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ED Pharmacists Keep Opioid-Naive Patients Naive

Dec 18, 2018

ED pharmacists Zachary Brent, Pharm.D., BCPS, and Julie Bennett, Pharm.D., MBA, BCPS, discuss opioid metrics.

IN THE EMERGENCY DEPARTMENT (ED) of Baptist Memorial Hospital in Memphis, Tenn., an innovative opioid stewardship program is showing real promise in keeping opioid prescriptions to a minimum while making sure patients are comfortable and pain-free. The program’s primary goal is to keep opioid-naive patients naive.

Opioids in the ED

“Opioids are an increasing problem in the ED, not because pharmacists are seeing so many more overdoses — those are often treated by EMTs — but because the ED is often where a patient is first exposed to opioids,” explained Julie Bennett, Pharm.D., M.B.A., BCPS, a pharmacist who works in Baptist Memorial Hospital’s bustling ED. “We realized that if we could find a way to eliminate that first exposure, then we could make a significant impact on the opioid crisis.”

With the full support of Baptist Memorial’s ED physicians and leadership, Dr. Bennett and Zachary Brent, Pharm.D., BCPS, also an ED pharmacist at Baptist Memorial, set out to create an opioid stewardship program that offers opioid alternatives to patients.

The two pharmacists, both members of ASHP, began the project in January 2017 by collecting data on opioid usage in Baptist Memorial’s ED. They chose milligrams of morphine equivalents per 100 emergency department patient visits as the primary metric. The data showed that in January 2017 the ED staff was giving 120 mg morphine equivalents per 100 ED patient visits. “This was sobering,” said Dr. Brent. “We were giving a dose of opioids to one out of every four patients in the ED.”

Opioid Alternatives

To reduce opioid dispensing, the hospital’s pharmacy team created an opioid stewardship program based on a program implemented at the Swedish Medical Center in Englewood, Colo. First, the Baptist Memorial pharmacy team identified five conditions that are typically treated with opioids: chronic abdominal pain, headache/migraine, renal colic, extremity fractures/joint dislocations, and musculoskeletal pain. The team then provided physicians with non-opioid alternative treatment options for each condition.

Dr. Bennett orders medications from an automated dispensing system.

“Treatment options are broken down into first-, second- and third-line options,” said Dr. Brent. “For example, first-line treatment for headache/migraine might include a liter of saline plus oxygen, ketorolac, ketamine, or lidocaine injections. A physician might choose one, two, or even three of these options.”

He noted that many of the first-line options are common OTC pain medications, but in IV form. “All of the treatment options are built into our computer physician order entry system so our physicians can easily access and order these alternative pain medications,” said Dr. Brent. “Most of the alternative options are also stocked in our automated dispensing cabinets in the ED to allow for quick retrieval by nurses.”

If an opioid is needed, then the pharmacy team will try to use the lowest effective dose. “If patients come in on opioids, that’s fine, but it doesn’t necessarily mean that we are going to give them opioids while they are in our ED,” said Dr. Brent. “The alternative medications we use tend to work quicker and more effectively to alleviate patients’ pain.”

For example, Dr. Bennett recalled a recent situation where a patient who used morphine and oxycodone at home for a certain condition wanted a prescription from the ED pharmacist to alleviate pain caused by her shoulder bursitis. “She already had topical lidocaine patches and creams and every other alternative I could think of at home,” said Dr. Bennett, who ultimately recommended a nonsteroidal anti-inflammatory drug called ketorolac. The patient remembered that she received ketorolac for a dental procedure and that it had really helped with the pain.

Communication and Education

Soon after rolling out the new opioid stewardship program, the pharmacists experienced a bit of pushback from physicians who were used to ordering opioids and from patients who expected to get them. The pharmacy team used a combination of communication and education to demonstrate why opioid alternatives can often be a better option.

ED physician Katrina Hutton, D.O., and Dr. Bennett talk about opioid alternatives for a patient being discharged.

On the patient side, the pharmacy team assisted nurses with answering patients’ questions about the alternative medications and made sure that patients’ pain needs were always being met. “There were many times when I was called to a room to explain to a patient how the alternative medication works and why it is better than an opioid,” explained Dr. Brent. “Sometimes the patient was satisfied with the explanation, and other times they weren’t.” He believes the conversations with patients helped them understand that the providers in the ED were trying to do what was best for them, instead of just defaulting to using opioids.

Although the physicians were excited about the change and enthusiastic about providing more appropriate care for their patients, “it was still difficult for them to curb their opioid use, since it was a habit for them to order opioids,” said Dr. Brent. “Once our providers knew they had support [from hospital leadership], and we provided them with the order sets and educated the nurses about opioid alternatives, they were all in.”

Satisfied Patients, Satisfied Providers

As a result of implementing the opioid stewardship program in the ED at Baptist Memorial, opioid use decreased by 73 percent. Where previously one out of four patients received a dose of an opioid in the ED, the number has now dropped to 1 out of 10. Patient satisfaction with how they felt their pain was being addressed increased by around 30 percent.

Dr. Brent believes the entire team of ED pharmacists, physicians, and nurses at Baptist Memorial has done a great job of communicating to the patient why they are being given an opioid alternative. “We are all focused on taking care of patients effectively and efficiently,” said Dr. Brent. “Through the opioid alternative program, pharmacists are providing physicians and nurses with the support to do that. ED pharmacists are in the perfect position to partner with our providers to give them the tools needed to take care of patients appropriately.”

 

By Ann Latner

 

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