1. Development & Implementation of “Sliding Scale” Pain Protocols Jayne Pawasauskas, PharmD, BCPS Clinical Professor URI College of Pharmacy & Clinical Pharmacy Specialist – Pain Management Kent Hospital

2. Objectives for Today  To describe the development and implementation of protocols developed to manage acute pain for patients admitted to a medical service  After participating in this presentation, you should be able to:  Discuss the rationale for implementation of acute pain protocols that can be effective for both opioid naïve and varying degrees of opioid tolerant patients  Demonstrate how use of acute pain protocols facilitates compliance with Joint Commission standards and regulations

3. Drivers for Change  Joint Commission  Sentinel Event Alert  Prevention of errors  Prevention of duplicate orders  Encourage use of Multimodal Approach (MMA)  Limit occurrence of opioid-related ADEs (ORADEs)  Our hospital specifics/background  sometimes poor opioid conversions during TOC  Provide consistent analgesia  Wish list: improve patient satisfaction (HCAHPS scores)

4. % Change

5. Background Information on the Protocols  Created from analysis of inpatient opioid usage/requirements in non-surgical patients  Total amount of opioid used by patients in a variety of medical states on first day of admission, then followed for 10 days or until discharge.  Sample patients did not require naloxone at any point during hospitalization  Sample deemed to have safe and effective use of opioids

6. Surveillance Data => High Dose

7. The 6 Acute Pain Protocols  Breakpoints were set to distinguish 3 groups of patients:  Low dose (0-50 MED per day or opioid naïve)  Medium dose (51 – 100 MED per day)  Patient continues on home med of long-acting analgesic and uses this protocol to manage breakthrough pain  High dose (>100 MED per day)  Patient continues on home med of long-acting analgesic and uses this protocol to manage breakthrough pain  For each of these dose ranges, there is a regular/normal PowerPlan, and one for NPO patients  Each protocol contains 3 steps of analgesia (and medications): mild (any pain >0), moderate (pain 4-7), and severe (pain 8-10)

8. LowDose Protocol

10. High Dose Protocol

12. High Dose NPO

14. Link to Global RPh

19. Preliminary Data  Initial 90 days after implementation Plan# patients (%) Low dose58 (84.1%) Low dose NPO5 (7.3%) Medium dose4 (5.8%)* Medium dose NPO1 (1.4%) High dose1 (1.4%) High dose NPO0 * One occurrence of medium dose protocol ordered on an opioid-naïve patient No other overt errors encountered with selection of appropriate protocol for Individual patient

20. Indications

21. Pharmacist interventions  Documentation of pharmacist interventions for 13% of patients  Therapeutic duplication  Tramadol issues (additive seizure risks with other meds on profile, fall risk)  Clarify home med vs. protocol med  Drug Allergy  General questions

22. Subgroup Analysis  Exlusion criteria  Patient received less than 2 doses of pain protocol med/24 hr  Patient admitted to ICU at any time during hospitalization  Surgical patient/post-op  Excluded nursing unit (4W or 2N)  N=26  Representing 12 different hospitalist prescribers

23. Efficacy subgroup analysis of patients meeting study inclusion criteria (n=26)*  Baseline pain score  Average = 7.13  Median = 7  17% were opioid tolerant  Time to analgesia  Average = 7.5 hr  Median = 4.35 hr * 2 patients excluded from analgesia analyses due to problems with documentation of pain scores

24. Safety  Use of naloxone  0  GI ADRs  3 patients had documented episodes of diarrhea  No additional treatments needed  C.diff  2 patients tested  One negative – admitted for Abd. Pain/diarrhea prior to use of protocols  One positive – admitted with h/o C.diff  Constipation  1 patient had documented constipation  Administered enema; addition of senna/docusate BID, bisacodyl PR prn  Nausea/Vomiting  6/5 patients – received additional ondansetron or prochlorperazine  Most patients had admitting diagnosis contributing to N/V (i.e. EtOH withdrawal, n/v, infections, cancer)

25. Potential Pitfalls….  Correlation of breakthrough pain medication to numeric pain scores  ?indications becoming too specific?  Incorrect use could create duplications  PowerPlan on profile + additional opioids ordered  Pharmacists must be very careful when reviewing new orders for analgesics

26. Questions?