THA Leadership Summit 2017

Transitioning to an Opioid-Light Emergency Department

Julie Bennett, PharmD, BCPS ED Pharmacy Lead

Dawn Waddell, PharmD, BCPS Clinical Pharmacy Manager

Baptist Memorial Hospital - Memphis

Background

• Rate of overdose deaths in Tennessee = 22 per 100,000

people

– MVAs = 14.7 per 100,000

• Tennessee ranked #2 in nation for opioid-related deaths

– 1186 deaths (2016); ~73% of total overdose deaths

– ~85% involve prescription opioid

• More opioid prescriptions than people in TN! – 1.14 prescriptions per capita (2016)

• CDC initiative to decrease opioid addiction

– Includes improving prescribing patterns to decrease exposure

Overdose Deaths in Tennessee

Majority of Overdoses involve Opioids

7,636,112 Opioid Prescriptions in TN (2016) 1.14 times our population!

CDC Vital Signs July 2017

CDC Recommendations

Emergency Department as First Opioid Exposure

Association of emergency department opioid initiation with recurrent opioid use. Hoppe J, Kim H, Heard K. Ann Emerg Med. 2015; 65: 493-499. • Retrospective evaluation of 4,801 patients treated in ED for acute painful

condition • 52% considered opioid-naïve

– 31% (n=775) of opioid-naïve received and filled opioid prescription – 12% (n=299) went on to recurrent use at 1 year follow up – Adjusted OR 1.8 (1.3-2.3) versus patients who did not receive opioid prescription at

ED visit

Emergency department prescription opioids as an initial exposure preceding addiction. Butler M et al. Ann Emerg Med. 2016; 68: 209-212. • Cross-sectional study of 59 patients with reported heroin or non-medical

opioid use • 59% (n=35) reported first opioid exposure by legitimate medical

prescription • 29% (n=10) reported first opioid exposure through ED

Baptist Memorial Hospital - Memphis: Opioid-Light Emergency Department Initiative

How we Started (January 2017)

• Physician Champion – Dr. Marilyn McLeod, ED Medical Director

• Collaboration with Swedish Medical Center, Denver CO – Piloted Opioid-Reduction program in their ED

– Pharmacist co-chaired CO American College of Emergency Physicians Opioid Task Force

– Developed and implemented opioid-alternative pathways

– Work currently being spread throughout CO

• Baseline data collection

Multi-Disciplinary Approach

• Pharmacy developed Opioid-Light order set – 5 pathways

• Migraine • Musculoskeletal • Renal colic/ kidney stones • Abdominal pain • Extremity fracture/ joint dislocation

– Approved by ED Service Line and P&T Committees – Built into CPOE and went live March 2017 – Adjusted pharmacy stock in ED to provide easy access to alternatives

• Nursing/Pharmacist/Provider education • Administrative support

– Concerns expressed by providers regarding patient satisfaction and opioid medications

– Pledged support for providers to take best care of patients even if means withholding opioids and potential patient complaints

Opioid-Light Order Set

• Goals: To utilize multi-modal non-opioid approaches as fist line therapy and educate our patients • Opioids as second line treatment

• Opioids as rescue medication

• Discuss realistic pain management goals with patients

• Discuss addiction potential and side effects with using opioids

• Multi-modal medications • Often more successful as able to target various

receptors: • Sodium, Calcium, NMDA, GABA, Serotonin, Dopamine

• Greater analgesia with lower doses and fewer side effects

Migraine/Headache • Immediate/First-line Therapy

– 1 L 0.9% NS + high-flow O2 – Ketorolac 15 mg IV – Metoclopramide 10 mg IV – Dexamethasone 8 mg IV – Trigger-point injection lidocaine 1%

• Alternative Options – APAP 1000 mg PO + ibuprofen 600 mg PO – Sumatriptan 6 mg SC – Promethazine 12.5 mg IV or Prochlorperazine 10 mg IV – Haloperidol 5 mg IV – Magnesium 1 g IV – Valproic acid 500 mg IV – Propofol 10-20 mg IV bolus

• Tension Component – Cyclobenzaprine 5 mg or diazepam 5 mg PO/IV – Lidoderm transdermal patch

Musculoskeletal

• Non-IV Options – APAP 1000 mg PO + Ibuprofen 600 mg PO – Cyclobenzaprine 5 mg or diazepam 5 mg PO/IV – Lidoderm transdermal patch – Gabapentin 600 mg PO – Ketamine 50 mg IN – Trigger point injections lidocaine 1%

• IV Therapy Options – Ketamine 0.2 mg/kg IV + 0.1 mg/kg/hr gtt – Ketorolac 15 mg IV – Dexamethasone 8 mg IV – Diazepam 5 mg IV

Extremity Fracture / Joint Dislocation

• Immediate/First-line Therapy

– APAP 1000 mg PO

– Ketamine 50 mg Intranasal

– Nitrous oxide (titrate up to 70%)

• Ultrasound-Guided Regional Anesthesia

– Lidocaine 0.5% perineural infiltration (max 5 mg/kg)

Renal Colic / Kidney Stones

• Immediate/First-line Therapy

– APAP 1000 mg PO

– Ketorolac 15 mg IV

– 1 L NS 0.9% NS bolus

• Second-line IV Therapy

– Lidocaine 1.5 mg/kg IV (max 200 mg)

• Alternative Options

– DDAVP 40 mcg Intranasal

Abdominal Pain

• Immediate/First-line Therapy

– Metoclopramide 10 mg IV

– Prochlorperazine 10 mg IV

– Diphenhydramine 25 mg IV

– Dicyclomine 20 mg PO/IM

• Second-line IV Therapy

– Haloperidol 2.5-5 mg IV

– Ketamine 0.2 mg/kg + 0.1 mg/kg/hr gtt

– Lidocaine 1.5 mg/kg (max 200 mg)

Data

• Utilized Omnicell reports for opioids dispensed/administered in ED – Hydromorphone IV/PO

– Morphine IV/PO

– Hydrocodone PO

– Oxycodone PO

• Converted to milligrams IV morphine equivalents (MME)

• Evaluated overall usage and per individual prescribers per 100 patient visits

• Evaluated usage of Opioid-Light Order Set

• Evaluated usage of alternative medications

Barriers & Tips

• Prescribers unaware of habits – Often default to high doses when opioids used

– Showed individual data compared to group

– One-on-one conversations and peer-to-peer “competition”

• Low-dose ketamine for analgesia – Initiated pilot with physician-only administration

– Required corporate approval, education and competencies to move forward with nursing administration

• PRN staff difficult to educate due to scheduling – ED pharmacists planned ahead to educate individual PRN providers

44%

Future Directions

• Determining appropriate patient presentations for increased use of alternatives – Potential additional disease states to utilize alternatives

• Evaluate discharge prescriptions – Ensure short durations of low doses when opioids prescribed

Acknowledgements

• Dr. Marilyn McLeod and ED provider team

• ED Nurses!

• Dennis Roberts, Pharmacy Director and ED pharmacy team

• Baptist IT team

• Baptist Administration

• Rachael Duncan, PharmD, BCCCP – Swedish Medical Center, Denver, CO

– CO Opioid Task Force