Pharmacy News

Scott Kollmeyer, Pharm.D., PGY1 pharmacy practice resident, St. Joseph Mercy Hospital, Ann Arbor

 

Opioid use and prescribing has been on an astronomical rise since 1999. According to the Centers for Disease Control and Prevention (CDC), opioid prescriptions have quadrupled from 1999 to 2014, while the amount of pain reported has stayed the same.1 Michigan clinicians are not immune to this issue and are actually among the largest prescribers of opioids with close to one opioid prescription per person.1 Nationwide this increase in prescriptions has correlated with a four-fold increase in opioid-related deaths to approximately one death per 10,000 people per year.1 This is an extensive problem that will only progress farther if practices are not changed.

 

Some of the highest rates of opioid prescribing occur after surgery. Approximately 50 percent of patients who undergo surgery are discharged with an opioid prescription.2 Many patients are prescribed quantities greater than what is required for their pain management. In a survey published in the Journal of the American Medication Association, over half of respondents had or expected to have leftover medications, and of those, 60 percent were keeping the opioid for future use.3 One particularly concerning statistic from this study is that one out of five respondents reported sharing their opioid medication with another person.3 These concerns are the focus of several opioid related programs at St. Joseph Mercy Hospital –Ann Arbor (SJMH-AA).

 

In order to combat these issues, several initiatives are ongoing in the surgical population (orthopedic, colorectal, neurologic and most recently, gynecologic) at SJMH-AA to standardize and reduce opioid prescriptions in the post-operative patient population. The goals of these initiatives are to adequately treat the patient's pain while giving the patient an opioid exit plan to help taper off of their opioid medication. An important aspect of pain management and reducing opioid use is utilizing non-opioid therapies. While in the hospital, all patients without contraindications are started on scheduled around-the-clock acetaminophen and ibuprofen as the backbone of the pain regimen. An opioid is started for breakthrough pain, typically oxycodone 5mg every four hours as needed and adjusted based on the pain requirements. The opioid utilized in these patients is oxycodone because it is not combined with acetaminophen and can be tapered down without affecting the amount of acetaminophen the patient is receiving. Intravenous opioid medications are avoided if possible, and patients are transitioned to oral medications as soon as appropriate. This regimen is continued until the patient is ready for discharge.

 

One of the most important aspects of these programs is the discharge plan. When ready for discharge, patients are given a written tapering schedule that walks through a stepwise plan to safely decrease their opioid medication. To aid in the taper, the smallest strength tablet is prescribed even if larger doses have been required while in the hospital. This allows the patient to easily decrease the dose without splitting tablets and offers some flexibility when designing the exit plan. The plan is individualized based on the opioid need during the 24-hours leading up to discharge. The general structure of the plan is to decrease the dose or frequency every two to three days (example provided below). The exit plan generally lasts one to two weeks, and the quantity written should reflect the tapering plan. Importantly, the scheduled around-the-clock acetaminophen is continued for the entire duration that the opioid is used, and the scheduled ibuprofen is continued for one week. Also included in the exit plan is information for the proper disposal of medications. This is a general guideline for tapering opioids; however, every patient is unique and experiences pain differently and therefore may require alterations to the original plan. Close follow up is necessary to make sure pain is adequately controlled and that the taper is going well.

 

Here is an example exit plan for a patient who received four doses of oxycodone 10mg during the 24 hour period leading up to discharge:

 

Home Days One-Three

Home Days

Four-Five

Home Days

Six-Seven

Quantity of oxycodone 5mg to prescribe

Two tabs x four doses

Two tabs x three doses

One tab x three doses

#50

 

References

  1. National Centers for Disease Control and Prevention. Opioid Overdose. Centers for Disease Control website. https://www.cdc.gov/drugoverdose/data/index.html. Updated Dec. 16, 2016. Accessed March 2017.
  2. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251.
  3. Kennedy-Hendricks A, Gielen A, McDonald, et al. Medication sharing, storage, and disposal practices for opioid medications among US adults. JAMA Intern Med. 2016;176(7):1027-29.

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