Zack Brent, PharmD, BCPS

Lead Pharmacist

Baptist Memorial Hospital – Memphis

I have no conflicts of interest to disclose

Lessons Learned in Sustaining an Opioid-Light Emergency

Department

Objectives

• Discuss background supporting multi-modal pain medications

• Review revised trends in opioid use in BMH-Memphis emergency department

• Report newly identified challenges and strategies

• Describe current transition to inpatient opioid reduction

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3

THA Opioid-Light ED Pilot Participants

• CHI Memorial Hospital-Chattanooga• CHI Memorial Hospital-Hixson• Henry County Medical Center• Maury Regional Medical Center• NorthCrest Medical Center• Parkridge East Hospital• Parkridge Medical Center• Parkridge West Hospital• Regional One Health• Saint Thomas Dekalb Hospital• Saint Thomas Hickman Hospital• Saint Thomas Highlands Hospital• Saint Thomas Midtown Hospital• Saint Thomas River Park Hospital• Saint Thomas Rutherford Hospital• Saint Thomas Stones River Hospital

• Saint Thomas West Hospital• Southern TN Regional Health System-

Lawrenceburg• Starr Regional Medical Center-Athens• Starr Regional Medical Center-

Etowah• Sumner Regional Medical Center• TriStar Ashlyn City Medical Center• TriStar Centennial Medical Center• TriStar Hendersonville Medical Center• TriStar Horizon Medical Center• TriStar Portland Medical Center• TriStar Skyline Medical Center• TriStar Southern Hills Medical Center• TriStar StoneCrest Medical Center• TriStar Summit Medical Center

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BACKGROUND

5

https://www.seattletimes.com/seattle-news/health/feds-halt-2-tennessee-pharmacies-opioid-dispensing-for-now/ 6

…told DEA agents that “he did not believe there is an opioid problem and that it is media hype.”

“Doctors need to be investigated. They are the ones writing prescriptions. We just fill them. The pharmacist is not responsible.”

Overdose Deaths by the Numbers

• In 2017, there were ~70,000 drug overdose deaths in the United States

• Overall overdose deaths increased by 9.6% from 2016 to 2017

7

Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018. Accessed at: https://www.cdc.gov/nchs/products/databriefs/db329.htm

Rates of Drug Overdose Deaths: 2017

Hedegaard H, Miniño AM, Warner M. Drug overdose deaths in the United States, 1999–2017. NCHS Data Brief, no 329. Hyattsville, MD: National Center for Health Statistics. 2018. Accessed at: https://www.cdc.gov/nchs/products/databriefs/db329.htm 8

Rates of Opioid Overdose Deaths

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Tennessee Overdose Deaths

10Tennessee Deaths from Drug Overdoses Increase in 2017. 2018 Aug 20. Tennessee Department of Health. Accessed at: https://www.tn.gov/health/news/2018/8/20/tennessee-deaths-from-drug-overdoses-increase-in-2017.html

698 756861

1,0341,186

1,268

1,0941,168

1,263

1,451

1,631

1,776

0

200

400

600

800

1000

1200

1400

1600

1800

2000

2012 2013 2014 2015 2016 2017

Nu

mb

er o

f D

eath

s

All Drug Overdose Deaths

Opioid Overdose Deaths

ALTERNATIVES TO OPIOIDS

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Alternatives to Opioids (ALTO)

• Multi-modal approach to target various pain receptor pathways; examples:

– COX inhibitors: NSAIDs/APAP

– Sodium channel blockers: Lidocaine

– NMDA receptor antagonists: Ketamine

– GABA agonists/modulators: BZDs/Gabapentin

– Inflammatory cytokine inhibitors: Steroids

• Opioids as “rescue” or second-line

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FIVE Pathways

• Headache / Migraine

• Musculoskeletal Pain

• Extremity Fracture / Dislocation

• Renal Colic / Kidney Stones

• Gastroparesis / Chronic Abdominal Pain

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BAPTIST MEMORIAL HOSPITAL –MEMPHIS EMERGENCY DEPARTMENT

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Baptist Memorial Hospital - Memphis• 571 beds

• Average 475 patients

• >75,000 ED visits (2018)

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Where were we?

• Baseline usage– MME (IV) = Milligrams IV Morphine Equivalents

• ED usage Dec 2016-Jan 2017– ~7,200 MME (IV) / month – ~120 MME (IV) / 100 patient visits

• Huge variability among providers– 5-6x difference between low providers and high

providers per 100 patient visits

• Percentage of patients receiving opioids– ~22% of patients received at least one dose of opioids

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Twelve Months In

• ED usage – ~3,035 MME (IV) / month (↓ 58%)

– ~45 MME (IV) / 100 patient visits (↓ 63%)

• Even larger variability among providers– 12-13x difference between low providers and high

providers per 100 patient visits

• Percentage of Patients Receiving Opioids– ~13% of patients received at least one dose of

opioids (↓ 41%)

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Baptist Memphis Opioid-Light ED Initiative

123.3

92.7

81.385.1

78.574.0

81.3

69.6

60.3

53.6 51.4

44.749.7 47.4

42.336.5

32.8 33.5 32.135.4 35.9 34.5

31.835.7

0

20

40

60

80

100

120

140

MM

E (I

V)

/ 1

00

Pt

Vis

its

January 2017 – December 2018

↓ 72%p<0.01

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Provider Specific MME(IV)/100 Visits: Nov 2018

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6.1 6.712.5 13.4

18.9 21.1 21.5 22.2 22.9 24.5 24.8 25.8 27.7 29.3 31.036.0 39.5 40.2

45.0 46.2 47.3 49.058.0

8.9

37.849.0

150.0

196

112

289

149

288

134

296290

282

227

357

231

211

182

233

372

135

204

284

219

351

274

292

73

1524 20

0

50

100

150

200

250

300

350

400

450

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA

MM

E (I

V)

/ 1

00

vis

its

Provider

mME/100 visits

#pts 31.8 MME (IV)/100 Visits

Provider Doses Per Patient: November 2018

0

5

10

15

20

25

30

35

40

45

50

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z AA

Pat

ien

ts (

%)

Provider

20

10.5% of Patients Received an Opioid

↓ 52%p<0.01

STRATEGIES THAT WORKED

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Tracking the Data

• Daily, weekly, & monthly numbers

• Real-time assessment

• Track trends, order-set/alternative usage

• Target interventions to high-usage providers

• Provided to ED Medical Director

• Presented at monthly ED provider meetings

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Recurring Progress Meetings

Recommend meeting at least weekly

• Evaluate data

• Incorporate feedback

• Identify obstacles

• Make changes

• Assess impact

• RepeatKATA

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Education, Education, Education

• Providers → Provider Meetings

• Nurses → Shift Huddles, Staff Meetings

• Patients → One-on-one Discussions, Signage, Flyers/Pamphlets

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Patient Interactions

• Consistent message

• Patient reported pain is important to manage

• Engage patients

• Using proven medications

• Discuss risks of opioids

• “We care about taking care of you now and in the future”

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Habits are Habits

“Any act often repeated soon forms a habit; and habit allowed, steady gains in strength. At first it may be but as a spider’s web, easily broken through, but if not resisted it soon binds us with chains of steel.” - Tryon Edwards

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Recognizing Poor Prescribing Habits

• Utilized % patients prescribed/patients seen

– Identified individuals prescribing opioids for >50% of patients seen

• Evaluated type of opioid and dose per prescriber

– Identified individuals prescribing high doses as default

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Changing Practice

• “A nail is driven out by another nail. Habit is overcome by habit. “ -Desiderius Erasmus

• Targeted one-on-one education

• Changed providers’ “favorites” in CPOE background

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Tap into Desire

• Providers want to take good care of patients

• Aware of opioid crisis

• Alternatives appealing to most

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Celebrate Progress!

• Change inherently challenging

• Recognize efforts of individuals and team

• Success leads to more success

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NEW/NOT SO NEW CHALLENGES

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Medication Considerations

• Opioids are dirt cheap; alternatives may not be

– Increased utilization of IV APAP

• Increased IV room time/storage/delivery

– Ketamine syringes

• Increased utilization of fentanyl???

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Fentanyl Use in ED 2017-2019

15

53

91

0

10

20

30

40

50

60

70

80

90

100

Jan-17 Jan-18 Jan-19

Ord

ered

Do

ses

of

Fen

tan

yl

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Hall Lives Matter

• Approximately 15-40 patients boarding in BMH-Memphis ED daily since mid-December

• Addition of ~15 hall beds to utilize for triage and boarding patients

• Maintenance and daily medication requirements

• Hydromorphone free…?

• Patients first

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Patient Satisfaction

• Increase in overall patient satisfaction scores

• Stable scores related to pain management

• Consider internal surveys, if feasible

Provider & Nurse Satisfaction

• Report fewer pain seeking “frequent flyers”

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PRN Providers

• Difficult to educate due to sporadic work schedule

• Did not see high number of patients over the month, but often high metrics

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NEW/NOT SO NEW FRONTIERS

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ED Opioid Reduction

• ED discharge prescription review

• System implementation of ED Opioid-Light program

– 22 Baptist hospitals in TN, AR, MS

• THA state-wide pilot

– Webinars

– Any way we can help!

• Automated Data!!

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Pain Team – Inpatient Focus• Inpatient provider opioid education

• Multi-modal order sets– Peri-operative

– General medicine

• Recommendations for post-op opioid duration– PCA 3-day automatic stop date

– Post-op pain management assessment

• Pharmacy pain management consults for specific patients– Sickle cell crisis

– PCAs

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Peri-Operative Multi-Modal Order-Set

• Pre-operative

– Acetaminophen

– Celecoxib

– Gabapentin

– Methocarbamol

• Other options

– Opioids

– Anti-emetics

– Bowel regimen

• Post-operative

– Acetaminophen

– Gabapentin

– Ibuprofen or ketorolac

– Lidocaine infusion

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General Multi-Modal Order-Set

• Acetaminophen & NSAIDs

• Neuropathic pain – TCAs, SNRIs, gabapentin, pregabalin

• Trigeminal neuralgia – duloxetine, venlafaxine

• Musculoskeletal pain – cyclobenzaprine, baclofen, tizanidine, methocarbamol

• Topical agents – lidocaine patch, capsaicin cream

• Bowel regimen

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Inpatient Opioid MMEMilligram Morphine (IV) Equivalents per 100 Patient *Days*

415.1440.3

698.9

569.1602.4

403.8

518.7

392.9

1060.6

916.6

1295.5

742.2

1099.8

339.0

485.2 475.0

952.0

464.0

0.0

200.0

400.0

600.0

800.0

1000.0

1200.0

1400.0

MM

E (I

V)

/ 1

00

Pt

Day

s

523.3 MME (IV)/100 Pt Days

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Final Charge

• Small bites

• Invest in education

• Find your champions

• Celebrate victories AND failures

• Join the THA Opioid-Light ED Pilot!

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Acknowledgements

• ED Providers and Nurses!

• Dawn Waddell, PharmD, BCPS

• Julie Bennett, PharmD, MBA, BCPS

• Marilyn McLeod, MD, FACEP, FAEMS

• Dennis Roberts, RPh, Pharmacy Director

• Melanie Mays, RN, ED Nurse Manager

• Rachael Duncan, PharmD, BCPS, BCCCP

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