Priscilla Kim, PharmD PGY-1 Pharmacy Practice Resident St. Joseph’s Regional Medical Center

651 bed Magnet TM designated private non-profit teaching facility Emergency Department Level II Trauma Center Over 170,000 visits in 2015 Geriatric Emergency Department ED-based palliative care program Alternatives to Opioids (ALTO) program Decentralized Pharmacy Model Medical/Surgical and Telemetry Units Critical Care Pediatrics Open 24 hours/day, 7 days/week Pharmacy Practice Residency Program

National estimate of 60-75% of the geriatric population with complaints of persistent pain Adverse outcomes in older adults from persistent pain and its inadequate treatment functional impairment falls slow rehabilitation increased health care utilization increased costs Molton et al. Am Psychol. 2014;69(2):197. American Geriatrics Society. J Am Geriatr Soc. 2009;57(8):

Evaluate current chronic musculoskeletal and joint pain management practices for older adults who present to the emergency department

Primary Evaluate mean reduction in pain score per medication class Secondary Evaluate correlation of medications administered with length of stay in the emergency department Analyze appropriateness of therapy utilized in the emergency department and at discharge Assess patterns in discharge medication prescribing practices

Study Design Single-center, retrospective study approved by the hospital Institutional Review Board (IRB) Study Period January 1, 2015 – June 30, 2015 Data collection Report generated from emergency department system Chief complaint or diagnosis including “pain”, “arthritis”, “joint” Chart review of physician and nursing notes

Inclusion Criteria Age ≥ 65 Chronic pain Diagnosis of joint or musculoskeletal pain Administration of at least one pain medication in the emergency department Documentation of pain scores before and after medication administration Exclusion Criteria Acute pain Pain not of joint or musculoskeletal areas Neuropathic pain

Excluded:1324 n = 769no musculoskeletal or joint pain n = 390acute pain n = 105neuropathic pain n = 44no pain medications given n = 16missing pain scores Patients screened N = 1379 Patients included N = 55

Medications given are more potent than as indicated by their pain score Numeric Rating ScaleWHO step ladder Mild: pain score 1-4acetaminophen, NSAIDs Moderate: pain score 5-7tramadol, codeine, hydrocodone Severe: pain score 8-10oxycodone, morphine, hydromorphone Malec M, et al. Med Clin North Am. 2015;99(2): Baumann TJ, et al. Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014

Skeletal muscle relaxants or benzodiazepine without noted muscle spasms or anxiolytic symptoms NSAIDs administered in patient with history of cardiac disease, gastritis, GERD, GI ulcers, CrCl <30 ml/min Medications administered when pain score is zero Total dose of medications prescribed accumulates to greater than maximum recommended total daily doses Multiple drug class prescriptions from same drug class American Geriatrics Society. J Am Geriatr Soc. 2009;57(8): American Geriatrics Society. J Am Geriatr Soc. 2015;63(11): O'Mahony D, et al. Age Ageing. 2015;44(2):

Initial drug therapy in ED AcetaminophenNSAID Opioid > 1 medication Patients n=4n=5 n=33 n=13 Sex, Male (%) Race, White (%) Mean age (years) [range] 71.8 [69-73]77 [66-90] 73.5 [66-90] 70.4 [65-74] Total mean initial pain score 8.0 ± ± ± ± 1.04 Musculoskeletal Pain ± ± 0.97 Joint Pain 8.0 ± ± ± ± 0.58 Musculoskeletal Pain (%) Joint Pain (%)

p=NS

Medications administered in emergency departmentReasons for inappropriate use NSAID given when not preferred (n=5) Medication administered more potent than indicated by pain score (n=2) Skeletal muscle relaxant with no description of spasm (n=2) Medication given when pain score zero (n=1)

Prescriptions at dischargeReasons for inappropriate use Total daily dose greater than maximum recommended (n=4) Skeletal muscle relaxant with no description of spasm (n=2) NSAID given when not preferred (n=2) Medication more potent than indicated by pain score  discharged on same medication (n=1) Medication given when pain score zero  discharged with medications (n=1)

Opioid discharge prescriptions = 45 Total number of tablets dispensed = 885 tablets Total average days supply = 5 days (range: 2-10 days) Medications Discharge Prescriptions Tablets Median # days supply Tramadol53%5485 Oxycodone/ acetaminophen 27%1663 Codeine/ acetaminophen 18%1418 Tramadol/ acetaminophen 2%308

There is room for improvement to reduce the use of opioids and other non-preferred pain medications There may be an opportunity to reduce the use of opioids and utilize more of the non-opioid analgesics to manage chronic geriatric pain

Small sample size (55 patients) Short study period (6 months) Broad pre-defined inappropriate use criteria Lack of documentation of medications taken prior to admission

Provider education on chronic geriatric pain management Develop a protocol for chronic geriatric pain management in the emergency department

Which of the following should be considered for chronic pain management in the geriatric population? a)Dosing: start low and go slow b)Caution use of NSAIDs and opioids c)Avoid use of skeletal muscle relaxants and benzodiazepines, if possible d)All of the above

Steven Nerenberg, PharmD Emergency medicine clinical pharmacist Marianna Karounos, DO, MS Chief of the geriatric emergency department

Molton IR, Terrill AL. Overview of persistent pain in older adults. Am Psychol. 2014;69(2):197. American Chronic Pain Association. ACPA Resource Guide to Chronic Pain Medication and Treatment: 2015 Edition American Geriatrics Society Panel on Pharmacological Management of Persistent Pain in Older Persons. Pharmacological management of persistent pain in older persons. J Am Geriatr Soc. 2009;57(8): American Geriatrics Society 2015 Beers Criteria Update Expert Panel. American geriatrics society 2015 updated beers criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2015;63(11): O'Mahony D, O'Sullivan D, Byrne S, O'Connor MN, Ryan C, Gallagher P. STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2. Age Ageing. 2015;44(2): Malec M, Shega JW. Pain management in the elderly. Med Clin North Am. 2015;99(2): Baumann TJ, Herndon CM, Strickland JM. Chapter 44. Pain Management. In:DiPiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey L. eds.Pharmacotherapy: A Pathophysiologic Approach, 9e. New York, NY: McGraw-Hill; 2014

Priscilla Kim, PharmD PGY-1 Pharmacy Practice Resident St. Joseph’s Regional Medical Center