ASPAN Presentation 2-10-18s3-us-west-2.amazonaws.com/ecms-uploads/mndakspan... · Patient Controlled Analgesia!Addiction Treatment Medications !Methadone, Buprenorphine, Suboxone,

The Opioid Crisis and Diversion:Impact on the Perianesthesia Care Nurse

Presentation for Minnesota/Dakotas Society of Perianesthesia Nurses Conference Saturday February 10th, 2018

By Clare Jones, RN, BSN, CentraCare Health Medication Diversion Prevention RN

Objectives! Describe impact of the opioid crisis on care for the

Perianesthesia patient ! Identify indications that a co-worker may be diverting

medications ! Describe impact of diversion on patients and healthcare

facilities ! Describe two elements of diversion prevention and

surveillance that can be used in the Perianesthesia setting

CentraCare Health! Non-profit healthcare system in

Central Minnesota ! Collaborative regional network

St. Cloud Hospital ! Founded in 1886 ! Largest health care facility in the

region ! 489 licensed beds ! 450 physicians ! 1,623 RNs and 298 LPNs

February 2011 Over a period of 5 days, St. Cloud Hospital Lab detected Ochrobactrum anthropi in blood cultures from four surgical patients complaining of fever and pain

! All patients were from the same surgical unit ! 2 cultures from patients on same unit grew

Klebsiella (more common bacteria, but still a red flag)

! All had received PCA dilaudid ! PCA bags were pulled - 2 grew Klebsiella, one

grew Ochrobactrum anthropi ! Unopened PCA and Normal Saline IV bags

were tested and negative ! Infection Control found 24 patients from the

surgical unit dating back to October 2010 who’s cultures grew Klebsiella, Ochrobactrum, or both

Investigation! Staffing/scheduling reports from

Nursing, Pharmacy and Lab pointed to one nurse on the surgical unit

! OMNIcell reports indicated he was removing unit’s PCA storage cabinet keys more frequently than his peers

! When he came to work on March 8, 2011 (a scheduled vacation day) and accessed the OMNIcell for keys, he was confronted and asked to submit to a drug test

Investigation continued

Blake Zenner was a well-liked and highly respected CentraCare employee for 17 years…

On September 26th, 2012: ! He admitted to diverting hydromorphone from PCA bags ! He plead guilty to one count of obtaining a controlled

substance by fraud

! He was ordered to pay $340,000 in restitution, and sentenced to 24 months in federal prison

Impact

Negative publicity

Corrective Actions

Legal/Financial

Employee Morale

What is addiction?

! A primary, chronic disease of the brain ! Like other chronic diseases, involves cycles of relapse

and remission ! Without treatment or engagement in recovery activities,

is progressive and can result in disability or premature death

American Society of Addiction Medicine

National Geographic 9/2017

Opioids:

! “Flood” the brain with dopamine and other “pleasure” chemicals

! Suppress pain, and deprive the brain of “warning” chemicals

! Inhibit anxiety and fear

! Impair judgment, impulse control, and the ability to evaluate risk

! Push the impulsive, reward-driven areas of the brain into overdrive

This is a Public Health Emergency:! The United States consumes 80% of the world opioid supply

! Surveys indicate tens of millions of Americans misuse prescription medications

! Most persons using heroin have a history of misusing prescription opioids first

! In the United States, drug overdose is now the leading cause of death for those under 50

! In 2015, overdoses claimed more lives than motor vehicle accidents and gun violence combined

! In 2016, health care, treatment, lost productivity and criminal costs related to the opioid crisis were estimated to be $78.5 billion

! Every 25 minutes in the United States, a baby is born in opioid withdrawal

CDC 2017

So, is the opioid crisis our fault?!?

! Doctors and medical associations argued that their profession had ignored the problem of chronic pain, causing unnecessary suffering for millions of patients

! Promoted the idea that pain should be assessed as a fifth vital sign, and treated accordingly

! Pharmaceutical industry told providers that new drugs like Oxycontin could be used without fear of addiction

Back in the ‘90’s:

CDC, National Center for Injury Prevention and Control

! By 2015, enough pills were being prescribed for every American to be medicated around the clock for three straight weeks

Opioids – Perioperative Benefits and Risks

Benefits: ! Legitimate, important

role in acute trauma, perioperative care, cancer pain, and pain associated with life-limiting illness

Risks:

Immediate: ! Respiratory depression

! Altered mental status ! Sedation

! Increased fall risk

! Nausea, vomiting and constipation

Long-Term: ! Hypersensitivity to pain

! Addiction

! Overdose and death

Factors to consider for surgical patients with history of opioid use or misuse:

!Tolerance

!Physical dependence and withdrawal

!Hyperalgesia

!Bias and judgement

Challenges of perioperative pain relief in an opioid crisis:

! Dosage required for pain relief ! Opioid-dependent patients can require four times the amount of

pain medications in the postoperative period compared to opioid-naive patients

! Patient Controlled Analgesia

! Addiction Treatment Medications ! Methadone, Buprenorphine, Suboxone, etc.

! Fentanyl Patches

Effective pain management of patients with history of opioid use or misuse requires a comprehensive, multidisciplinary approach

Best practices include: ! Identify the history of opioid use or misuse

! Guarantee baseline requirements of opioids, regardless of the anesthetic technique

! Do not restrict opioid treatment - provide effective analgesia and treat pain aggressively

! Avoid judgmentCaluzzi et al.

Predictors of Opioid Abuse in the Surgical Patient:

! Prescriptions that lead to prolonged opioid use tend to be written by doctors in outpatient settings, not hospitals

! Risk factors for new persistent opioid use after a surgical procedure: preoperative tobacco use, alcohol and substance abuse disorders, mood disorders, and preoperative pain disorders (back, neck, “centralized” and chronic pain; arthritis)

! The rate of continued opiate use was not significantly different between minor and major surgical procedures

Journal of Arthroplasty 2017

The strongest predictor of continued opioid use is the number of days supplied for the first post-operative prescription

One- and 3-year probabilities of continued opioid use among opioid-naïve patients, by number of days’ supply* of the first opioid prescription — United States, 2006–2015

MMWR 2017

Complex problem that requires a multi-faceted response:

! Patient Communication

! Express a commitment to managing pain, and change focus to “comfort”

! Discuss realistic expectations: “reasonable” amount of pain (not zero)

! Patient Education

! Provide ongoing, perioperative information to patient and family about the risks and benefits of opiates

! Discuss available alternative therapeutic options (acupuncture, massage, guided imagery)

! Prepare patients and families for safe use and storage of medications at home

! Process:

! “Start low and go slow” – administer the lowest effective dose

! Include non-opiate pharmaceutical options, i.e. IV acetaminophen

! Limit intravenous opioids to acute need and when patients are unable to take oral medications

! Team approach with Nursing, Pharmacy, Anesthesia and Providers

What about healthcare workers?

Substance abuse in healthcare

! 10-15% of health care providers and nurses will misuse drugs/alcohol at some point in their career

! 6-8% of nurses use to an extent that impairs their professional judgment

Critical Care Medicine, American Nurses Association

Why healthcare workers?

➢ Work-related stress

➢ Irregular shift work, repeated emotional trauma, and workplace injury causing chronic pain

➢ Culture that accepts medications as desirable and permissible cures for complex feelings or illnesses

➢ “Pharmacological Optimism”: belief about personal skills and level of knowledge to self medicate without becoming addicted

NCSBN

Early reasons to misuse:! To Feel Good:

! Curiosity

! Fun

! To Feel Better: ! Anxiety

! Stress

! Depression

! Insomnia

! Pain

! To Do Better: ! Energy

! Increased cognitive performance

Late stages: Drug and/or alcohol use becomes necessary:

! Other pleasurable activities become less pleasurable

! Have to use just to feel “normal”

! Have to use to avoid withdrawal

! “Use so I won’t die”

Diversion: Scope of the Problem

! Reliable statistics on prevalence are not available

! By nature, diversion is a secret activity, and cases can go undiscovered

2014: University Hospital, Madison, Wisconsin

! Cluster of 5 cases of serratia marcescens bacteremia within 5 weeks

! Soon after first case presented, dilaudid and morphine PCA syringes were found missing “tamper evident” caps

! Further investigation revealed more than 40 syringes found on several units that had evidence of tampering

! Common risk factor for 4 patients: exposure to the post-anesthesia care unit

! Investigation identified a nurse working in the post-anesthesia care unit

“In May 2011, the Minnesota Department of Health and the Minnesota Hospital Association invited a coalition of hospital, provider, law enforcement, licensing and other health care stakeholders to collaboratively address this important issue.

Diversion Prevention: Best Practice Recommendations Storage and SecurityRoad Map: ! “The organization stores CS and other high

risk items securely, in all settings and circumstances”

! “Organization uses camera surveillance in high risk areas as appropriate”

Surveillance Reports:

Road Map: “Organization reviews and audits relevant data which could indicate potential CS diversion”

Facility Expectations: Reporting:Road Map:

“Organization has established and communicated ways for staff to anonymously speak up (e.g. hot line, paper or electronic submission)”

Recognition of Diversion “Typical” diverter profile

! “Never would have suspected them”

! Ambitious

! Achievement-oriented

! Highly skilled

! Well-liked

! Respected

! Intelligent

! Persuasive

Work patterns:! Present at workplace on days off

! Regularly volunteering for overtime

! Arriving at work early or leaving late

! Decreased productivity/competency

! Frequently volunteering to perform controlled-substance counts, or administer, return and waste controlled substances for coworkers

! Excessive errors, including medications

! Prolonged or frequent breaks or absences from work area

“Chain of custody” and the “Virtual Witness”:

! The individual who removes a controlled substance should be the person who administers the medication and makes any necessary returns or wastes

! NEVER SIGN YOUR NAME that you have witnessed a waste, return or controlled substance count if you do not actually witness it

Physical and behavioral signs:! Deterioration in personal

appearance and hygiene

! Sweating, chills, pallor, tremors, weakness

! Excessive energy or lethargy

! Mood swings, personality changes

! Difficulty listening or concentrating

! Increasing personal and professional isolation

! Deterioration in relations with coworkers, patients, volunteers or visitors

Unusual circumstances:

! Patients complaining of unrelieved pain

! Syringes, vials or medications in unusual locations

! Missing medications or discrepancies

! Evidence of tampering with controlled substance packaging, sharps containers or waste containers

Police:University of Michigan doctor overdosed

! 32-year-old Anesthesia Resident

! Found in a locked bathroom in cardiac arrest with a syringe and fentanyl at his side

! Discovered after a nurse noticed the bathroom had been occupied for a long time, and got a janitor to open the door

! Later admitted to police that he had injected himself with fentanyl immediately prior to the overdose

Mlive.com Ann Arbor News, Michigan

! About 3 hours before the Resident’s overdose, a cardiovascular intensive care Nurse was found dead in a locked bathroom at the same hospital with empty vials and a syringe

! The autopsy report revealed she died from a mix of fentanyl and midazolam

Mlive.com Ann Arbor News, Michigan

Tragedy…

Out of the shadows…

! Change the conversation

! Talk about healthcare worker addiction, treatment and recovery

! Step forward for ourselves and/or our peers if we are concerned about addiction or diversion

Thank You!

Questions?

• American Society of Addiction Medicine https://www.asam.org/ • Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. New Persistent

Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504

• Centers for Disease Control and Prevention. Annual Surveillance Report of Drug-Related Risks and Outcomes — United States, 2017. Surveillance Special Report 1. Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Published August 31, 2017. Accessed 11/1/17 from https://www.cdc.gov/ drugoverdose/pdf/pubs/2017- cdc-drug-surveillance-report. Pdf

• Coluzzi F, Bifulco F, Cuomo A, et al. The challenge of perioperative pain management in opioid-tolerant patients. Therapeutics and Clinical Risk Management. 2017;13:1163-1173. doi:10.2147/TCRM.S141332.

• Kim, K. Y., Anoushiravani, A. A., Chen, K. K., Roof, M., Long, W. J., & Schwarzkopf, R. (2017). Preoperative Chronic Opioid Users in Total Knee Arthroplasty—Which Patients Persistently Abuse Opiates Following Surgery? The Journal of Arthroplasty. doi:10.1016/j.arth.2017.07.041

• Mozes, A. (2017, August 16). Hospitals Not to Blame for Most Opioid Addiction: Study: MedlinePlus Health News. Retrieved November 01, 2017, from https://medlineplus.gov/news/fullstory_167855.html

• Opioid Overdose. (2017, July 18). Retrieved August 30, 2017, from https://www.cdc.gov/drugoverdose/data/index.html; Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention

• Ray, W. A., Chung, C. P., Murray, K. T., Hall, K., & Stein, C. M. (2016). Prescription of Long-Acting Opioids and Mortality in Patients With Chronic Noncancer Pain. Jama, 315(22), 2415. doi:10.1001/jama.2016.7789

• SAMHSA - Substance Abuse and Mental Health Services Administration. (2017, September 17). https://www.samhsa.gov/ • Shah, Anuj et al., Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial

Prescription Characteristics and Pain Etiologies, The Journal of Pain , Volume 18 , Issue 11 , 1374 - 1383 • Smith, F. (2017, September). How Science is Unlocking the Secrets of Addiction. National Geographic. http://

www.nationalgeographic.com/magazine/2017/09/the-addicted-brain/ • What You Need to Know About Substance Use Disorder in Nursing, National Council of State Boards of Nursing, Inc. 2014

References: