Penobscot Community Health Care, Bangor, ME
Interdisciplinary Controlled Substance Stewardship Committee
At Penobscot Community Health Care (PCHC), we have developed and implemented an interdisciplinary committee with a focus on improving controlled substance stewardship which we call the Controlled Substance Stewardship (CSS) committee. This committee includes representatives from pharmacy and care management, a pain specialist, a primary care provider, our Chief of Psychiatry, and our Chief Medical Officer. This committee has been in place since 2013.
The CSS committee meets on a weekly and reviews patients who are taking chronic opioids, benzodiazepines, and/or stimulants. Patients are referred to the committee by their primary care provider or as a result of reports assessing for high-risk prescribing. High-risk prescribing includes high-dose opioids (>100 daily morphine equivalents), concomitant benzodiazepine and opioid use, high-risk for abuse or diversion, or the presence of co-morbidities negatively impacted by use of controlled substances.
Patients are reviewed and presented to the committee by the pharmacy department. The committee then assesses the appropriateness of therapy and develops recommendations for a treatment plan. A treatment plan is then developed and submitted to the prescriber. The committee follows up on recommendations to determine the need for further intervention.
Key Elements of SuccessThe success of our CSS committee is due in part to the support from our clinical leadership. Our Chief Medical Officer and Chief Psychiatry Officer sit on the committee and are in full support of its goals and objectives. Another element to our success is the effort our pharmacy residents put into researching and presenting patients. We keep this committee current by shifting our focus to various areas of high risk controlled substance use (i.e. use of benzodiazepines and opioids, use of opioids with a diagnosis of COPD). The work of the committee has focused on providing evidence base recommendations in a educational, non-punitive structure.
Impact on Patient OutcomesSince 2013, the number of patients on chronic opioids and benzodiazepines has reduced from 1700 and 700 patients to 400 and 200. MMEs for patients on chronic opioids, without specified state defined exemptions, has decreased from an average of 290 to having less than 5 patients total on more than 100 MMEs. We have seen a reduction in the number of patients on chronic opioids and benzodiazepines by 66.4 percent and 68 percent. Additionally, we have seen a reduction of premature deaths in patients on chronic opioids from 55 in 2013 to 28 in 2015.
Role of the Pharmacy and Pharmacists
PCHC pharmacy residents and interns, under the oversight of a primary care pharmacist, are responsible for preparing and presenting patients at our committee meetings. Their preparation includes pulling data from our state PMP and reviewing medications, diagnoses, labs, and relevant office visit summaries. The pharmacy residents present patients and facilitate the discussion of appropriateness of controlled substance use and make recommendations for alternative treatment regimens. The residents then create a comprehensive provider recommendation based on the committee discussion.
Lessons LearnedEarly in the implementation of the committee, there was resistance from some of our providers, specifically those who were heavy prescribers. During this time, the residents were relaying committee recommendations from their personal company emails and were retaliated against by certain providers. We developed a designated CSI email which is now utilized specifically for recommendations to prevent further retaliation. (CSI was the abbreviation for the original committee name controlled substance initiative, however the negative implication of the acronym led to a name change to Controlled Substance Stewardship Committee.) Another positive outcome was that the PCHC clinical leadership have championed this initiative which has been instrumental for its success. Over time, we have seen a significant decrease in push back from providers.
Budget & Resource AllocationOur program is budgeted with an estimated yearly cost of $156,000 to $200,000 which is projected based on lost time for care team and preparation time for pharmacy residents. Funding for this program comes from resources generated through the340B Drug Discount Program.
Future GoalsFuture objectives will include focuses on new areas of high risk prescribing including chronic use of benzodiazepines, non-benzodiazepine sedatives, and stimulants. We also would like to focus on reducing chronic prescribing of opioids in individuals with inappropriate palliative care exemption designations. Details of PCHC's controlled substance stewardship initiative have been published in AJHP in September of 2017. A future publication may include an assessment of reduction in opioid related mortality second to this initiative.