Cone Health Greensboro, NC
Pharmacist intervention to monitor and reduce opioid use in patients with chronic non-cancer pain as part of interdisciplinary pilot monitoring program
OverviewIn 2016, the CDC released guidelines for prescribing opioids for chronic pain. The guidelines recommended the following actions: establishing goals for pain and function; evaluating risks and benefits of opioids, and using non-pharmacologic and non-opioid therapy when possible. This pilot program is a pharmacist-driven interdisciplinary opioid monitoring initiative to address these guidelines. There are two crucial pieces to the program: Provider-detailing interventions and pharmacist-initiation interventions. The provider-detailing interventions include ongoing pharmacist-provided education of providers on chronic opioids for non-cancer pain and the use of non-opioids for chronic pain. The education was comprised of two one-hour lectures on chronic opioid medications for non-cancer pain and the use of non-opioids for chronic pain. The intent of the provider-detailing intervention is to make providers aware of the opioid crisis and available alternatives to reduce opioid needs. The pharmacist-initiated intervention phase includes evaluation of the chronic pain treatment plan and recommendations communicated with the provider prior to the patients’ clinic visit using an EHR note. This intervention includes standardized opioid education to providers, evaluation of chronic pain treatment plans, recommendations to providers including taper and discontinuation needs, consideration of non-opioids, and the need for related interventions including urine drug screens and naloxone.
Key Elements of SuccessBuilding a strong interprofessional relationship with providers is crucial. A pharmacist staff member educated in chronic pain management is necessary to make interventions and build this professional relationship amongst other healthcare members. Morphine milligram equivalents (MME) were calculated for patients to stratify who received pharmacist evaluation. For those patients identified as high risk — those using than 90 MME per day — 93 percent were evaluated by a pharmacist.
Impact on Patient OutcomesThere was a marked decrease in MME in both the provider-detailing group as well as the pharmacist-intervention group in the pilot program. Results included an overall decrease from 30.61 to 21.66 MME/day. This translated to a decrease of 7.6 MME/day in the provider-detailing group (N=84) and a decrease of 11.01 MME/day in the pharmacist-intervention group (N=55). In patients with greater than 90 MME/day, there was a decrease of 28.77 MME/day in the pharmacist-intervention group.
Role of the Pharmacy and PharmacistsPharmacists were an integral part of the interdisciplinary team to help guide interventions for prescribers. Providers are faced with many limitations in assessing patient opioid requirements that include both limited training and visit time with patients to evaluate their opioid requirements. Clinic-based pharmacists have developed expertise in the management of chronic conditions and are uniquely positioned to provide thorough recommendations with regards to a patient’s opioid requirements. For the provider-detailing intervention, pharmacists are subject matter experts on current literature and new developments to provide continuing education to providers. Clinic pharmacists also dedicate time to evaluate high-risk patients in response to recent opioid trends. This allows pharmacists to provide a thorough assessment of a patient’s pain management needs and supplement the limited time providers have with patients. Pharmacists also served as advocates for prescribing naloxone and utilizing urine drug screens in order to collaboratively evaluate a patient’s pain management needs.
Lessons LearnedThe winning element of this project is the collaborative approach that was utilized via education to all providers and included a pharmacist targeting certain patients that were seen in clinic. Pharmacists are not able to reach all patients at risk for opioid misuse and abuse so a collaborative approach is needed to successfully decrease opioid prescribing and associated use.
Budget & Resource AllocationThis was a pilot program, as part of a residency research project. There were no additional resources or assets required to establish the program initially.
Future GoalsNext steps include expanding the residency research project to a pharmacy service in the clinic setting. An article has been submitted for potential journal publication.
Reference1. American Hospital Association, Stem the Tide: Addressing the Opioid Epidemic.. http://www.aha.org/content/17/opioid-toolkit.pdf