Med-Surg Nurse Practice Conference September 22, 2017 Bridget Shears, MBA, MA, RN Pain Mgmt Clinical Services Nick Weaver, PharmD., BCPPS ED Pharmacist – Primary Children’s Hospital Intermountain Healthcare Opioid Misuse Management
Med-Surg Nurse Practice ConferenceSeptember 22, 2017
Bridget Shears, MBA, MA, RNPain Mgmt Clinical Services
Nick Weaver, PharmD., BCPPSED Pharmacist – Primary Children’s Hospital
Intermountain HealthcareOpioid Misuse Management
Disclosures
• No commercial or financial relationships to disclose
Prescription Opioid Crisis in Utah
• 89 opioid prescriptions per 100 adults annually
• There are 7,000 opioid prescriptions filled daily
• Utah is the only western state that is consistently in the top ten for opioid overdose deaths
• 41.6% of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23%
• Drug poisoning deaths are the leading cause of unintentional deaths in Utah, surpassing deaths due to firearms, falls, and motor vehicle collisions combined
• 54% of individuals taking illegal opioids obtain them from friends or family members
System Goal
System Goals
• Acute pain prescribing40% reduction of average number of pills prescribed/prescription
• Chronic pain prescribing15% reduction in the % of patients on chronic opioid therapy co-prescribed benzodiazepines
• TreatmentDevelop comprehensive treatment for opioid use disorder and chronic pain to support the above goals
Postoperative Opioid Survey
• over7,000 respondents
• 55% of tablets are unused
• 37% reported they received instructions on how to dispose of unused medications
One Intermountain Approach
Clinical Programs and Service Lines
• Aligned goals• Prescribing
guidelines
SelectHealth
• 7-day fill post surgery
• Aligned messaging
Community Health
• Aligned partnerships
• Aligned physician payment model
System Goals
Community Initiatives
Opioid Community Collaborative
Opioid Community Collaborative
Funded 2,500 Naloxone kits
306 people in treatment
(85% abstinence)
83% have discussed risks
53% have discussed
alternatives
Prescriber focused education
MD, APC, DentistPodiatrist,
Chiropractic
Prescription Drop Boxes
Provider EducationTreatment
Use Only As Directed
15,000 lbs. collected
GRANT FROM
Prescribing & TreatmentInitiatives
Pain Management Clinical Services
Chronic PainConservative Team-based Management
Care Process Models
Clinical Guidelines
EHR Decision Support – mPage
Chronic Pain Registry
Patient Education
Opioid Video
Self Management Workshops
Opioid Fact Sheets
Wellness Focus
Complementary Therapies
Exercise
Group Therapies
Acute PainAcute Pain Opioid Prescribing Guidelines
Intermountain Pain Assessment Tool (iPAT)
Comfort Channel
Perioperative Services
Multimodal therapies
Regional anesthesia/analgesia
Inpatient rounding/consultation
Pending EHR Decision Support
MME Calculator
Direct access to CS Database
Risk Assessment Tool
Complex PainPain Rehabilitation Centers
Multidisciplinary Team-based
Referral based
Telehealth
Consultative Support
Caregiver Education
Alternative Therapies
Interventional
Complementary
Referral to Specialty Services
Surgical Intervention
Substance use disorder Treatment
TeleHealth
Caregiver Education
Opioid Community Collaborative
• 35 presentations over 2 years
• Informed over 2500 providers
• Next Stepso Individualized presentations
w/providers and provider groups
oBroaden message to include APCs, Dentist and Chiropractic
2017 Integrated Pain Symposium
• Multidisciplinary Audience
• Includes REMS Course
Mental Health Provider Education
• Primer for pain psychology
Caregiver Education
Nursing
• Inpatient Nursing ToolkitoNon-pharmacologic options
oNon-opioid pharmacologic options
oOpioid administration/safety guidelines
oComfort Channel
o Living Well w/Chronic Pain
Chronic Pain Toolkit
• Care Process Models
• Prescribing Guidelines
• iCentra Decision Support
Naloxone Education
• Pharmacist Speakers Bureau
Patient Education
Fact Sheets
• Acute Pain mgmt
• Chronic Pain mgmt
• Opioid mgmt
• Naloxone
Integrated Discharge Education
Living Well w/Chronic Pain
Comfort Channel
Compliance
New Regulatory Guidelines• Prescribing requirements & limits• 7 day quantity – acute pain• Controlled Substance Database - for 1st time prescriptions • 200mg MED • Opioid education
New Joint Commission Standards• Pain mgmt lead/team• Risk assessment • Patient education• Caregiver education• Data collection & quality improvement
Opioid Prescribing and Use Dashboard
Opioid Prescribing and Use Dashboard
• Each physician will have access to their own prescribing• They will be able to benchmark• Leadership will have access• We now have the technology to monitor this by
• Clinical program• Geography (clinic, region, zip code, etc.)• Prescriber• Patient• Diagnoses• Procedure• High risk prescribing (co-prescribing with benzodiazepine)
Disclosures
• No commercial or financial relationships to disclose
• Volunteer with Utah Naloxone
Objectives
• Describe the opioid epidemic
• Explore opioids involved in overdose
• Understand the role of naloxone and compare the different formulations available
• Discuss collaborative efforts
• Explain naloxone collaborative practice agreement
• Identify at risk patients and how the Medical/Surgical Nurse can make a difference in their patient population.
Outline
• The Opioid Epidemic
• Opiates and Opioids
• Naloxone
• Collaborative Efforts
• Med/Surg Patient Interaction
Opioid Epidemic
https://www.cdc.gov/drugoverdose/images/epidemic/91Americans.jpg
https://cdn.aarp.net/content/dam/aarp/health/conditions_treatments/2017/05/1140-opioid-menace-epidemic-chart-aarp.imgcache.rev2de2c7ebf013c0b38169c5620a80dd2a.jpg
Utah Prescription Opioid Overdose Numbers
Year Rx Deaths Rx Opioid DeathsRx Opioid Death Rate per
100,000
2011 306 246 12.0
2012 327 268 13.1
2013 354 274 13.2
2014 363 301 14.0
2015 357 282 12.6
2015 - include heroin: 423 deaths
Opioid Epidemic
Bad to
Worse
Opioid Epidemic
Highest risk
• Female• 45 years +
http://health.utah.gov/vipp/pdf/RxDrugs/PDODeaths2015.pdf
Opioid Epidemic
http://health.utah.gov/vipp/pdf/RxDrugs/PDODeaths2015.pdf
>7,000 Opioid Rx’s filled every
day in Utah
Opioids
Opiate and opioid often used interchangeably• Opiate: substance/drug derived from opium
• Opioid: newer term that includes synthetic drugs
Opioids include• Prescription pain medications
• Prescription medications used to treat opioid use disorder
• Heroin
• Synthetic, illicit substances (fentanyl analogs, U47700)
https://addictionresource.com/drugs/oxycodone/ http://www.bradenton.com/latest-news/57cirv-about-heroin-2.jpg/ALTERNATES/LANDSCAPE_1140/about-heroin-2.jpg
Opioids
Stimulate opioid receptors:
• Control nociceptive pain signals (analgesia)
• Decrease breathing (can lead to death)
• Produce euphoria, leading some to addiction
Properties of opioid receptors
• Mu1: supraspinal analgesia, decreased heart rate, sedation
• Mu2: respiratory depression, euphoria, dependence
• Delta: spinal analgesia, respiratory depression
• Kappa: spinal analgesia, respiratory depression, sedation
http://previews.123rf.com/images/p6m5/p6m51205/p6m5120500020/13453898-Bronchial-system-Human-lungs-Stock-Vector-lung-human-respiratory.jpg
Opioids with increased overdose/death risk
• Higher dosage
• Methadone
• Long-acting opioids
• Opioids for chronic pain management
• Rotating opioid regimens
Naloxone• Safe prescription medication
• No clinical effect in the absence of opioids
• Not a controlled substance
• Onset as quickly as 1 minute
• Effects last 30-90 minutes
• Could last 30 minutes or longer
• Another dose may be needed when effects wear off
• Effective when administered intravenously, intranasally, intramuscularly, subcutaneously
Naloxone Pharmacology
• Opioids bind to opioid receptors in the central nervous system
• Naloxone kicks opioids off opioid receptors
- Blocks receptors so opioids cannot bind- Reverses an opioid overdose- No effects if there are no opioids present
Micromedex; Image from: http://www.noperi.org/images/receptors_naloxone.png
Opioid and Naloxone PharmacodynamicsOpioid side effects and
overdose signs/symptoms➜
Opioid withdrawal signs/symptoms
• Euphoria • Agitation/dysphoria
• Constipation • GI upset/diarrhea
• Analgesic • Pain/irritability
• Warming/flushing • Goosebumps/chilling
• Drowsiness/Sleepiness • Restless/Insomnia
• Respiratory Depression • Increased Respiration
• Pinpoint pupils • Dilated pupils
• Decreased HR/BP • Increased HR/BP
• Decreased temperature • Increased temperature
• Drying effect • Yawning/sweating
Naloxone
• Same Dose of Naloxone for Everyone
- Adult- Child- Infant- Pregnancy- Obesity- Kidney disease- Liver disease
Naloxone – Products
Intranasal and intramuscular (IM) rescue kits • Kits contain 2 doses of naloxone, and nasal atomizers or IM syringes to
administer the naloxone
• Naloxone must be prepared for use before being administered
• Do not prepare until ready to use
Two commercially available products (no assembly)• Auto-injector (Intramuscular)
• Nasal spray (Intranasal)
Not all pharmacies will have all products
Intramuscular Naloxone Kit
• Two 1 mL single-dose vials of naloxone 0.4 mg/mL
• Two 3 mL intramuscular (IM) syringes
• Inject in large muscle mass (thigh, deltoid)
• Avoid storing in heat and light
Intranasal Naloxone Kit
• Absorption occurs via nasal mucosa – not from inhalation
• Two 2 mL pre-filled needless syringes of naloxone 1 mg/mL
• Two mucosal atomization devices (MAD’s)
Commercial Naloxone Products
•Nasal spray (Narcan® Nasal Spray)–Approved 2015, entered market in 2016
–Two 4 mg nasal spray devices
•Auto-injector (EvzioTM)–Approved in 2014
–2 mg/0.4 mL naloxone in a pre-filled auto-injector
–Two auto-injectors and one trainer per package
–May not be readily available in all pharmacies due to cost
Collaborative Efforts
• Joint efforts with local and state governments
• Utah Naloxone efforts in community
• EMS and Law enforcement
• Public health initiatives
• Intermountain corporate committees and goals
• Collaborative practice agreement (CPA)
• Healthcare professional participation
Naloxone Collaborative Practice Agreement (CPA)
A CPA allows a pharmacist to prescribe naloxone, according to an agreement with a licensed prescriber
Naloxone CPAs increase everyone’s access to naloxone
Several pharmacies in Utah have naloxone CPAs, in which:
• A person requests naloxone at the pharmacy
• Pharmacist issues a prescription for use in that pharmacy (no written Rx required)
• Education provided on opioid overdose and naloxone, naloxone dispensed
• Some pharmacies do not have a naloxone CPA and use ”Utah State Standing Order”
• Pharmacy may not stock and/or CPA may not include all naloxone products
• Consent forms or other requirements
• Prices will vary (cash versus insurance and preferred naloxone med by insurance)
What can the Med/Surg RN do?
• Recognize risk factors
• Educate about opioid misuse and naloxone
• Okay to have difficult discussions
• Understand Intermountain Naloxone CPA• Refer patients to Intermountain pharmacies to obtain naloxone
• Ask providers to write prescriptions for naloxone
Intermountain Resources
1. Go to Intermountain.net2. Enter “naloxone” or “opioid management information”
in search field3. Choose Opioid Management Information
• Prescription Opioids: What You Need to Know• Cutting Back on Opioid Pain Medication• Naloxone resources for patients and families• Naloxone resources for healthcare professionals• Flashcards for quick resources
Intermountain Resources
Other Resources
• CDC Guideline for Prescribing Opioids for Chronic Pain: http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm
• Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid Overdose Prevention Toolkit: http://store.samhsa.gov/shin/content//SMA14-4742/Overdose_Toolkit.pdf
• Prescribe to Prevent http://prescribetoprevent.org/
• Safe medication disposal: http://useonlyasdirected.org/drop-off-locator/
• Overdose pocket card: http://health.utah.gov/vipp/pdf/RxDrugs/rxdrug-overdose-pocketcard.pdf
• Spanish: http://www.health.utah.gov/vipp/pdf/RxDrugs/updatedrxdrug-overdose- pocketcard-spanish12.18.15.pdf
• Utah Naloxone: http://www.utahnaloxone.org
Other Resources
Thank You!