Impact of a Changed Approach to the Use of Opioid Medications in

5/5/2015
Opioid Epidemic
Impact of a Changed Approach to the Use
of Opioid Medications in the Treatment of
Chronic Non-Cancer Pain Management in
Older Adults
Brenda Thiel, Pharm.D.
PGY-2 Ambulatory Care Resident
Detroit Medical Center, Harper University Hospital
• 99% of hydrocodone products
used by the United States
• More than 20,000 Americans
die each year due to
prescription drug abuse
• In 2012, U.S. doctors wrote
more than 125 million
prescriptions for hydrocodonecontaining drugs
Gaskin et al. The Journal of Pain. 2012; 13(8):715-724.
IMS Health
The speaker has no actual or potential conflicts of interest in relation to this presentation.
Misuse of Prescription Medication in Older Adults
DOUBLE
Opioid Medications in Older Adults
Percent of Older Adults
Regulatory Changes
• August 18th, 2014
• Rescheduling of tramadol to Schedule IV
• Refill maximum of 5 times
• October 6th, 2014
• Rescheduling of hydrocodone-containing products
to Schedule II
• No prescription refills, no phone prescriptions
Sadick B. Wall Street Journal. Sept 14, 2014.
Annual National Estimate of Hospitalizations (%)
Safety: Emergency Hospitalizations for
ADEs in Medications in Older Adults
Reasons:
• Pharmacokinetics
• Drug-drug
interactions
• Multiple
comorbidities
Top High Risk Medications
Budnitz et al. NEJM. 2011;365:2002-2011.
US Department of Justice- Drug Enforcement Administration: Office of Diversion Control Aug 22, 2014.
Treatment of Pain in Older Adults:
The Best Approach?
• Current evidence-based literature does not serve
as an adequate guide
– Target disease-specific conditions or younger
population
– Number of controlled studies with patients >75 years
old remain low
– High quality studies involving older adults from different
ethnic groups rare
Journal of American Geriatrics Society. 2009;57:1331-1346.
1
5/5/2015
Treatment
Safety of Opioid Analgesics in Older Adults
Type of Pain
Somatic
Acetaminophen
Topicals
-capsaicin cream
- NSAIDs
-others
PO NSAIDs*
Neuropathic
Centralized
SNRIs
Lidocaine patch
Topicals
-capsaicin cream
-NSAIDs
-others
Pregabalin/gabapentin
SNRIs
SSRIs
Pregabalin/gabapentin
- Opioids not indicated
The
Comparative
Safety of
Analgesics
in Older
Adults with
Arthritis
12,800 patients:
Medicare
beneficiaries
Propensity-score
matched 3
analgesic cohorts
Non-selective
NSAIDs
Selective
NSAIDs
Opioids
Solomon et al. Arch Intern Med. 2010;170(22):1968-1978.
Patient Education
Safety of Opioid Analgesics in Older Adults
NSAIDs
Patient Recall of Health Care Provider Counseling for
Opioid-Acetaminophen Prescriptions
Determine the frequency and nature of
counseling and patient recall
Opioids
The
Comparative
Safety of
Analgesics
in Older
Adults with
Arthritis
↑25%
Patient Recall
↑45%
↑50%
↑75%
1. Administration
2. Activities to avoid
3. Indication
44.3%
36.2%
32.9%
4. Addictive potential
9.3%
Patients infrequently recall counseling from
providers on important topics to prevent harm
Solomon et al. Arch Intern Med. 2010;170(22):1968-1978.
McCarthy D et al. Pain Med. 2014.
Study Aims: Practice Change in Treating
Pain in Older Adults
Impact of a Changed Approach to the Use
of Opioid Medications in the Treatment of
Chronic Non-Cancer Pain in Older Adults
Brenda Thiel, Pharm.D.1,2
Candice Garwood, Pharm.D., FCCP, BCPS1,2,3
Lisa Binns-Emerick, MSN, CNP2,4
Aim 1
• Compare opioid utilization before and after
the practice change
Aim 2
• Evaluate provider opinions and knowledge
of a new systematic approach
Aim 3
• Educate patients about alternative therapy
options and evaluate opinions
1Department
of Pharmacy Services, Harper University Hospital, Detroit, Michigan
2Rosa Parks Wellness Institute for Senior Health, Detroit Medical Center Geriatric Center of Excellence
3Wayne State University, Detroit, Michigan
4 Wayne State University Physician Group
2
5/5/2015
Hypotheses:
With Implementing of the Practice Change
Methods
• Retrospective, single center study
• Utilization of opioids will decrease
• IRB approved, Quality Improvement
Aim 1
• Rosa Parks Geriatric Center
Aim 2
• Providers will understand the practice
change protocol
– Over 3300 patients
– 68% female
– Average age 78 years old
Aim 3
• Patients will have a better understanding of
their pain and identify alternative therapies
Methods
Methods
Inclusion
• Pre-Implementation
• Greater than 12 weeks of
an opioid for pain:
– September 2013 through September 2014
–
–
–
–
–
–
–
• Post-Implementation
– January 2015 through March 2015
Practice Model
•
•
•
•
•
• CBT/ACT
• Meditation
• Address
mood/trauma
issues
Psychobehavioral
Physical
Promote
Wellbeing
SELF
CARE
Medication
•
•
•
•
•
Reduce
Pain
Procedural
NSAIDS
Anticonvulsants
Antidepressants
Topical agents
Opioids
• Cancer patients
• Patients who receive pain
management elsewhere
Practice Change
Restore
Function
Exercise
TENS
Yoga
Heat
Cold
Oxycodone products
Codeine/acetaminophen
Hydrocodone/acetaminophen
Oxymorphone products
Morphine
Fentanyl
Tramadol
Exclusion
Clinic Policy and Procedure:
-Pain contract agreement
-Drug Screen
-Patient Assessment
-STOP BANG/PHQ2
-Automated Prescription System
-No paper prescriptions
-Refer as appropriate (pain, sleep, PT, etc)
• Nerve blocks
• Steroid
injections
• Stimulators
Improve
Quality
of Life
3
5/5/2015
Practice Change
Baseline Characteristics
Provider Education:
Pre-Implementation (n=348)
-Opioid Addiction Lecture
-Chronic Pain in Older Adults Lecture
Age
Patient Education:
-Self Management of Pain Class
-Follow up classes offered
Evaluation:
-Retrospective patient chart review
-Provider questionnaire
-Patient survey
Primary Outcome
75 ± 9
African American
290 (83%)
Female
261 (75%)
Pain Indication:
Osteoarthritis
Back Pain
Other
191 (55%)
72 (21%)
79 (23%)
Basic Activities of Daily Living:
Independent
Limited
Not available
223 (64%)
49 (14%)
76 (22%)
Antidepressant Use
87 (25%)
Opioid Selection
(n=348)
(n=132)
1 year
Assuming the same clinic
volume, documented
opioid prescribing rates
increased.
3 months
Number of Older Adults
Results- Patient Assessment
Results- Patient Education Survey (n=9)
Did you
learn
something
new about
pain?
12%
YES 100%
NO 0%
Did you
learn a
different
way to
treat pain
today?
YES 100%
NO 0%
12%
76%
Do you
believe
exercise
will help
pain?
YES 78%
NO 22%
Do you
believe that
exercise will
help you do
more daily
activities?
YES 100%
NO 0%
4
5/5/2015
Results- Patient Education Survey (n=9)
Would you
try an
activity at
a senior
center?
YES 89%
NO 11%
YES 78%
Percent of Patients
Would you
try a new
way to
treat pain?
NO 22%
Results- Alternatives to Pain Medication
Results- Process Assessment
Exercise can improve
symptoms and function in
patients with chronic
pain.
Percent of Providers (n=10)
Percent of Providers (n=10)
Antidepressants usually
improve symptoms and
function in patients with
chronic pain.
Study Limitations
•
•
•
•
•
•
Results- Provider Education Survey
Single center design
Retrospective
Electronic medical record
Changes in documentation
Limited patient assessment
Small patient education participation
If you have a new
patient to the clinic who
inquires about opioid
medication for their
osteoarthritis, which
procedures should be
included
Conclusions
• Measurable change in opioid utilization will require
addition time
• Similar opioid selection trends before and after
practice change
• Improved understanding of clinic protocol
implementation by providers
• Increase in patient awareness of pain management
alternatives
5
5/5/2015
Learning Question #1
Learning Question #1
What is considered a contributing factor to age
related challenges of older adult pain
management?
What is considered a contributing factor to age
related challenges of older adult pain
management?
A.
B.
C.
D.
Multiple comorbidities
Pathophysiology
Pharmacokinetics
All of the above
A.
B.
C.
D.
Multiple comorbidities
Pathophysiology
Pharmacokinetics
All of the above
Learning Question #2
Learning Question #2
Which adverse event is not considered to be
attributed to opioid medication use in older
adults for chronic pain management?
Which adverse event is not considered to be
attributed to opioid medication use in older
adults for chronic pain management?
A.
B.
C.
D.
Increase risk of cardiovascular events
Fall risk
GI bleed
Respiratory depression
A.
B.
C.
D.
Increase risk of cardiovascular events
Fall risk
GI bleed
Respiratory depression
Acknowledgements
• Candice Garwood, Pharm.D., FCCP, BCPS
Questions
• Lisa Binns-Emerick, MSN, CNP
• Niketh De Souza, MD
• Rajavardan Bandaru, MD
6
5/5/2015
Impact of a Changed Approach to the Use
of Opioid Medications in the Treatment of
Chronic Non-Cancer Pain Management in
Older Adults
Brenda Thiel, Pharm.D.
PGY-2 Ambulatory Care Resident
Detroit Medical Center, Harper University Hospital
The speaker has no actual or potential conflicts of interest in relation to this presentation.
7