Physician ALTO Training - PowerPoint Presentation

Physician ALTO Training CO’s CURE: Hospital Medicine Revised 8.19.19

Colorado Opioid Solution: Clinicians United to Resolve the Epidemic “CO’s CURE” Our Shared Vision: To formulate the nation's first comprehensive, multispecialty medical guidelines to address and end the opioid epidemic in Colorado.

Calcaterra, et al. JGIM 31(5):478-85. 2015 Opioids prescribed on hospital discharge increase the risk of the patient becoming a long-term opioid user. Root Cause?

Big Picture Solution Reduce the number of long-term opioid users Reduce the number of deaths from opioid overdose The Opioid Epidemic

CO’s CURE Framework Treat dependence Reduce harm Increase ALTOs Decrease opioids

CO’s CURE Goal: Treat pain, reduce harm

Current Prescribing Practices: The Inpatient Problem J of Hosp Med, 2014 Of 1.1 million nonsurgical inpatients across 286 US hospitals, 51% received an opioid during hospitalization. More than half with inpatient exposure were prescribed opioids at discharge. Half a million inpatient discharges in Colorado. ​ 125,000 discharged inpatients will get an opioid Rx. 7,500 new long term opioid users.​ In Colorado (2017)

For Long-Term Opioid Users(>100 MMEs Daily for 90 Days) 5% concomitant benzo users 1% diagnosed with OUD Greater risk of overdose death 1/3 concomitant benzo use Chang et al. BMC med; 16:69, 2018. Higher medical utilization Total costs 40% Medical 3% Pharmacy 172%

For Opioid-Naïve The Patients Age 45-54 years Tobacco use Acute or chronic pain Mental health diagnosis The Prescriptions Number of prescriptions filled (refills) Duration Long-acting > short-acting Cumulative and daily ME dosing Deyo, et al. JGIM 32(1):21-7.2016 Calcaterra, et al. JGIM 33(6):898-905.20185-6% become long term users Co-prescribedNSAIDsBenzosNeuropathic agents Muscle relaxants

For Opioid-Naïve The Patients Age 45-54 years Tobacco use Acute or chronic pain Mental health diagnosis The Prescriptions Number of prescriptions filled (refills) Duration Long-acting > short-acting Cumulative and daily ME dosing Deyo, et al. JGIM 32(1):21-7.2016 Calcaterra, et al. JGIM 33(6):898-905.2018 5-6% become long term usersCo-prescribedNSAIDsBenzosNeuropathic agents Muscle relaxants

Traditional approach: Pick one therapy Non-pharmacologic Non-opioids Opioids Severe Moderate Mild 0 10

Modern approach: Additive And Multimodal Non-pharmacologic Non-opioids Opioids Last line Second line First line

Who has done this? Now across the state Piloted at 10 Emergency Departments across Colorado Using suggested alternatives for headache, musculoskeletal pain, renal colic, abdominal pain and extremity pain Reduced opioids by 36% Increase use of nerve blocks, lidocaine, ketamine, etc. Increased alternatives by 31%

WHY? Non-opioid Medications for Pain Renal disease, liver disease, cardiac disease Medical comorbidities Minimal education on pain management Minimal training Limited options available Run out of options Over-prescribing of opioids Habit, Culture The most challenging step

Alternatives to Opioids

Pleuritic Pain With NSAIDS, consider gastric ulcer bleeding risk: For pneumonia, PE, inflammatory pleurisy, or uncomplicated rib fracture

Extremity Pain For cellulitis, deep vein thrombosis or neuropathy

Pharmacologic Guidance Visit www.cha.com\hospitalistCURE

Lidocaine infusions Evidence : lidocaine reduces pain scores and is opioid-sparing. Evidence supports use for neuropathic pain, limb ischemia and renal colic. MOA : Blocks conduction of nerve impulses through inhibition of sodium channels. Literature: Meta-analysis of 32 controlled trials states “IV lidocaine was safe for neuropathic pain, better than placebo and as effective as other analgesics.” Systemic administration of local anesthetic agents to relieve neuropathic pain (Cochrane Review, 2005). Eipe N, Gupta S and Penning J. Intravenous lidocaine for acute pain: an evidence-based clinical update. British Journal of Anesthesia 2016. Daykin H. The efficacy and safety of intravenous lidocaine for analgesia in the older adult: a literature review. British Journal of Pain 2017. Metabolism: Metabolized by the liver, excreted in the urine. Contra-indications: ACS, heart failure, arrhythmia (especially heart block, WPW), severe electrolyte disturbances, cirrhosis/liver impairment, seizure d/o, renal impairment What you need to know

Lidocaine infusions Lidocaine Toxicity: Predictable escalation of symptoms. What you need to know Early: Tongue and perioral numbness Metallic taste Lightheadedness Tinnitus Hallucinations Muscle fasciculations and tremors Late: Decreased level of consciousness (confusion, sedation) Tonic-clonic seizures HR <50 or >120, decrease in BP greater than 30 mmHgApneaVentricular dysrhythmias Cardiac Arrest Signs or symptoms of lidocaine toxicity may include:

Lidocaine infusions More on indications: Where is the evidence? Evidence supports use Evidence does not support use Neuropathic pain Post-operative: Hysterectomy, arthroplasty, CABG, breast surgery Critical limb ischemia Malignancy-associated pain*Renal colicPost-operative: colorectal surgery, urologic, spinal surgery, post-amputation, multi-trauma Rib fracturesBurnPalliative care* *Higher incidence of adverse effects in patients with malignancy (up to 52% of patients having a side effect). Cancer or cancer treatment thought to affect lidocaine plasma concentration and raise risk for toxicity. More evidence is needed. What you need to know

Lidocaine Infusions What you need to know Stored for reference at www.cha.com/hospitalistCURE

Abdominal Pain What about pancreatitis? M ay be able to reduce opioid use in this population but likely will still use opioids. For non-pregnant patients without a gastrointestinal bleed, perforation or obstruction. Suspected etiology should guide appropriate pain treatment

Musculoskeletal Pain For joint/arthritis and muscular/myofascial pain

Oral Ketamine Evidence: oral ketamine may have a role as add-on therapy in complex chronic pain patients when other therapeutic options have failed MOA: antagonize NMDA receptors in the CNS Adverse effects: HTN, tachycardia, myocardial depression, increased ICP, vivid dreams, anxiety, hallucinations, tremors, tonic- clonic movements, nausea, sedation. If acute change in vitals or intolerable psycho-mimetic effects, stop ketamine and consider benzodiazepine. Discharge: Can NOT prescribe ketamine on discharge. Not dispensed by pharmacies and has abuse potential (ie special K, use as a date rape drug) Contra-indications: seizures or NES, psychosis, mania, dissociative psychiatric disease, history of ketamine abuse, poorly controlled HTN, heart failure, arrhythmia, increased ICP, recent stroke, severe respiratory insufficiency or PTSD.Dosing: 25 - 50mg po TID prn. Using IV formulation as a liquid. Mix in sweet drink. When dosed orally, there is lower bioavailability and reduced side effects. What you need to know

Oral Ketamine What you need to know Stored for reference at www.cha.com/hospitalistCURE

Renal Colic For nephrolithiasis Pain Note* Desmopressin: provides comparable pain relief in renal colic to opioids; thought to relax ureter smooth muscle. No added benefit to NSAIDs. (Avoid if serum sodium abnormalities, others. See pharmacologic guidance document for further details.) See pharmacologic guidance document for references

If Opioids…

Goal: Treat pain, reduce harm  Treating Pain SHM recommends: Choose wisely Screen for abuse potential Tell patients and families Set expectations Herzig, et al. Improving the Safety of Opioid use for Acute Noncancer Pain in Hospitalized Adults: a Consensus Statement from the Society of Hospital Medicine. JHM; 13(4). 2018.

When to Choose Opioids Moderate pain or severe pain that has not responded to non-opioid therapy Non-opioid therapy is contraindicated or anticipated to be ineffective

Perform a rapid risk assessment to screen for abuse potential and medical comorbidities and alternative methods of pain control should be sought. Patients are a high risk for addiction include: 1. Hx of addiction themselves or in the family. 2. Hx of anxiety/depression/PTSD or other mental illness Smoking history. Age 16-45 (mainly men) High risk medical comorbidities include: 1. Pulmonary (COPD, sleep apnea)2. Cardiac (CHF)3. Organ dysfunction (renal or hepatic failure)4. Elderly age5. Combining opioids with other sedatives.Screen for Abuse Potential

Review the Colorado’s Prescription Drug Monitoring Program (PDMP) to assess for a history of prescription drug abuse, misuse or diversion. Screen for Abuse Potential

Tell the Story, Again Educate patients and families/caregivers: Risks and side effects of opioid therapy ALTOs for managing pain Nursing and pharmacy staff should repeat the same message

Set Expectations Communicate frequently with patients about: Expectations for pain management Trajectory for recovery and healing

PEARLS Plus Partnership, Empathy, apology, respect, legitimize, support Plus a plan For chronic pain: “I am sorry that you have such longstanding pain, Unfortunately, we are unlikely to cure your chronic pain in the hospital. This will be a potentially long journey of learning how to improve your function and quality of life with pain. We will support you in getting the follow up that you need.” “I am sorry that you are in so much pain. Let’s create a plan for your pain management.” “We have several effective medication options that we can use to control your pain while you are here.” “I recognize that you are in a great deal of pain right now, we will work on figuring out why you have pain and target your pain treatment towards that cause.” If using opioids for acute pain: “Opioids are powerful pain medications that can be helpful in the short term but lead to dependence and tolerance in the long term. We aim to use the lowest effective dose for the shortest period of time. Oral opioids are preferred to IV opioids in most cases because it gives longer, more steady pain control.” “We want to optimize your function and keep your pain at a manageable level. Unfortunately, we generally cannot take your pain away completely right away because this often means the medications are causing sedation or other side effects that will impair your ability to function.” Adapted from ALTO PEarLS by Patrick Kneeland, MD

When prescribing opioids: Last resort Start low and go slow Use sparingly Oral route Immediate release rather than long-acting Be aware of conversions between opioids Pair with non-opioids and non-pharmacologic interventions Goal: Treat pain, reduce harm  Reducing harm

Goal: Treat pain, reduce harm  Reducing harm When prescribing opioids, also: Use a bowel regimen Avoid co-prescribing with barbiturates, benzos or other CNS depressants Assess for response to therapy

Assessing the response to opioid therapy: 1. Functional improvement 2. Development of adverse effects Goal: Treat pain, reduce harm  Reducing harm Assess daily Ask about pain severity in context of function If no improvement, reconsider opioid therapy

Goal: Treat pain, reduce harm  Reducing harm How to assess improvement in pain? Compare to patient’s pre-existing function Verbal report with numeric scale or continuous visual analog scale Nonverbal behavioral pain scales are used frequently in the ICU: facial expression (grimace to relaxed) upper limb movements (partial retracted to no movement) muscle tension compliance with vent

Goal: Treat pain, reduce harm  Reducing harm At Time of Hospital Discharge Medication reconciliation Check past prescriptions (PDMP) Check home supply Naloxone? Patient Education Tell the story, again  risk, addiction, side effects