Changing Practice: From Opioid Crisis to Advanced Pain Management Page Muthusubramanian, FNP-BC Anne Stadelmaier, BSN RN-BC, CPAN Nancy Farish, BSN RN-BC

The New Opioid Crisis Why did this shortage happen? How did we save drugs for people who needed them? How did we emergently implement a wide-scale, long-term solution? Did we do this safely? Did it work?

DEA mandate to pharmaceutical companies February 2017 October 2016 DEA mandate to pharmaceutical companies February 2017 Pfizer cited for IV opioid production March – May 2017 UVA pharmacy has initial problems ordering IV opioids October 2017 UVA restricts use of IV morphine and hydromorphone October 2016 DEA mandate to pharmaceutical companies February 2017 Pfizer cited for IV opioid production March – May 2017 UVA pharmacy has initial problems ordering IV opioids October 2017 UVA restricts use of IV morphine and hydromorphone

IV Opioid Production *Not to scale!

DEA mandate to pharmaceutical companies February 2017 October 2016 DEA mandate to pharmaceutical companies February 2017 Pfizer cited for IV opioid production March – May 2017 UVA pharmacy has initial problems ordering IV opioids October 2017 UVA restricts use of IV morphine and hydromorphone March 5, 2018 UVA pharmacy – IV opioid supply rapidly declining March 23, 2018 Multidisciplinary stakeholder meeting March 27, 2018 Trial of new regimen in select patients April 2, 2018 Use of all IV opioids restricted April 18, 2018 Full scope application in adult Main OR patients

Brief Recap of Shortage Protocol Preoperative Phase Non-opioid cocktail: Celecoxib (NSAID) Acetaminophen Gabapentin ERAS*: Intrathecal Duramorph Opioid options: Short Acting: - Hydromorphone - Oxycodone Long Acting: - Methadone - MS Contin - Oxycontin

Brief Recap of Shortage Protocol Preoperative Phase Non-opioid cocktail: Lidocaine Ketamine Dexmedetomidine Esmolol Volatile Anesthetics IV Acetaminophen (redose) Rectal Acetaminophen (redose) Opioid options: Rectal Morphine Rectal Hydromorphone Intraoperative Phase

Brief Recap of Shortage Protocol Preoperative Phase Non-opioid cocktail: IV/Rectal Acetaminophen Ketamine Rescue Lidocaine gtt continuation Ketamine gtt continuation Redose NSAID where appropriate Opioid options: Rectal Morphine Rectal Hydromorphone Oral Oxycodone Oral Hydromorphone Intraoperative Phase Postoperative Phase

Brief Recap of Shortage Protocol Neuraxial: Epidural Local anesthetic spinal Surgeon: Intercostal blocks Local infiltration Regional: Significantly increased the number of TAP blocks Consideration of regional approach in operative cases where not routine

Identifying key stakeholders

Hospital Administration Pharmacy Inpatient Nursing Ethics EPIC/Informatics Acute Pain Service Ambulatory Nursing Media House Staff Hospital Administration Patient & Family Education Marketing Surgeon

Meetings Messages Emails EPIC notes Administration Notes News/Media

Patient messaging Clinics Pre-op Calls SAS/PACU Postop Floor

Treating Pain: A Practice Change PACU Survey: Which would you administer first? Oral opioids were rarely given as a first line medication for acute pain Ketamine was used frequently; mostly influenced by prior use with the ERAS protocol IV acetaminophen was dependent on timing of the most recent dose

Treating Pain: A Practice Change What did the staff find most helpful? Assistance from colleagues 96% Daily Huddles 81% Emails 78% Staff meetings 67%

Treating Pain: A Practice Change What did the staff find most challenging? Drug onset differences Issues related to the new order sets Patients arriving in significant pain Nausea and vomiting

Opioid consumption in MMEs

Opioid MME per patient by phase of care

PACU pain scores per patient

Questions?

Special thanks to Bethany Sarosiek, RN, Steve Morton, RN and Reza Salajegheh, MD for their contributions to this presentation