1. 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

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3. 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.

4. 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?

5. https://www. drugabuse*

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

7. Causes of opioid-centric analgesia

9. Deja-Vu - Antibiotics

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

11. What are we doing?

12. What are we doing?

13. Ongoing Challenges

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

15. 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

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

17. 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

18. 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

19. 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

20. Thank You

21. Questions about the Topic
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22. Case Conference and Feedback
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23. 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

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

25. 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

26. 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

27. 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?