Nissen 20 0

Laparoscopic PEH repair 20 0

Hemorrhoidectomy 30 1

lateral internal sphincterotomy 10 0

Fistulotomy (fistula related procedures) 20 1

8

EXAMPLES OF ORTHOPEDIC GUIDELINES

HIP

• THA

• Wean goal: 4-6 weeks

• Initial Rx: Oxy #75

• Refill Rx: Oxy #50

SHOULDER

• Rotator Cuff Repair

• Wean goal: 6 weeks• Possible intermittent

usage: 8-12 weeks• Initial Rx: Oxy #60• Refill Rx: Oxy #50

KNEE

• TKA• Wean goal: 6 weeks• Possible intermittent use:

8-12 weeks• Initial Rx: oxy #120• ≥1st refill Rx (< 6 weeks post op): Oxy #80• >3rd refill Rx (6 - 12 weeks post op): Oxy #50

LONG ACTING OPIOIDS

PAT_MRN_ID rx_name dispense_dt quantity surgery_dt primary_surgeon or_specialty clarity_specialty md_dispense last_md_to_dispense last_md_to_dispense_specialty last_dispense_dt days_dispensed_after_surgery

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/28/2017 15.0000 01/10/2017 Urology Urology Dermatology 02/28/2017 49

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/09/2017 20.0000 08/31/2016 Anesthesiology Anesthesiology Surgery, General 02/09/2017 162

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/27/2017 15.0000 12/14/2016 Ophthalmology Ophthalmology DERMATOLOGY,MOHS-Micrographic Surgery 02/27/2017 75

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/20/2017 30.0000 11/22/2016 Radiology Radiology Surgery, Plastic 02/20/2017 90

xxxx-xx-xx OXYCODONE HCL 100 MG/5ML CON LUPI 02/02/2017 60.0000 12/15/2016 Radiology Radiology Surgery P.A. 02/02/2017 49

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/27/2017 30.0000 01/04/2017 General Surgery Surgery, General Surgery, General 02/27/2017 54

xxxx-xx-xx OXYCODONE/ACETAMINOPHEN 5-325 MG TAB AURO 02/27/2017 30.0000 01/13/2017 General Surgery Surgery, General Surgery, General 02/27/2017 45

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/16/2017 15.0000 10/18/2016 Head and Neck Otolaryngology Dermatology 02/16/2017 121

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/02/2017 8.0000 10/21/2016 Cardiology Cardiology Dermatology 02/02/2017 104

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/23/2017 15.0000 10/12/2016 Neurosurgery Neurosurgery Dermatology 02/23/2017 134

xxxx-xx-xx FENTANYL 72HR 50 MCG/HR DIS MYLA 02/09/2017 10.0000 12/22/2016 Radiology Radiology Surgery, Colon/Rectal 02/09/2017 49

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/01/2017 40.0000 11/28/2016 Spine Surgery, Neurology Neurosurgery P.A. 02/01/2017 65

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/17/2017 60.0000 12/20/2016 Spine Surgery, Neurology Neurosurgery P.A. 02/17/2017 59

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/02/2017 15.0000 09/07/2016 Urology Urology Dermatology 02/02/2017 148

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/21/2017 40.0000 12/29/2016 General Surgery Surgery, General Surgery, Plastic 02/21/2017 54

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/17/2017 50.0000 12/15/2016 General Surgery Surgery, Plastic Surgery, Colon/Rectal 02/17/2017 64

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/22/2017 15.0000 10/15/2016 General Surgery Surgery, General Surgery, General 02/22/2017 130

xxxx-xx-xx FENTANYL 72HR 25 MCG/HR DIS MYLA 02/01/2017 10.0000 10/15/2016 General Surgery Surgery, General Surgery, General 02/22/2017 109

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/23/2017 15.0000 11/03/2016 Ophthalmology Ophthalmology DERMATOLOGY,MOHS-Micrographic Surgery 02/23/2017 112

xxxx-xx-xx MORPHINE SULFATE 100 MG/5ML SOL MALL 02/14/2017 120.0000 09/30/2016 Radiology Radiology Cardiothoracic Surgery 02/14/2017 137

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/25/2017 20.0000 10/04/2016 General Surgery Surgery, General Surgery, Plastic 02/25/2017 144

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/02/2017 20.0000 12/01/2016 General Surgery Surgery, General Surgery, General 02/02/2017 63

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/17/2017 5.0000 09/15/2016 Plastics Surgery, Plastic Surgery, Plastic 02/17/2017 155

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/24/2017 15.0000 12/23/2016 PARSONS, DAVID PAUL General Surgery Surgery, General PARSONS,DAVID P PARSONS,DAVID P Surgery, General 02/24/2017 63

xxxx-xx-xx ACETAMINOPHEN/CODEINE 300-30 MG TAB MALL 02/16/2017 30.0000 09/06/2016 Radiology Radiology, Interventional Surgery, General 02/16/2017 163

xxxx-xx-xx MORPHINE SULFATE 15 MG TAB WEST 02/23/2017 20.0000 09/30/2016 Plastics Surgery, Plastic Surgery, Plastic 02/23/2017 146

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/23/2017 8.0000 11/22/2016 Plastics Surgery, Plastic Surgery, Plastic 02/23/2017 93

xxxx-xx-xx MORPHINE SULFATE 15 MG TAB WEST 02/01/2017 60.0000 10/27/2016 Urology Urology Neurosurgery P.A. 02/01/2017 97

xxxx-xx-xx OXYCODONE/ACETAMINOPHEN 5-325 MG TAB AURO 02/10/2017 30.0000 11/03/2016 Ophthalmology Ophthalmology Surgery, General 02/10/2017 99

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/23/2017 40.0000 12/12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/2017 73

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/16/2017 40.0000 12/12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/2017 66

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/09/2017 60.0000 12/12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/2017 59

xxxx-xx-xx HYDROMORPHONE HCL 2 MG TAB RHOD 02/02/2017 60.0000 12/12/2016 Thoracic Surgery, Thoracic Surgery, General 02/23/2017 52

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/14/2017 25.0000 10/25/2016 Cardiology Cardiology Surgery, General 02/14/2017 112

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/23/2017 60.0000 01/06/2017 Neurosurgery Neurosurgery Neurosurgery 02/23/2017 48

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/21/2017 30.0000 01/06/2017 Neurosurgery Neurosurgery Neurosurgery 02/23/2017 46

xxxx-xx-xx OXYCODONE HCL 5 MG TAB RHOD 02/06/2017 80.0000 12/15/2016 Neurosurgery Neurosurgery Neurosurgery P.A. 02/06/2017 53

xxxx-xx-xx HYDROCODONE/ACETAMINOPHEN 5-325 MG TAB PARP 02/19/2017 50.0000 12/22/2016 Neurosurgery Neurosurgery Neurosurgery P.A. 02/19/2017 59

xxxx-xx-xx ACETAMINOPHEN/CODEINE 300-30 MG TAB MALL 02/08/2017 20.0000 09/12/2016 Orthopedics Orthopaedics Oral & Maxillofacial Surgery Dental 02/08/2017 149

45 DAY OPIOID DATA

0

500

1000

1500

2000

2500

3000

Jan 2016 Feb 2016 March 2016 April 2016 May 2016 June 2016 July 2016 Aug 2016 Sep 2016 Oct 2016 Nov 2016 Dec 2016 Jan 2017 Feb 2017

Opioids Dispensed 45 Days After Surgery

0

2000

4000

6000

8000

10000

12000

14000

16000

18000

20000

# Pills Dispensed per 1000 Surgeries

# Surgeries Pills Dispensed per 1000 Surgeries Linear (Pills Dispensed per 1000 Surgeries)

QUANTITIES OF TABLETS PRESCRIBED TO SURGICAL PATIENTS AT KP

• January 2015: 53,068 tablets prescribed

• November 2016: 32,542 tablets prescribed

• Monthly difference: 20,526 tablets

• Calculated annualized reduction: 246,312 tablets

• Estimated overall cost reduction: $135,000 @$0.54 per tablet)

WHAT NEXT?

• Continue to educate prescribers

• Continue to educate patients.

• Re-evaluate and modify the order sets/preferences

• Study opioid use rates and use data to further adjust script quantities for

common operations.

Wide Variation and Excessive Dosage of Opioid Prescriptions forCommon General Surgical ProceduresMaureen V. Hill, MD, Michelle L. McMahon, BS,y Ryland S. Stucke, MD,and Richard J. Barth Jr., MD

Annals of Surgery Volume 265, Number 4, April 2017

THE CHALLENGE: HOW TO MAKE THIS WORK FOR YOU?