opioid prescribing: stemming the tide · acute pain in the ed (2017) em clinicians should make...
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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