Physician ALTO Training CO’s CURE: Hospital Medicine

1. Physician ALTO Training CO’s CURE: Hospital Medicine Revised 8.19.19

2. Colorado Opioid Solution: Clinicians United to Resolve the Epidemic “CO’s CURE” Our Shared Vision: To formulate the nation's first comprehensive, multispecialty medical guidelines to address and end the opioid epidemic in Colorado.

3. Opioids prescribed on hospital discharge increase the risk of the patient becoming a long-term opioid user. Root Cause? Calcaterra, et al. JGIM 31(5):478-85. 2015

4. Big Picture Solution The Opioid Epidemic Reduce the number of long-term opioid users Reduce the number of deaths from opioid overdose

5. CO’s CURE Framework Increase ALTOs Reduce harm Decrease opioids Treat dependence

6. CO’s CURE Goal: Treat pain, reduce harm

7. Current Prescribing Practices: The Inpatient Problem In Colorado (2017) Of 1.1 million nonsurgical inpatients across 286 US hospitals, 51% received an opioid during hospitalization. More than half with inpatient exposure were prescribed opioids at discharge. Half a million inpatient discharges in Colorado. ​ 125,000 discharged inpatients will get an opioid Rx. 7,500 new long term opioid users.​ J of Hosp Med, 2014

8. For Long-Term Opioid Users(>100 MMEs Daily for 90 Days) • Higher medical utilization • Total costs 40% • Medical 3% • Pharmacy 172% • 5% concomitant benzo users • 1% diagnosed with OUD • Greater risk of overdose death • 1/3 concomitant benzo use Chang et al. BMC med; 16:69, 2018.

9. For Opioid-Naïve 5-6% become long term users • The Prescriptions • Number of prescriptions filled (refills) • Duration • Long-acting > short-acting • Cumulative and daily ME dosing • The Patients • Age 45-54 years • Tobacco use • Acute or chronic pain • Mental health diagnosis • Co-prescribed • NSAIDs • Benzos • Neuropathic agents • Muscle relaxants Deyo, et al. JGIM 32(1):21-7.2016 Calcaterra, et al. JGIM 33(6):898-905.2018

10. For Opioid-Naïve 5-6% become long term users • The Prescriptions • Number of prescriptions filled (refills) • Duration • Long-acting > short-acting • Cumulative and daily ME dosing • The Patients • Age 45-54 years • Tobacco use • Acute or chronic pain • Mental health diagnosis • Co-prescribed • NSAIDs • Benzos • Neuropathic agents • Muscle relaxants Deyo, et al. JGIM 32(1):21-7.2016 Calcaterra, et al. JGIM 33(6):898-905.2018

11. Non-pharmacologic Non-opioids Opioids Traditional approach: Pick one therapy Moderate Mild Severe 10 0

12. Non-pharmacologic Non-opioids Opioids Modern approach: Additive And Multimodal Last line Second line First line

13. Who has done this? Piloted at 10 Emergency Departments across Colorado Now across the state Reduced opioids by 36% Using suggested alternatives for headache, musculoskeletal pain, renal colic, abdominal pain and extremity pain Increased alternatives by 31% Increase use of nerve blocks, lidocaine, ketamine, etc.

14. Minimal training Habit, Culture Medical comorbidities Run out of options Non-opioid Medications for Pain Minimal education on pain management Renal disease, liver disease, cardiac disease Over-prescribing of opioids Limited options available The most challenging step WHY?

15. Alternatives to Opioids

16. For pneumonia, PE, inflammatory pleurisy, or uncomplicated rib fracture Pleuritic Pain With NSAIDS, consider gastric ulcer bleeding risk:

17. Extremity Pain For cellulitis, deep vein thrombosis or neuropathy

18. Pharmacologic Guidance Visit www.cha.com\hospitalistCURE

19. Lidocaine infusions What you need to know Evidence: lidocaine reduces pain scores and is opioid-sparing. Evidence supports use for neuropathic pain, limb ischemia and renal colic. MOA: Blocks conduction of nerve impulses through inhibition of sodium channels. Metabolism: Metabolized by the liver, excreted in the urine. Contra-indications: ACS, heart failure, arrhythmia (especially heart block, WPW), severe electrolyte disturbances, cirrhosis/liver impairment, seizure d/o, renal impairment • Literature: • Meta-analysis of 32 controlled trials states “IV lidocaine was safe for neuropathic pain, better than placebo and as effective as other analgesics.”Systemic administration of local anesthetic agents to relieve neuropathic pain (Cochrane Review, 2005). • Eipe N, Gupta S and Penning J. Intravenous lidocaine for acute pain: an evidence-based clinical update. British Journal of Anesthesia 2016. • Daykin H. The efficacy and safety of intravenous lidocaine for analgesia in the older adult: a literature review. British Journal of Pain 2017.

20. Lidocaine infusions What you need to know Lidocaine Toxicity: Predictable escalation of symptoms. Signs or symptoms of lidocaine toxicity may include: • Early: • Tongue and perioral numbness • Metallic taste • Lightheadedness • Tinnitus • Hallucinations • Muscle fasciculations and tremors • Late: • Decreased level of consciousness (confusion, sedation) • Tonic-clonic seizures • HR <50 or >120, decrease in BP greater than 30 mmHg • Apnea • Ventricular dysrhythmias • Cardiac Arrest

21. Lidocaine infusions What you need to know More on indications: Where is the evidence? *Higher incidence of adverse effects in patients with malignancy (up to 52% of patients having a side effect). Cancer or cancer treatment thought to affect lidocaine plasma concentration and raise risk for toxicity. More evidence is needed.

22. Lidocaine Infusions What you need to know Stored for reference at www.cha.com/hospitalistCURE

23. For non-pregnant patients without a gastrointestinal bleed, perforation or obstruction. Suspected etiology should guide appropriate pain treatment Abdominal Pain What about pancreatitis? May be able to reduce opioid use in this population but likely will still use opioids.

24. Musculoskeletal Pain For joint/arthritis and muscular/myofascial pain

25. Oral Ketamine What you need to know Evidence: oral ketamine may have a role as add-on therapy in complex chronic pain patients when other therapeutic options have failed MOA: antagonize NMDA receptors in the CNS Adverse effects: HTN, tachycardia, myocardial depression, increased ICP, vivid dreams, anxiety, hallucinations, tremors, tonic-clonic movements, nausea, sedation. If acute change in vitals or intolerable psycho-mimetic effects, stop ketamine and consider benzodiazepine. Discharge: Can NOT prescribe ketamine on discharge. Not dispensed by pharmacies and has abuse potential (ie special K, use as a date rape drug) Contra-indications: seizures or NES, psychosis, mania, dissociative psychiatric disease, history of ketamine abuse, poorly controlled HTN, heart failure, arrhythmia, increased ICP, recent stroke, severe respiratory insufficiency or PTSD. Dosing: 25 - 50mg po TID prn. Using IV formulation as a liquid. Mix in sweet drink. When dosed orally, there is lower bioavailability and reduced side effects.

26. Oral Ketamine What you need to know Stored for reference at www.cha.com/hospitalistCURE

27. Renal Colic For nephrolithiasis Pain Note* • Desmopressin: provides comparable pain relief in renal colic to opioids; thought to relax ureter smooth muscle. No added benefit to NSAIDs. (Avoid if serum sodium abnormalities, others. See pharmacologic guidance document for further details.) See pharmacologic guidance document for references

28. If Opioids…

29. Goal: Treat pain, reduce harm  Treating Pain • SHM recommends: • Choose wisely • Screen for abuse potential • Tell patients and families • Set expectations Herzig, et al. Improving the Safety of Opioid use for Acute Noncancer Pain in Hospitalized Adults: a Consensus Statement from the Society of Hospital Medicine. JHM; 13(4). 2018.

30. When to Choose Opioids • Moderate pain or severe pain that has not responded to non-opioid therapy • Non-opioid therapy is contraindicated or anticipated to be ineffective

31. Perform a rapid risk assessment to screen for abuse potential and medical comorbidities and alternative methods of pain control should be sought. Screen for Abuse Potential Patients are a high risk for addiction include: 1.Hx of addiction themselves or in the family. 2.Hx of anxiety/depression/PTSD or other mental illness Smoking history. Age 16-45 (mainly men) High risk medical comorbidities include: 1.Pulmonary (COPD, sleep apnea) 2.Cardiac (CHF) 3.Organ dysfunction (renal or hepatic failure) 4.Elderly age 5.Combining opioids with other sedatives.

32. Review the Colorado’s Prescription Drug Monitoring Program (PDMP) to assess for a history of prescription drug abuse, misuse or diversion. Screen for Abuse Potential

33. Tell the Story, Again • Educate patients and families/caregivers: • Risks and side effects of opioid therapy • ALTOs for managing pain • Nursing and pharmacy staff should repeat the same message

34. Set Expectations • Communicate frequently with patients about: • Expectations for pain management • Trajectory for recovery and healing

35. Partnership, Empathy, apology, respect, legitimize, support Plus a plan PEARLS Plus For chronic pain: “I am sorry that you have such longstanding pain, Unfortunately, we are unlikely to cure your chronic pain in the hospital. This will be a potentially long journey of learning how to improve your function and quality of life with pain. We will support you in getting the follow up that you need.” “I am sorry that you are in so much pain. Let’s create a plan for your pain management.” “I recognize that you are in a great deal of pain right now, we will work on figuring out why you have pain and target your pain treatment towards that cause.” “We have several effective medication options that we can use to control your pain while you are here.” “We want to optimize your function and keep your pain at a manageable level. Unfortunately, we generally cannot take your pain away completely right away because this often means the medications are causing sedation or other side effects that will impair your ability to function.” If using opioids for acute pain: “Opioids are powerful pain medications that can be helpful in the short term but lead to dependence and tolerance in the long term. We aim to use the lowest effective dose for the shortest period of time. Oral opioids are preferred to IV opioids in most cases because it gives longer, more steady pain control.” Adapted from ALTO PEarLS by Patrick Kneeland, MD

36. Goal: Treat pain, reduce harm  Reducing harm When prescribing opioids: • Last resort • Start low and go slow • Use sparingly • Oral route • Immediate release rather than long-acting • Be aware of conversions between opioids • Pair with non-opioids and non-pharmacologic interventions

37. Goal: Treat pain, reduce harm  Reducing harm When prescribing opioids, also: • Use a bowel regimen • Avoid co-prescribing with barbiturates, benzos or other CNS depressants • Assess for response to therapy

38. Goal: Treat pain, reduce harm  Reducing harm Assessing the response to opioid therapy: 1. Functional improvement 2. Development of adverse effects • Assess daily • Ask about pain severity in context of function If no improvement, reconsider opioid therapy

39. Goal: Treat pain, reduce harm  Reducing harm • How to assess improvement in pain? • Compare to patient’s pre-existing function • Verbal report with numeric scale or continuous visual analog scale • Nonverbal behavioral pain scales are used frequently in the ICU: • facial expression (grimace to relaxed) • upper limb movements (partial retracted to no movement) • muscle tension • compliance with vent

40. Goal: Treat pain, reduce harm  Reducing harm • At Time of Hospital Discharge • Medication reconciliation • Check past prescriptions (PDMP) • Check home supply • Naloxone? • Patient Education • Tell the story, again  risk, addiction, side effects