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

2. 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?

4. 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

6. IV Opioid Production
*Not to scale!

7. 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

10. 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

11. 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

12. 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

13. 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

15. Identifying key stakeholders

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

17. Meetings
Messages s
EPIC notes
Administration Notes
News/Media

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

21. 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

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

26. 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

27. Opioid consumption in MMEs

28. Opioid MME per patient by phase of care

29. PACU pain scores per patient

30. Questions?

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