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October 26, 2018

Pharmacists Spearhead Opioid Stewardship at Virginia Mason

ON A SPRING DAY IN 2016, a female patient walked into the Physical Medicine and Rehabilitation clinic at Virginia Mason Medical Center in Seattle. The patient, who came to Virginia Mason after her previous provider moved out of state, was receiving more than 1,300 morphine milligram equivalents (MMEs) per day for chronic low back pain.

As one of the medical center’s Ambulatory Pharmacy Managers—and one of the first pharmacists at Virginia Mason to join its innovative team-based care model for opioid stewardship — Amanda Locke, Pharm.D., M.B.A., BCACP, is well equipped to care for this patient and others receiving potentially dangerous amounts of opioids for chronic pain.

Opioid Interventions

Amanda Locke, Pharm.D., M.B.A., BCACP

Since 2012, when she helped establish the opioid stewardship program, Dr. Locke and other ambulatory care pharmacists at Virginia Mason have been meeting with patients receiving chronic opioid therapy for persistent pain. The goal is to reduce or eliminate opioid use. Under the new model, patients have an average of four routine clinic visits per year — one with both their opioid-prescribing provider and a clinic pharmacist provider, and three other appointments alternating between the pharmacist and the prescribing provider.

Prior to and during clinic visits, pharmacists review the patient’s medication regimen, assess the risk for opioid-related complications, and conduct and review urine screens. They also provide education on pain management and opioid use, and explain the medical center’s opioid use policy. The pharmacists recommend non-opioid and non-pharmacological treatments, such as physical therapy, mindfulness, and acupuncture, and they prescribe naloxone.

Lowering MMEs, Standardizing Care

According to Dr. Locke, patients partaking in the opioid stewardship program have seen their total MMEs decrease during a 32-month period. In addition, the program helps ensure that each patient receiving chronic opioid therapy is treated according to the same best practices at every visit, whether the patient is seen by a pharmacist or another provider.

“Since the program has been in place, we’ve seen prescribers adhering more closely to safe prescribing guidelines and state regulations, and using risk-assessment tools, urine screens, and patient agreements significantly more often,” Dr. Locke said.

Supporting Patients Through Life Changes

While treating patients receiving opioids for chronic pain, Dr. Locke has learned some important lessons. For example, tapering opioid doses can lead to emotional responses from many patients, and they need to feel supported and listened to within the provider-patient relationship.

“The best and most effective tapering experiences involve working with the patient and supporting them, rather than just telling them how to taper,” she said. “We have lots of discussions with the patient and try to understand their goals and concerns. We also use shared decision-making tools and motivational interviewing to make sure they have the goal of reaching that lower dose.”

Non-pharmaceutical care — such as physical therapy, mindfulness, and acupuncture — during the opioid-tapering process has also been an important component, Dr. Locke said, noting that opioid use and persistent pain can be driven by unmet needs like uncontrolled depression, anxiety, and sleep deprivation. “Our clinic pharmacist providers are trained to address behavioral health concerns and sleep care, and we’re also getting more involved in substance use disorder management,” she said.

Word Is Spreading

The success of the opioid stewardship program has inspired a growing list of departments at Virginia Mason, such as rheumatology and neurology, to include pharmacists in the management of their patients receiving opioids for chronic pain.

Because managing opioid treatment in patients with neurological and movement disorders patients presents unique challenges, Virginia Mason brought Lorifel Nabong, Pharm.D., BCACP, on to its neurology clinic in early 2017. “It can be a challenge to manage medications. Patients may lose their prescriptions or tablets, so coming to the clinic to see a provider once a month or every three months for refills can reduce the likelihood of that happening,” said Dr. Nabong. “Meeting with patients more often also means they can be monitored more closely than they might be, if they were to have access only to their primary care provider.”

Lorifel Nabong, Pharm.D., BCACP, talks to a patient about how opioids affect brain function. Photo credit: Bob Riedlinger, Medical Photography Department at Virginia Mason

In addition to being an invaluable opioid management resource at the neurology clinic, Dr. Nabong has also seized upon other opportunities for medication therapy management. “I’ve been helping the team with a variety of conditions, including managing seizure medications for epilepsy, symptom relief medications for patients with multiple sclerosis, and finding financial assistance for patients with Parkinson’s disease who cannot afford the newer, more expensive medications,” said Dr. Nabong.

Both Dr. Nabong and Dr. Locke feel that greater pharmacist involvement in the opioid and pain management process has been an opportunity for health-system pharmacists to provide the high-level clinical care they are trained for. Moreover, their work has also freed other providers to practice at the top of their licenses.

“For example, two days a week of having a pharmacist see patients in the Physical Medicine and Rehabilitation Clinic has meant physicians can see an additional 1,200 patients annually,” said Dr. Locke. “And taking on some medication-heavy tasks that nurses were frequently called on to do — like creating a drug-tapering schedule — has allowed them to focus on providing the care that best fits their skill set.”

Group Sessions to Meet High Demand

Demand for pharmacist involvement in the care of patients receiving chronic opioid therapy has been so high at Virginia Mason that, at some clinics, offering group meetings has been the most effective way to reach as many patients as possible.

Emily Sullivan, Pharm.D.

Emily Sullivan, Pharm.D., Primary Care Pharmacist at Virginia Mason, meets with groups of six to 12 patients for 20 to 40 minutes, twice a month. “During the sessions, I talk about pain and opioids, and emphasize the effectiveness of complementary and non-opioid pain treatments,” she explained.

Despite the group format, Dr. Sullivan individualizes care by checking each patient’s prescription drug monitoring program record prior to a session and scouring their medical record for potential drug interactions. She also reviews their drug screens and writes naloxone prescriptions for patients receiving high-risk doses of opioids.

Dr. Sullivan said the group format offers patients an opportunity to ask questions, share their experiences, and learn about approaches that have been effective for others with persistent pain. “Something I like about the group format is that patients can see that they’re not alone. Pain can be very isolating, and meeting others who are in similar situations can alleviate some of that isolation,” she said. “Caring for patients using chronic opioids can be challenging, but the experience has been extremely rewarding.”

The results have also been rewarding for patients, including the woman who walked into Dr. Locke’s office receiving 1,300 MMEs per day. “Initially, as we were lowering her opioid dose, she said her pain was increasing, but after a while she also began noticing other things, like not dozing off on the couch as much at the end of the day, sleeping better, and being more active,” recalled Dr. Locke. “Now, two years after the initial visit, we’ve cut her opioid dose to 300 MMEs, and we plan to keep going until we reach 90 MMEs.”


By David Wild




October 5, 2018

Pharmacy and the Art of Resilience

PAUL MILLIGAN, PHARM.D., a Medication Safety Pharmacist at BJC HealthCare in St. Louis, has worked in the pharmacy profession for 35 years. His career, while incredibly rewarding, has required him to contend with plenty of daily stress, manage the expectations of doctors and other practitioners at busy healthcare facilities, and regularly face the pressure that comes with saving lives. When the rewards of the job don’t outweigh the struggle, however, Dr. Milligan said it can leave him feeling burned out.

Pharmacy Sculpture

Pharmacists are increasingly suffering from professional burnout, which is why Dr. Milligan was immediately interested when the National Academy of Medicine (NAM) Action Collaborative on Clinician Well-Being and Resilience issued a call for submissions for original artwork from healthcare professionals. The organization’s goal was to curate a digital art gallery that shows how clinicians are affected by burnout. By allowing healthcare providers to creatively express their experiences with burnout, Expressions of Well-Being: An Art Exhibition captures critical moments in their journey toward well-being.

Paul Milligan, Pharm.D., used sculpture to capture the moment a clinician holds a patient’s hand to make them feel safe and comfortable.

Dr. Milligan, who serves as Director-at-Large of the ASHP Section of Inpatient Care Practitioners, has created sculptures as a hobby for the last decade and welcomed the opportunity to submit his artwork for a project that is so close to his heart. He sent images of two of his works, and one was accepted for the project. He named the sculpture “Treat the Person, Treat Yourself,” at title that aptly sums up the professional mission that has carried him through his career.

“I wanted to capture that moment when a clinician is holding a patient’s hand and making them feel safe and comfortable,” he said. “It is really a two-way street at that point. These are the moments that I remember most, the ones that keep me going.”

Opioid Imagery

ASHP member Elizabeth Canterbury, Pharm.D., an emergency department resident at SwedishAmerican Hospital in Rockford, Ill., is another contributor to the NAM collaborative’s digital art gallery. She saw the project as a way to comment on current challenges plaguing the healthcare system.

”Don’t Slip“ was created by Elizabeth Canterbury, Pharm.D., who used Photoshop to superimpose a photo of herself on a chair with prescription bottles spilling on the floor.

Dr. Canterbury submitted a powerful image of herself on a chair superimposed with prescription bottles spilling on the floor, an image she created with the magic of Photoshop. The work is a commentary on the opioid epidemic, which in 2016 alone killed more than 42,000 Americans, according to the Centers for Disease Control and Prevention (CDC).

At age 26, Dr. Canterbury is closer to the beginning of her career, but she’s already found ways to stay levelheaded and avoid burnout. In addition to her artwork, she remains involved in activities that allow her to network with colleagues, which provides an outlet to voice her concerns with like-minded people.

“Holding leadership positions and taking advantage of opportunities like attending ASHP’s Midyear Clinical Meeting and doing a resident rotation at ASHP headquarters have helped me stay engaged and feel like I am contributing to the growth of the profession in addition to helping the patients I see on a day-to-day basis,” she explained.

A Portrait of Pharmacy

Evan Slagle, Pharm.D., BCPS, Antimicrobial Stewardship Pharmacist at Penn State Health St. Joseph in Reading, Pa., has also found solace and stress relief in activities outside of his job. Dr. Slagle, an avid runner, lived in South Philadelphia while attending the Jefferson College of Pharmacy. He would frequently go for runs toward the northern end of the city. The route would always take him past the Edgar Allen Poe National Historic Site, a tribute to the beloved 19th-century writer.

Evan Slagle, Pharm.D., BCPS, based “Imp of the Perverse” on a portrait of Edgar Allen Poe.

Dr. Slagle became fixated on a mural of Poe at the site. The writer, Dr. Slagle said, approached the themes of depression and anguish in uniquely expressive ways. One day, Dr. Slagle felt especially inspired after his run. The endorphins were rolling, he said, and so he sat down to recreate the portrait as best he could recall it. It took him four hours to complete, and he then submitted the work to the collaborative’s digital art gallery.

Over time, Dr. Slagle has come to realize that creative expression through art is a way to help him process the stress of his job. In fact, doing so became a necessity early in his career. Dr. Slagle initially dropped out of his PGY1 residency program because of stress, but later completed his PGY1 at a different hospital.

“I experienced burnout before I could define it,” he said. “Detaching yourself a little bit from the work and getting some perspective is the key. You need to totally separate yourself from time and the constant bombardments you get on a daily basis. We all need a reprieve from that.”


By Jessica Firger


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