ASHP InterSections ASHP InterSections

Pharmacists at Riverside discuss patient pain control in daily interdisciplinary rounds with providers, nurses, and therapists.

PHARMACISTS AT RIVERSIDE HEALTH SYSTEM in Newport News, Va., are at the helm of an innovative paradigm shift in post-operative pain management. Historically, most joint replacement patients who sought to eliminate post-operative pain presumed opioids would be the cornerstone their pain control strategy. In 2017, Riverside’s pharmacy team rolled out a new  initiative aimed at reducing the amount of opioids prescribed for post-operative pain. The results have been nothing short of remarkable.

Multiple pain interventions

According to Cynthia Williams, Pharm.D., B.S., FASHP, two essential elements make the opioid reduction initiative a success: managing patient expectations regarding post-operative pain and provider use of multimodal analgesia (MMA).

“Unlike opioid-based regimens, MMA relies on non-opioid treatments, such as acetaminophen, non-steroidal anti-inflammatory drugs, neuropathic pain medications, and muscle relaxants, thus reducing the use of opioids,” Dr. Williams said. She is vice president and chief pharmacy officer at Riverside Health System and led the initiative along with a multidisciplinary team.

Cynthia Williams, Pharm.D., B.S., FASHP

Riverside’s “Joint University”

Dr. Williams, an ASHP member for over 20 years, said the efforts to change how Riverside’s total joint replacement patients think about post-operative pain begins well in advance of the procedure during conversations between patients and providers, and through group education sessions known as the “Joint University.”

“Joint University is our structured program that gives joint replacement patients, their caregivers, and families a chance to learn about all of the aspects and steps of total joint replacement surgery, from the pre-operative period to post-discharge home health care,” explained Dr. Williams.

While the Joint University was in place before this opioid reduction initiative was rolled out, Ms. Williams and her colleagues revised the educational materials to emphasize the need to balance post-operative pain control with safety and physical recovery.

The educational materials are reviewed with a nurse, who explains to patients that eliminating post-operative pain is unrealistic, may slow recovery, and place patients at risk of misuse and complications. “Chipping away at the commonly held patient expectation that there should be no pain post-operatively has been challenging, but the educational initiative has been effective,” said Dr. Williams.

Pharmacists take the lead

While addressing patient expectations, the Riverside team has also been encouraging providers to use MMA regimens, explained Katherine Koehl, Pharm.D., system director of clinical pharmacy services at Riverside Health System, and an ASHP member since 2006.

She said pharmacists have played a key role in achieving this shift in practice, through presentations at grand rounds, at provider retreats, and in one-on-one discussions with physicians, she noted. Pharmacists have also helped revise order sets to “make it easier for providers to do the right thing, which is to use fewer opioids,” Dr. Koehl said.

“Physicians can still order opioids, but the revised order sets for total joint replacement now default to include MMA components and require providers to take additional steps to prescribe opioids,” said Dr. Koehl. We’ve driven clinical practice by how we built our order sets, she added, pointing to a 95% adoption rate of MMA for total joint replacement surgeries.

Juanita Baer, Pharm.D.

Morning rounds

Ensuring joint replacement surgery patients are managed with MMA is a priority for Juanita Baer, Pharm.D., who is Riverside Health System’s surgical team lead for pharmacy.

“When I do my morning rounds, if a patient has high levels of pain, I’ll glance down at their chart and make sure that if they are receiving an opioid, they’re also being given multimodal components when appropriate, because pain medications work much better together than individually,” Dr. Baer said.

Indeed, she said having multiple components in place has led to less opioid use and is helping patients progress more rapidly in their physical therapy and through to discharge and rehabilitation. “By combining several different classes of drugs, we can find that individual optimal pain level where the patient is comfortable enough to sleep, while also being able to stand up safely and participate in physical therapy,” she said.

Expanding the program

Since the initial effort on elective total joints, Riverside has moved the focus to Enhanced Recovery After Surgery (ERAS) implementation in several specialty areas, including total colectomy and neurosurgery. One of the components of ERAS is the minimization of opioids, with a focus on multimodal pain management.

In early 2019, Riverside embarked on rapid performance improvement focused on ERAS implementation in colectomy surgery. “During the process, which included provider engagement from anesthesia and surgeons, the focus was placed on opioid-sparing treatment by utilizing multimodal pain management pre-operatively, the use of surgical blocks during the procedure, and the continuation of scheduled non-opioid medications post-operatively,” said Dr. Williams.

Katherine Koehl, Pharm.D.

Based on chart review, patients were successfully managed on limited or no opioid therapy and reported management pain levels. When opioids were needed for break-through pain, the oral route was utilized, which is a component of ERAS pathways, she added.

Leveraging the success of colorectal ERAS implementation, a neurosurgery project was launched in Summer 2019 and is showing early success, noted Dr. Williams.

Optimizing pain management

While there is now near-complete adoption of MMA regimens in Riverside’s total joint replacement, colectomy, and neurosurgery patient populations, Dr. Koehl said there was some initial resistance.

Perhaps the greatest reluctance, which was seen among both providers and patients, was that acetaminophen was thought of as a “low-value pain medication,” despite the evidence showing “it can be very powerful,” said Dr. Koehl. Some nurses were also initially apprehensive about spending more time administering the multiple medications included in an MMA regimen.

However, with education from pharmacists, providers and nurses ultimately placed the welfare of patients and others affected by the opioid epidemic over any hesitation, said Dr. Koehl.

“At the end of the day, we all want to minimize exposure to opioids and prevent large quantities of these drugs from getting into the community, and optimizing post-operative pain management is one way we have achieved this,” she said.

By David Wild

# # #