Today, 11 percent of Americans experience daily chronic pain, for which opioids are frequently prescribed. Unfortunately, what started as standard prescribing practice has become detrimental, and due to their highly addictive nature, we’ve seen a quadrupling number of opioid overdose deaths from 1999 to 2015, killing more than 90 people per day. While state and national legislatures continue to search for ways to combat this epidemic, significant change can be made at the community level starting with medical staff, hospitals and health systems. This webinar will provide a comprehensive overview of the pain crisis and how it affects various patient populations, outline CDC guidelines on opioid use for chronic pain and identify strategies to positively impact the use of opioids and outcomes. Sources: NCCIH, NPR Key Takeaways: - Recognize the relationship between opioid use on clinical and economic outcomes in various patient populations and the community - Outline recommendations suggested by CDC guidelines on opioid use in chronic pain and new pain standards just released by TJC - Identify strategies to impact multiple drivers of the opioid crisis

1. Pain Points: Overcoming the
Opioid Crisis
CompleteRx Knowledge Series Webinar
July 26, 2017

2. Speakers
2
Julie Rubin, Pharm.D., BCPS
Director of Clinical Services
CompleteRx, Ltd
Kenneth Maxik, MBA, MBB, FACHE
Director of Patient Safety and Compliance,
CompleteRx

3. 3
Agenda
 The Epidemic
 Accreditation Standards
 IHI Initiative
 Opioid selection, dosage, duration, follow-up, and
discontinuation
 Assessing risk and addressing harms of opioid use

4. The Epidemic

5. 5
Chronic Pain and Prescription Opioids
11% of Americans experience daily (chronic) pain
Opioids frequently prescribed for chronic pain
Primary care providers commonly treat chronic, non-cancer pain
 Account for ~50% of opioid pain medications dispensed
 Report concern about opioids and insufficient training

6. 6
Sharp Increase in Opioid Prescriptions
Increases in Deaths

7. Role of Prescribing Opioids and Overdose Deaths
*Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System

8. 8
Why is this a difficult problem to address?

9. 9
Need for Opioid Prescribing Guidelines
Previous opioid prescribing guidelines have been developed by several states
and agencies, but were inconsistent
Most recent national guidelines are several years old and don’t incorporate the
most recent evidence
Need for clear, consistent recommendations

10. Accreditation and Pain Management

11. 11
The Joint Commission
Release of new standards for implementation January 1, 2018

12. 12
Which of the following identified areas has your hospital
or health system accomplished related to pain
management?
A. Assigned an executive leadership champion
B. Developed a team charter
C. Conducted a GAP Analysis
D. Both A & B
E. All of the above
12
Quick Poll

13. Institute for Healthcare Improvement
Addressing the Opioid Crisis in the United States

14. 14
IHI
Recommendation's for a systems approach to the opioid crises:
four main drivers to reduce opioid use.
 Limit supply of opioids
 Raise awareness of risk of opioid addiction
 Identify and manage the opioid-dependent population
 Treat opioid-addicted individuals

15. 15
Reverse the opioid crisis
in a community
Measures:
• Overdose rate
• Fatal overdose rate
• Individuals in treatment
• Prescription opioid rate
Source: IHI
Limit supply
of opioids
• Prescribing practices
• Dispensing practices
• Diversion
• Pharmaceutical
production
• Availability of alternative
pain management
treatment
Raise
awareness of
risk of opioid
addiction
• Identification/education
of patients at greater risk
for addiction
• Provider education
• Adolescent education
• Adult education
• Reducing stigma around
substance abuse

16. 16
Who has been educated amongst hospital staff on
changing opioid guidelines and management?
A. Medical Staff
B. Nursing Staff
C. Pharmacy Staff
D. Both A & B
E. All of the above
16
Quick Poll

17. 17
Reverse the opioid crisis
in a community
Measures:
• Overdose rate
• Fatal overdose rate
• Individuals in treatment
• Prescription opioid rate
Source: IHI
Identify and
manage
opioid
dependent
population
• Compassionate, consistent
care
• Tapering
• Pain management education
• Availability of alt. pain
management treatment
• Education of
patients/families
Treat opioid-
addicted
individuals
• Identification of opioid
addicted individuals
• Availability of detox facilities
• Availability of long-term
ongoing comprehensive
addiction treatment
• Availability of supportive
social services
• Prevention of fatal overdose

18. 18

19. 19
Clinical Evidence Summary

20. 20
Recommendation #1: Nonpharmacologic
Therapy
 Nonpharmacologic therapy and nonopioid pharmacologic
therapy are preferred for chronic pain
 If opioids are used, they should be combined with
nonpharmacologic therapy and nonopioid pharmacologic
therapy, as appropriate.
(Recommendation category A: Evidence type: 3)

21. 21
Recommendation #2: Establish and measure
progress toward goals
Before initiating opioid therapy for chronic pain:
 Determine how effectiveness will be evaluated
 Establish treatment goals with patients
– Pain relief
– Function

22. 22
Who in your organization is responsible for educating
patients on opioid abuse?
A. Medical Staff
B. Nursing Staff
C. Pharmacy Staff
D. Both A & B
E. All of the above
22
Quick Poll

23. 23
Recommendation #3: Patient Education
Before starting and periodically during opioid therapy, clinicians should discuss
with patients known risks and realistic benefits of opioid therapy and patient
and clinician responsibilities for managing therapy.
(Recommendation category A: Evidence type: 3)

24. Opioid selection, dosage, duration, follow-
up, and discontinuation

25. 25
Recommendation #4: Prescribing
When starting opioid therapy
for chronic pain, clinicians
should prescribe immediate-
release opioids instead of
extended-release/long-acting
(ER/LA) opioids.
(Recommendation category A:
Evidence type: 4)

26. 26
Recommendation #5: Start low and go slow
 Start with lowest effective dosage and increase by the smallest
practical amount.
 Total opioid dosage >50 MME/day
 Avoid increasing opioid dosages to >90 MME/day.
 High, hard to treat patients

27. 27
Recommendation #6: When opioids are
needed for acute pain
 Prescribe the lowest effective dose.
 Often < 3 days and rarely more than 7 days needed.
 Do not prescribe additional opioids “just in case”
 Re-evaluate patients with severe acute pain that continues
longer than the expected duration
 Revise the initial diagnosis and to adjust management
accordingly
 Do not prescribe ER/LA opioids for acute pain treatment

28. 28
Recommendation #7: Follow up
Re-evaluate patients
 within 1-4 weeks of starting
long-term therapy or of
dosage increase
 at least every 3 months or
more frequently

29. 29
Tapering Opioids
 Work with patients to taper opioids down or off
 Taper slowly enough to minimize opioid withdrawal
 Access appropriate expertise for tapering during pregnancy
 Optimize non-opioid pain management and psychosocial
support

30. 30
Strategic Recommendations For Your Hospital
 Retrain providers
 Consider all providers
 Identify alternative treatment options for pain management
 Create a role for pharmacists and retail pharmacy
(“corresponding responsibility”)
 Engage in public messaging
 “Flood the zone”
 Recognize that geography is important
 Include law enforcement

31. Assessing risk and addressing harms of
opioid use

32. 32
Certain factors increase risks for opioid-
associated harms
 Moderate or severe sleep-disorders
 Pregnancy
 Renal or hepatic insufficiency, aged >65 years
 Patients treated for depression
 Consider offering naloxone when patients

33. 33
Drug Diversion in the Hospital

34. 34
Who comprises your team to help
combat opioid abuse?
A. Hospital Personnel
B. Local Law Enforcement
C. Community Leaders
D. Both A & C
E. All of the above
34
Quick Poll

35. 35
A Systems Approach to Treatment of Pain Management
35
Key Takeaways
 Non pharmacological
approaches should be reviewed
 A GAP Analysis should be
conducted to understand current
processes
 The pharmacist plays an
important role in the
management of patients
 Change prescribing practices
 Educate physician about the
risk of long term opioid use
 Educate the patients about
chronic, opioid use
 Tapering opioids
 ADE prevention
 Alternative pain medications

36. Questions?
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