Clinical
Pharmacy Practice News • November 2020
21
Pain Management
How One Urban Med Center Tackled the Opioid Crisis I
n 2016, Kevin Horbowicz, PharmD, BCPS, was tired. Every day, he came to work at Boston Medical Center (BMC), the large urban hospital in the historic South End neighborhood, which has been hit hard by the opioid crisis. As the associate director of inpatient clinical pharmacy services, Horbowicz saw the signs of suffering all around—crime, homelessness and addiction. He and other stakeholders believed they could do better to confront this crisis. So they decided to tackle the problem in the only way they could: by changing the way BMC doctors prescribe opioids and treat addiction. It was a comco plex process, which included expanding nding the presence of pharmacists on surgery floors, and overhauling the electronic health record (EHR) to modify default prescription settings. But it was all worth it, said Horbowicz; in fiscal year (FY) 2018, BMC providers dispensed 74,000 fewer opioid pills than the year before. “I’m very proud of the collaborative multidisciplinary work that we did,” Horbowicz said.
A Local Issue Massachusetts is one of the top 10 states with the highest rates of opioid-related overdose deaths. To help combat the crisis, in 2017, BMC received a $25 million grant from Eilene and John Grayken. Executive leadership and other stakeholders—from surgery, nursing, emergency medicine, information technology and, of course, pharmacy—were all committed to making a difference in prescribing habits. The first place they tackled was inpatient utilization. They started by expanding the presence of pharmacists on acute care surgery floors, so pharmacists could suggest opioid alternatives, such as acetaminophen, ketorolac and other nonopioid pain medications, for appropriate patients. The strategy “gave pharmacists a seat at the table to help them contribute to those daily decisions that were made by the surgical team,” Horbowicz said. Indeed, this change alone reduced the use of opioids among acute care surgery inpatients by 12%, according to data that Horbowicz presented at the ASHP 2019 Midyear Clinical Meeting, in Las Vegas. In the emergency department, the pharmacy team worked with nurses and doctors to administer buprenorphine-naloxone (Suboxone, Indivior) or methadone earlier, connect more patients to treatment, and increase access to intranasal naloxone (Narcan, Adapt Pharma). And for patients who want to seek treatment for opioid use disorder, the emergency department now hands out free two-day buprenorphine-naloxone kits, a “bridge
agreed that many of BMC’s opioid-related interventions are possible elsewhere, and said many health systems are taking similar approaches. “The way BMC has done it with a multipronged [strategy] is the right way,” McLellan told Pharmacy Practice News. “It’s not just one solution that solves the problem.”
BMC Successes: Reduced the use of opioids among acute care surgery inpatients by 12% Dispensed nearly 74,000 fewer opioid pills in FY 2018 than in FY 2017 Reduced inpatient use of opioids among surgical patients by 41% Source: Kevin Horbowicz, PharmD, BCPS
therapy,” until they can th aattend their appointment with providers, he said. Perhaps the most effective change was e modifying the EHR to alter pain scale range orders and the 55 postoperative order sets used by more than two dozen surgical specialties at BMC. “Those two IT changes were the most important,” Horbowicz said, adding that in the past, surgical patients who reported pain scores of 1 to 3 (out of 10) were given 5 mg of oxycodone every four hours as needed— which was “just too much.” So stakeholders agreed on a new set of standard doses for pain scales, in which patients do not receive an opioid unless their pain is at 4 or higher. If patients had additional pain,
prescribers had the option to prescribe more opioids as needed. As noted, BMC dispensed nearly 74,000 fewer opioid pills in FY 2018 than in FY 2017; between 2016 and 2019, the inpatient use of opioids among surgical patients fell by 41%. Horbowicz acknowledged that smaller facilities may not have the same resources as BMC, given the size of the grant that fueled many of his team’s opioidreduction initiatives. Still, “many of these changes—such as changing order panels to omit opioids for mild pain—are possible anywhere,” he said. “It just requires some persistence, focus and courage.” Christine McLellan, PharmD, MHA, the pharmacy clinical coordinator at Emerson Hospital, in Concord, Mass.,
Move Away From Opioids For instance, she said, many other organizations have moved away from giving opioids to patients with only mild pain. “Some of this can be done without a grant, but you definitely need the support of administration, and you need physician champions to support those efforts,” she said. Seeing the success of a large center such as BMC helps make the case that well-designed and executed opioid management strategies will be worth it, added McLellan, who moderated the session at the ASHP Midyear Clinical Meeting. “It helps other hospitals recognize they can do this, too.” To McLellan, giving pharmacists an integral role is the most crucial step at any facility to reducing opioid use. Pharmacists can help with everything, she said: revising order sets, being on the surgical floor to recommend nonopioid therapies, and suggesting intranasal naloxone for high-risk patients at discharge. “The pharmacist is primed for opportunities like this to be able to combat the opioid crisis,” she said. “I think the pharmacist is the key to a lot of it.” —Alison McCook The sources reported no relevant financial relationships.
Helping you deliver better medicine to more people. Leiters is an FDA registered and inspected 503B outsourcing provider of high-quality compounded sterile preparations and services including: Pre-filled syringes, IV bags and vials Opioid-free surgical pain services medications ON-Q* Pain Relief System fill services Ophthalmology medications including FDA-compliant repackaged Avastin®
COMPOUNDING HEALTH™
Leiters.com | 800.292.6772
ON-Q* is a registered trademark of Avanos Medical, Inc., or its affiliates. Avastin® is a registered trademark of Genentech, Inc.
