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Objectives. The objectives of this study were (1) to assess the impact of the 2016 Centers for Disease Control and Prevention (CDC) Guideline for Prescribing Opioids for Chronic Pain (GPOCP) on tramadol and opioid prescription rates in patients with chronic kidney disease (CKD), (2) to identify if tramadol was being properly dosed based on kidney function, and (3) to identify the number of clinically relevant drug-drug interactions related to tramadol. Design. Retrospective cohort study. Setting and Participants. Patients with a diagnosis of CKD stage IV or V or end-stage renal disease (ESRD) with a hospital discharge were identified. Participants were distributed into a pre-GPOCP cohort (January to December 2015) and post-GPOCP cohort (January 2017 to May 31, 2018) based on their hospital discharge date. Participants were then further divided into three categories: those who were discharged with a new prescription for tramadol, those who were discharged with a prescription for another opioid product, or those who were discharged with no new opioid or tramadol prescription. Outcome Measures. The primary outcome was incidence of new outpatient tramadol and opioid hospital discharge prescriptions. The secondary outcomes were the number of correctly dosed tramadol discharge prescriptions based on kidney function and incidence of clinically significant drug-drug interactions with tramadol. Results. New tramadol and opioid prescription rates upon hospital discharge for CKD stage IV and V and ESRD patients decreased from 76 (2.5%) to 54 (1.1%) and from 145 (4.7%) to 119 (2.5%), respectively (P < .001). Among the patients discharged with a new tramadol prescription, 113 (86.9%) patients did not have any clinically significant drug-drug interactions, and 94 (72.3%) patients were dosed correctly based on kidney function. Conclusion. The incidence of new outpatient tramadol and opioid prescriptions at discharge was significantly lower after the CDC GPOCP publication than before the publication.
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BACKGROUND: Misuse of prescription opioids is a public health crisis in the United States. In 2016, it was estimated that 3.3 million Americans were misusing prescription opioids (SAMHSA, 2017) and nearly 63,632 deaths were due to prescription opioid misuse. From 1999 to 2010, the number of prescription opioid drugs sold to health care facilities from pharmaceutical companies, nearly quadrupled. Cesarean delivery is the most common surgical procedure performed in the United States and opioids are most often chosen to manage post-operative pain. Research has shown that women, who deliver via cesarean section, are prescribed an excess of opioid tablets upon discharge and often store them in unsecure locations. Furthermore, the vast majority, are not disposed of properly. AIMS: The purpose of this quality improvement project was to assess whether a shared decision-making tool between a discharging obstetric provider and post-cesarean section patient can reduce the pool of unused opioids in the community. DESIGN: A one-group pre/post survey design was used to conduct this study. SETTING: 537-bed teaching hospital composed of 12 labor, delivery and recovery suites, 3 operating suites, and 33 postpartum suites. PARTICIPANTS: Engish speaking women, 18 years or older who delivered by cesarean section. METHODS: A shared decision-making session was implemented on a computer-based tablet, led by the discharge provider and woman following cesarean section on day of discharge. The tool focused on pain expectations, multi-modal methods (both pharmacologic and non-pharmacologic) to manage pain, safe storage, and disposal of excess medication. Women chose the number of 5-mg oxycodone tablets they would be prescribed, up to the institutional standard of 30. Women were provided a home opioid deactivation system to dispose of any excess tablets. A follow-up phone call was completed two weeks following discharge. RESULTS: Sixty women participated in the initiative. The mean number of 5-mg oxycodone tablets prescribed was 18. Women consumed a mean of 13 tablets, with 6 remaining. Eighty-eight percent (n = 33) of women disposed of their excess tablets, with 52% utilizing the opioid deactivation system provided. The initiative resulted in 92% (n = 47) of patients utilizing all of their prescribed tablets or properly disposing of them. CONCLUSION: Engaging post-operative patients in decisions regarding pain management, educating women on multi-modal methods to manage pain, and providing women with a means to properly dispose of excess tablets, can reduce opioid tablets available for misuse and diversion in the community.
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Analgésicos Opioides , Cesárea , Dolor Postoperatorio , Pautas de la Práctica en Medicina , Mejoramiento de la Calidad , Analgésicos Opioides/efectos adversos , Analgésicos Opioides/uso terapéutico , Cesárea/efectos adversos , Femenino , Humanos , Oxicodona/efectos adversos , Oxicodona/uso terapéutico , Dolor Postoperatorio/tratamiento farmacológico , Embarazo , Estados UnidosRESUMEN
The opioid stewardship model is born out of the antimicrobial stewardship model, and thus there are many shared characteristics. Both opioid stewardship and antimicrobial stewardship are based on the principle that there is an indication for a particular medication in the right patient at the right time. As antimicrobial stewardship is in a later stage of development, looking at the two in parallel can lead to interesting learning and development opportunities for opioid stewardship. Two requirements of antimicrobial stewardship that need to be applied to opioid stewardship for optimum outcomes are the requirement for dedicated resources, more specifically a trained pharmacist, and a declaration that opioid stewardship is essential for health-system accreditation.
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Programas de Optimización del Uso de los Antimicrobianos , Analgésicos Opioides , Antibacterianos , Humanos , FarmacéuticosRESUMEN
BACKGROUND: Multimodal pain management is an integral part of enhanced recovery pathways. The most effective pain management strategies have not been determined. OBJECTIVE: The purpose of this study was to compare liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing colorectal surgery. DESIGN: This is a single-institution, open-label randomized (1:1) trial. SETTING: This study compared liposomal bupivacaine transversus abdominis plane block with epidural analgesia in patients undergoing elective open and minimally invasive colorectal surgery in an enhanced recovery pathway. PATIENTS: Two hundred were enrolled. Following randomization, allocation, and follow-up, there were 92 patients with transversus abdominis plane block and 87 patients with epidural analgesia available for analysis. INTERVENTIONS: The interventions comprised liposomal bupivacaine transversus abdominis plane block versus epidural analgesia. MAIN OUTCOME MEASURES: The primary outcomes measured were numeric pain scores and the overall benefit of analgesia scores. RESULTS: There were no significant differences in the Numeric Pain Scale and Overall Benefit of Analgesia Score between groups. Time trend analysis revealed that patients with transversus abdominis plane block had higher numeric pain scores on the day of surgery, but that the relationship was reversed later in the postoperative period. Opioid use was significantly less in the transversus abdominis plane block group (206.84 mg vs 98.29 mg, p < 0.001). There were no significant differences in time to GI recovery, hospital length of stay, and postoperative complications. Cost was considerably more for the epidural analgesia group. LIMITATIONS: This study was conducted at a single institution. CONCLUSIONS: This randomized trial shows that perioperative pain management with liposomal bupivacaine transversus abdominis plane block is as effective as epidural analgesia and is associated with less opioid use and less cost. These data and the more favorable risk profile suggest that liposomal bupivacaine transversus abdominis plane block is a viable multimodal perioperative pain management option for this patient population in an established enhanced recovery pathway. CLINICAL TRIAL REGISTRATION: http://www.clinicaltrials.gov (NCT02591407). See Video Abstract at http://links.lww.com/DCR/A737.
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Músculos Abdominales/efectos de los fármacos , Analgesia Epidural/métodos , Bupivacaína/farmacología , Colon/cirugía , Cirugía Colorrectal/normas , Bloqueo Nervioso/métodos , Dolor Postoperatorio/tratamiento farmacológico , Músculos Abdominales/inervación , Músculos Abdominales/fisiopatología , Adulto , Analgesia Epidural/economía , Analgesia Epidural/estadística & datos numéricos , Analgésicos Opioides/administración & dosificación , Analgésicos Opioides/uso terapéutico , Anestésicos Locales/administración & dosificación , Anestésicos Locales/farmacología , Bupivacaína/administración & dosificación , Procedimientos Quirúrgicos del Sistema Digestivo/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Manejo del Dolor/métodos , Manejo del Dolor/normas , Dimensión del Dolor/métodos , Atención Perioperativa/normas , Periodo PosoperatorioRESUMEN
OBJECTIVES: The benefits of a pharmacist's involvement in medication reconciliation and discharge counseling are well documented in the literature as improving patient outcomes. In contrast, no studies have focused on the initiation of a pharmacist-led opioid exit plan (OEP) for acute postoperative pain management. This paper summarizes a pharmacist-led OEP practice model and the potential role that pharmacists and student pharmacists can have at the point of admission, during postoperative recovery, and on discharge in acute pain management patients. SETTING: The pain management team at St. Joseph Mercy Hospital in Ann Arbor, MI, has developed and implemented a pharmacist-led OEP to better manage acute postoperative pain in neurosurgery and orthopedic and colorectal surgery in an effort to ensure appropriate patient and provider education and understanding of pain management. PRACTICE DESCRIPTION: OEP is a tool with the potential to expand the role of pharmacists in managing acute pain in postoperative patients at the point of admission, during the postoperative inpatient stay, and on discharge. Its benefits include medication reconciliation review and prescription drug-monitoring program search before admission, interdisciplinary rounds with the medical team to provide optimal inpatient postoperative pain management, clinical assessment of outpatient prescriptions with opioid discharge counseling, and medication evaluation of prescribed pain regimen and opioid discontinuation status at the post-discharge follow-up appointment. CONCLUSION: A hospital pain management team operating a pharmacist-led OEP can be key to guiding the appropriate prescribing practice of opioids and assisting with transitions of care on discharge. Further outcomes-based evaluations of the practice model are planned and encouraged to validate and improve the pharmacist-led OEP practice.
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Dolor Agudo/tratamiento farmacológico , Analgésicos Opioides/administración & dosificación , Dolor Postoperatorio/tratamiento farmacológico , Farmacéuticos/organización & administración , Humanos , Conciliación de Medicamentos/métodos , Admisión del Paciente , Grupo de Atención al Paciente/organización & administración , Alta del Paciente , Educación del Paciente como Asunto/métodos , Transferencia de Pacientes/organización & administración , Servicio de Farmacia en Hospital/organización & administración , Pautas de la Práctica en Medicina/estadística & datos numéricos , Rol Profesional , Estudiantes de FarmaciaRESUMEN
OBJECTIVE: To determine whether an educational intervention combined with a voluntary decision support system improves inpatient pain control. DESIGN: Retrospective serial cross-sectional study. SETTING: Community teaching hospital. PATIENTS: Patients admitted to internal medicine teaching service from October to December 2011 and 2012. The study cohorts consisted of a random sample of 75 patients each from both time periods. INTERVENTIONS: Beginning in August 2012, internal medicine residents participated in an interactive training session on the use of opioids for hospitalized patients and concurrently, a user initiated voluntary computerized decision support system (CDSS), in the form of computer order entry (COE) and pocket cards were introduced. The COE options correspond to the standardized opioid dosing regimen on the pocket card. Pain scores and opioid doses and demographic information were obtained from administrative databases. Additional covariates were abstracted via programmed electronic medical record (EMR) review. MAIN OUTCOME MEASURES: Pre- and postintervention, maximum reported pain score in every 8-hour period from first analgesic dose, to 72 hours after the first analgesic dose, were compared by fitting a multivariable linear mixed model. Naloxone use was a surrogate measure for secondary outcome of opioid overdose. RESULTS: The intervention had no effect on maximum pain score (MPS) over time, p = 0.0930. The estimated mean MPS (95% confidence interval) was 4.7 (3.9, 5.5) preintervention and 5.2 (4.4, 6.0) postintervention. CONCLUSIONS: A combination of a resident educational intervention, CDSS, and pocket cards did not improve MPSs over time for patients on an internal medicine teaching service.