Opioid Stewardship Johnathan Goree, MD Director of Chronic Pain Division Chair of Opioid Stewardship Committee Assistant Professor Department of Anesthesiology University of Arkansas for Medical Sciences

Poll Everywhere Phone Computer Text JOHNATHANGOR491 to 37607 to respond Computer Respond at Pollev.come/johnathangor491

Disclosures I have no financial interests to disclose related to this presentation I will present some non-FDA approved uses of medications which include steroids (dexamethasone) for lumbar epidural steroid injections and anti-convulsants/anti-depressants for the treatment of neuroinflammatory chronic pain. Both of these medications have been used for these indications for over 20 years.

Outline Is the Opioid Epidemic Our Fault? Have We Caused Iatrogenic Epidemics in the Past? What is Opioid Stewardship? How Can it be Applied in Your Practice?

https://www. drugabuse * https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates

Addiction is Iatrogenic In the 1960’s 20% of heroin users started with prescription opioids. Today 80% do.

Causes of opioid-centric analgesia

https://www.polleverywhere.com/discourses/lTUhpDfrUKW3a5jyDoeNI

Deja-Vu - Antibiotics

Antibiotics. Inappropriate antimicrobial prescribing Increased antimicrobial resistance Increased antimicrobial side effects Increased morbidity &/or mortality

What are we doing?

What are we doing?

Ongoing Challenges

Opioids Inappropriate opioid prescribing Increased opioid tolerance Increased misuse of opioids Increased morbidity &/or mortality

Hospital Opioid Stewardship. Mission and Values: To provide safe and effective inpatient pain care at UAMS, to promote responsible prescribing upon discharge, to promote evidence based treatments for outpatient chronic pain, and to facilitate harm reduction and treatment for patients with addiction. Quality patient care Evidence-based medicine Community responsibility Continuous improvement Advancement of knowledge

Who does it take? Physicians Pharmacy Nursing Hospital Leadership Informatics Educators

Opioid Stewardship? Opioid Enhancing Chronic Pain Prevention and Control (indentification and treatment of acute pain Controlling Pain at the Source (regional anesthesia, physical therapy, interventional techniques) Prescribing Opioids when truly needed Prescribing Appropriate Opioid Doses (CDC guidelines, other guidelines Using the Shortest Duration based on evidence (Work by Corey Hayes and others) Reassessment (post surgical, in house nursing) Education of Staff Supporting an interdisciplinary approach Opioid

How can you bring this into your practice? Operate using the principles outlined in Abx Stewardship Appoint an Opioid Stewardship Director in your Practice Can be a nurse, pharmacist, or physician Collect and Analyze Data Prescriber Reports Electronic Medical Records (prescribing, outcomes, pain scores) Staff Education Patient Education

UAMS Opioid Stewardship Committee Opioid Education Initiative Coming in Fall of 2019 Lead by Carrie Hyde – Palliative Care Chronic Pain Acute Pain Emergency Physician Addiction Medicine Physician

Thank You

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28471-24581

Case Conference and Feedback Continuing Education Credit: TEXT: 501-406-0076 Event ID: 28471-24581

Case: Mr. R 70 y/o male with multiple medical conditions BMI – 38 DMII – Last A1C 6.4. (well controlled as of late) CKD – Cr. 1.3 Depression – diagnosed but not currently treated, patient says pain is cause. Heart Disease – multiple stents, uses Nitroglycerin “liberally” Recurrent Falls Chronic Pain

Medications: Oxycodone 15mg q4 PRN (~ 5 doses a day) Insulin Metformin Bystolic Promethazine q6 prn for nausea (opioid induced) And others…

Chronic Pain Complaints Diabetic Peripheral Neuropathy Severe. Has tried Cymbalta with no improvement. Feels that opioids help Severe Bilateral Shoulder Pain L Artificial Shoulder with severe pain to all motion and R Shoulder, s/p Humeral head fracture after fall in April. Not Amenable to Surgery. Feels that opioids help both

Other Information: Has had physical therapy for his feet and shoulders in the past. Feels it wasn’t helpful. Would try again. Ambulates with a Cane at home and uses a walker in public. Patient lives in Little Rock

Questions? How can we alter his medication regimen to improve his fall risks? Are there any physical therapy interventions that could be helpful for this patient? Are there any interventions for his mood? Are there any procedural interventions that could decrease his opioid need?