10/18/19 1 Caring for Patients on Opioids Lorri Shaver, PharmD Shanna O’Connor, PharmD Caitlin Brown, PharmD 2 1
10/18/19 Disclosure There are no relevant financial rela5onships with ACCME- defined commercial interests for anyone who was in control of the content of the ac5vity. 3 Pharmacist and Pharmacy Technician Learning Objectives • Describe workflow best practices for utilizing prescription drug monitoring programs. • List non-opioid pain treatment including, but not limited to, other prescription and non-prescription medications and non-pharmacologic treatments. • Discuss how to best document interventions in the patient care plan. 4 2
10/18/19 Plan for Today • PDMP Refresher • Worksheet activities • Workflow Best Practices and Resources • Worksheet activities • Alternate therapeutic options for pain treatment • Case and engagement • Documentation strategies • Worksheet activities 5 Orientation to handout and worksheet 6 3
10/18/19 Potato Pharmacy: Normal Tuesday • Mr. Spud is a 34-year-old male with complaints of chronic pain. He is currently taking oxycodone 10mg BID and hydrocodone/APAP 5/325 Q4h prn. He presents to the pharmacy with new prescriptions for oxycodone 15mg BID and hydrocodone/APAP 7.5/325 Q4h prn. You look back in his record and note a steady increase in MME over the past 6 months and he is 10 days early. • Does this sound familiar? • What happens next? 7 What should be done for Mr. Spud? • Corresponding Responsibility • Call the physician • Call the insurance • Document • Naloxone Protocol? 8 4
10/18/19 Activity • Who does what in your pharmacy • Initial opioid assessment • Checking PDMP • Documenting PDMP • Offering enhanced services related to opioids • Delivering enhanced services related to opioids • Documenting enhanced services related to opioids 9 PDMP Refresher 10 5
10/18/19 PrescripKon Drug Monitoring Programs (PDMP) • National Association of State Controlled Substances Authorities: PDMP resources, interactive US map • National Association of Boards of Pharmacy: State sharing information • Centers for Disease Control and Prevention: educational information, handouts, app 11 12 6
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10/18/19 Submitting to PDMP • Who is required to submit informa5on to PDMP? • h`p://www.pdmpassist.org/pdf/Mandatory_condi5ons_use.pdf • Most pharmacy sobware placorms report directly to PDMP through PMP Clearinghouse • Can be done through pharmacy sobware, online report upload, manual entry • See your specific state regula5ons 15 16 8
10/18/19 Workflow best practices for prescription drug monitoring programs Notable or want to try? Mark on your worksheet 17 Literature-guided • Risk-stratified, patient-centered screening • Open-ended questions paired with active listening • Identify red flags related to opioid misuse • Check the PDMP as part of workflow • Advocate for safe medication disposal (www.deadiversion.usdoj.gov/drug_disposal/index.html) • Naloxone access • Referral • Prescribing under collaborative practice/protocol • Independent prescribing Reynolds V et al. N C Med J. 2017; 78(3): 202-205.; Kennedy-Hendriks A et al. JAMA Intern Med. 2016; 176 (7):1027- 1029. 18 9
10/18/19 Example Workflow Sample Workflow Rx Drop-off <50 MME >50 MME In store or picking Someone else is Dispense Rx Delivery up later picking up Opioid Monitoring Send packet home Send packet with Form to patient driver Packet reviewed at Call patient in 7 Bring (or mail) back checkout, offer days to check signed packet naloxone status Must have signed Mail or deliver packet on file naloxone if desired before dispensing by patient 3rd opioid fill 19 20 10
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10/18/19 23 Another workflow 24 12
10/18/19 25 Pause: Brainstorm 26 13
10/18/19 PDMP Tools 27 28 14
10/18/19 29 PDMP Resources http://www.nascsa.org/rxMonitoring.htm 30 15
10/18/19 NASCA Map of State Profiles http://www.nascsa.org/stateprofiles.htm 31 32 16
10/18/19 PDMP Resources http://www.nascsa.org/rxMonitoring.htm 33 34 17
10/18/19 Working at the top of licenses • What steps in workflow does your state MANDATE be completed by pharmacists? • What roles can technicians take on? • What role can cashiers have? 35 Worksheet: What works for your workflow 36 18
10/18/19 Potato Pharmacy: Normal Tuesday Mr. Spud is a 34-year-old male with complaints of chronic pain. He is currently taking oxycodone 10mg BID and hydrocodone/APAP 5/325 Q4h prn. He presents to the pharmacy with new prescriptions for oxycodone 15mg BID and hydrocodone/APAP 7.5/325 Q4h prn. You look back in his record and note a steady increase in MME over the past 6 months and is 10 days early. • What kind of pain is Mr. Spud experiencing? Is his pain regimen optimized? 37 Review of non-opioid pain treatment What questions might we ask Mr. Spud in order to better • assess his pain? • Brief Pain Inventory: http://www.npcrc.org/files/news/briefpain_long.pdf • Opioid Therapy Assessment: http://www.trmc.net.au/pdf/sixas-opioid-therapy-monitoring-tool.pdf • Substance Misuse Assessments: SOAPP-R, DIRE Score, Opioid Risk Tool, SBIRT, CAGE-AID • Sensory, affective, cognitive, psychiatric, psychosocial, trauma, and sleep assessments What therapy can we recommend to augment Mr. Spud’s • current pain regimen? 38 19
10/18/19 Review of non-opioid pain treatment options • Using the drug table posted online, compare and contrast non-opioid treatment options available • Indications • Side effects • Potential drug duplication(s) 39 Review of non-opioid pain treatment What therapy can we recommend to augment Mr. Spud’s • current pain regimen? 40 20
10/18/19 Potato Pharmacy: Normal Tuesday Ms. Tot is a 42-year-old female with complaints of pain. She has arthritis in her hands, lower back pain (throbbing, sharp pain, and tingling/burning pain). • What drug categories may be appropriate for Ms. Tot? • How might an assessment of Ms. Tot be offered and delivered in your pharmacy? 41 Patient care documentation For the following patient cases, choose at least two and • document as you would in an eCare plan Things to think about: • • When do you need to follow-up? • How do you ensure that follow-up happens? • Who else should be made aware of your intervention? 42 21
10/18/19 Potato Pharmacy: DocumenKng PaKent Care • Mr. Spud • After a discussion and counseling session, you recognize that Mr. Spud may have a need for naloxone at home to avoid overdose. You can prescribe under protocol with a local physician so write and fill the prescription. • Ms. Tot • You make the recommendation that Ms. Tot try acetaminophen 650mg Q 6 hours for her chronic pain. • Cheecie Tatr (non-binary) • You make the recommendation that Cheecie Tatr try ibuprofen 400mg Q 6 hours with food for their acute pain needs. 43 Wrap Up Workflow implementation of opioid interventions • Patient care opportunities and documentation • Resources for finding out more information • 44 22
10/18/19 Thank you for your participation! 45 Lorri Shaver, PharmD Shanna O’Connor, PharmD Caitlin Brown, PharmD 46 23
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