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Pharm.D.-M.D. Team Successfully Enacts Opioid-Free ED Shift

A pharmacist-physician team at Maimonides ED successfully substituted non-opioid pain meds for its patients in a recent IRB-approved study.

OPIOIDS ARE OFTEN THE GO-TO ANALGESICS in the emergency department (ED). They’re fast, powerful, and easy to prescribe and administer. But opioids are also addictive and a favorite among drug-seekers.

At Maimonides Medical Center, a 705-bed academic medical facility in Brooklyn, N.Y., a team of pharmacists, physicians, and researchers designed and implemented an eight-hour opioid-free shift in the ED to determine whether non-opioid analgesics could provide sufficient pain relief to help avoid some of the challenges of opioid overuse, such as dependency.

The project arose from a discussion between Victor Cohen, Pharm.D., BCPS, CGP, then clinical pharmacy manager of emergency medicine, Department of Pharmacy, and Sergey Motov, M.D., FAAEM, assistant program director, Department of Emergency Medicine, about the growing national problem of opioid addiction.

Victor Cohen, Pharm.D., BCPS, CGP

“We were getting stories from psychiatry physicians about OxyContin and other opioids. There is a significant OxyContin epidemic,” said Dr. Cohen, who is now corporate clinical director of pharmacy services at the Health and Hospital Corporation of New York City. “I thought we really needed to try to achieve an opioid-free ED for a day.”

Because Dr. Motov had conducted prior research on the effectiveness of ketamine vs. morphine in the ED, he was on board with the idea from the start and went to the Maimonides ED administration and institutional review board with the concept.

“I let them know that I would take full responsibility for provider education and for writing the protocol,” he said. “We were very clear that we didn’t want anyone to suffer, and we promised to designate a time limit for patients. If they were still in pain after other alternatives were used, we would use an opioid such as morphine, fentanyl, or hydromorphone as a rescue therapy.”

We knew based on personal experience that we would get a reasonable response to the [non-opioid] medications.

From there, Dr. Motov assembled a team of staff from the departments of emergency medicine, pharmacy, and clinical informatics to design a pain management strategy based on channel/enzyme/ receptor-targeted analgesia.

The team then developed a corresponding order set for input into their computerized prescriber order entry system. Options for treatment depended on the type and severity of pain and included acetaminophen PO/IV, dexamethasone sodium phosphate, diazepam, ibuprofen, ketamine, ketorolac IV, lidocaine IV, and methocarbamol

Challenges and Results

One of the greatest challenges to implementing the opioid-free day was in getting other clinicians acclimated to using other medications, according to Dr. Motov. “There was a fair amount of discomfort [among the team] about using unfamiliar medications,” he noted. “The nursing team, in particular, was uncomfortable with off-label uses.”

Sergey Motov, M.D., FAAEM

Fortunately, Drs. Cohen and Motov had conducted comparative studies of the medications to be used that allowed them to assemble provider education that set the other clinicians at ease. “We had extremely high-level safety guidance in how to do these activities in the ED due to the studies we did,” said Dr. Cohen. “The protocols were all within accepted standards of care.”

The team’s combined clinical experience also came in handy, said Dr. Motov. “We knew based on personal experience that we would get a reasonable response to the [non-opioid] medications. But we actually had a higher rate of patient satisfaction than we anticipated.”

Of the 17 patients who were managed during the shift, 83 percent were satisfied with their pain relief after 30 minutes of treatment, and 86.7 percent were satisfied after 60 minutes. Two patients were admitted, and four received no prescriptions for pain medications. Of the remaining patients, only one received a prescription for an opioid. The rest received prescriptions for non-opioid analgesics. The details of the protocol and study appear in the December 1, 2015, issue of AJHP, co-authored in part by Drs. Cohen and Motov.

This represents a real opportunity to change patient care for the better.

As part of the initiative, the team also developed a pocket-sized card for acute pain management that includes the protocol. The cards have ensured that ED physicians continued the process after the opioid-free day, said Dr. Cohen.

“We found that attending physicians who weren’t part of the research team did not continue the process,” he noted. “Although some would do it intermittently, many of the seasoned practitioners didn’t change their typical prescribing behavior. The card has helped more physicians adapt to the new protocol.”

Pharmacists were integral to both the protocol development and the project’s implementation. According to Dr. Cohen, the team conducted the study as a public health exercise with the blessing of Fredrick Cassera, MBA, R.Ph., Maimonides vice president of outpatient pharmacy services and director of pharmacy.

An Opportunity to Reduce Opioid Addiction

Dr. Cohen feels there is a large and important role for pharmacists in the implementation of new non-opioid pain management protocols in both the ED and across the healthcare enterprise.

“Our roles lie in conception, adjudicating guidelines, preparing admixtures, developing order sets, assisting physicians in entering orders, and implementing the protocols,” he said. “This represents a real opportunity to change patient care for the better.”

For pharmacists in other hospitals and health systems who wish to do something similar, Dr. Motov had some helpful advice.

“Pharmacists know better than physicians what medications can do for patients,” he said, adding that pharmacists should actively collaborate with physicians when pursuing this new protocol. “You only need one doctor to agree to try something, and then that doctor will bring another one on board, who will bring another one. All it takes is that first physician, and it will all fall into place.”

Protocols for non-opioid pain management stand to have a great impact on emergency department care, according to Dr. Cohen. “We can’t get rid of opioids altogether, but we can certainly streamline their use and help to cut down on abuse and dependency in this country.”

–By Terri D’Arrigo