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!