Without appropriate monitoring, opioid pain medications carry a catastrophic risk of addiction and overdose. For almost a decade, our 500-bed, community teaching hospital in Western Pennsylvania has run a pharmacist-driven pain management team, the Acute Pain Service, to ensure the appropriate, safe use of opioid pain medications. Over the years, the team has taken on additional responsibilities, including order set development and monitoring of naloxone use.

Creating a Pharmacist-Based Inpatient Acute Pain Service
The impetus for creating the pharmacist-based Acute Pain Service to provide pain management consults for patients resulted from anesthesiologists requesting a full-time pharmacist in pain service. This coincided with the hospital’s receipt of grant funding to improve pain management in our facility.

The team consists of nurses, anesthesiologists, and clinical pharmacists. The nurses are responsible for chart auditing as well as some of the educational initiatives, while the anesthesiologists focus on performing the interventional procedures for pain management. The role of the pharmacists is to provide education to patients, caregivers, and practitioners; perform pain assessments and complete documentation; make analgesic recommendations; and conduct discharge medication counseling. Operating under a collaborative practice agreement, the pharmacists can adjust or change analgesic doses, frequency, and route, as well as prevent and treat adverse effects. In addition to verifying medication doses at our outpatient pain clinic, the pharmacists also work to refer patients to either our outpatient pain clinic or, if an alternative is needed, to provide a list of other pain clinics patients can discuss with their primary care physician for referral. Currently, there are 1.5 FTE pharmacists on the pain team, with two clinical pharmacists providing support for on-call responsibilities. All members of the team monitor patient satisfaction scores related to pain, and follow-up phone calls can be made to those patients who have undergone an interventional procedure or have been seen by a clinical pharmacist.

Four years into the program, the team averaged 66 consults per month, typically ordered by general medicine, surgery, and psychiatry, and that number holds true today. The pharmacists worked closely with the palliative care service to provide recommendations on pain treatment for symptom control, including end-of-life care. The nurses monitored Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, and a greater than 2% increase was seen over four years. Follow-up phone calls were made to 593 patients after discharge. Patients were queried as to whether they felt their pain control improved after being seen by the pain service, if they were satisfied by the care provided by the team, and if there was anything the team could have done better. Answers were more than 90% positive for all questions asked. Due to the success of the Acute Pain Service, after the initial grant funding ended, the cost for the team’s continued operation was incorporated into the hospital budget.

Opioid Safety Initiatives
The team’s initial goal was to ensure pain medications were used appropriately and safely. As such, a hydromorphone administration and monitoring policy was created in recognition of the potency of this medication and the risks associated with high doses. The policy requires the nurse to check the patient’s vital signs prior to administering the dose and again 30 minutes afterward. The hospital’s nursing pain management protocol was updated with guidelines requiring nurses to assess patients for pain throughout their admission and to reassess after any interventions. Chart auditing is conducted by the pain nurses to ensure patients are evaluated in a timely manner after receiving intravenous or oral pain medications, and to confirm that the documentation is appropriate. To prevent diversion, controlled substance infusions are stored in lock boxes. The team also added new methods of administration for pain medications; for example, orthopedic and obstetrical patients have the option of using an oral, patient-controlled analgesia (PCA) device, and oral PCAs have been recently introduced to some neurosurgery patients as well.

Order Set Development
Members of the pain team also are responsible for pain management order set development. Orthopedic pain management orders were updated to help standardize medication dosing where appropriate and to incorporate nonopioid options. Epidural infusion order sets were updated to improve and standardize monitoring parameters while epidurals are in place. A low-dose ketamine infusion protocol was created for patients who fail first-line pain medications; education on this protocol is provided to nursing annually. A nursing education sheet is attached to the order set for review by nurses each time the infusion is ordered for a new patient. Initially, this protocol was restricted to anesthesiologists only, and use was only available on a few nursing units. As more patients received this type of analgesia, the trauma physicians were incorporated into the protocol, and education was expanded to other nursing floors.

Education has been a significant team priority from the beginning. Guidelines were developed for nurses and physicians to ensure appropriate use of PRN medications based on age, opioid tolerance, and overall status. Nurses and pharmacists from the pain team created a pocket guide that is still regularly distributed throughout the hospital. Multiple educational activities are conducted for physicians and residents, including noon conference lectures, grand rounds, and mandatory annual training/education. The pain management pharmacists are also involved in our facility’s annual Palliative Care Symposium as well as the Pain Symposium, which occurs every other year. Furthermore, nurses receive one-on-one education from the pain nurses and pharmacists, and pharmacists provide education to local nursing schools.

In 2012, the hospital joined a Hospital Engagement Network (HEN) project that focused on opioid safety. The pain management team worked closely with the risk management department and administration to complete an organizational assessment designed to identify areas where additional improvements could be made. A variety of practice improvements resulted from this effort, including providing further education to nursing and physicians, and updating pain management guidelines. To improve communication, inter-department transport forms now include documentation indicating when patients were last medicated with an opioid or sedative. Respiratory status and vital signs are included on nursing pain charting. A reminder tag is placed on all PCA pumps to reinforce that only the patient is to push the dosing button. Anesthesia documents opioid tolerance preoperatively, which is incorporated into the anesthesia plan. The formulations of opioids available in automated dispensing cabinets are also limited to prevent dosing errors.

Pharmacy and physicians also created standardized opioid dosing recommendations for addition to existing order sets. Previously, order sets included multiple options for opioids, often without specific directions as to when to utilize a particular agent. For example, some order sets contained range orders for both an oral and an intravenous opioid, all ordered “for pain.” Providing dosing options for physicians to choose from and limiting the number of available as-needed medications can help reduce medication errors. Medication options are now divided by pain intensity using pain ratings (ie, mild=0-3/10, moderate=4-6/10, and severe=7-10/10). Other order sets were updated to include an automatic order for naloxone when a PCA is ordered, and to require that pediatric doses of opioids be weight-based.

Measuring Naloxone Use
Among the various factors monitored during the HEN project, naloxone use was the primary measure for determining the impact of our opioid safety initiatives. By tracking the number of naloxone doses given to inpatients receiving opioids and the number of rapid response calls requiring naloxone administration, we demonstrated that both measures declined over 3 years. For a short period, we also monitored documentation by anesthesia of opioid tolerance prior to operative procedures and nursing documentation of vital signs prior to administration of an opioid. These measures also showed improvement during that period.

In addition, we are supporting a pharmacy resident project wherein the use of naloxone in Acute Pain Service patients is compared to use in the general hospital population. A straight comparison between these populations is difficult, given the differences in opioid use between the groups. General hospital population patients included in the analysis may have received only a single dose of opioids during their hospitalization, while most patients in the Acute Pain Service group experience difficult-to-control pain, frequently use opioid pain medications, and receive consultations due to a need for more intensive therapy. The study compares factors that put patients at higher risk of adverse effects to opioids, including concomitant use of sedatives and 24-hour opioid requirements, and will continue to be evaluated as the study progresses.

While monitoring naloxone use in the inpatient setting may correlate with the safe use of opioids, it is not a perfect measure. We reviewed the charts of patients treated with naloxone to determine appropriateness of use; in some cases, naloxone was given in response to a change in mental status in order to determine if this change was caused by opioids. Some of these patients had not received any opioids in the previous 24 hours, while other patients demonstrated no improvement in mental status after administration of naloxone, making it likely that opioids were not the cause of the mental status change. Other patients had not received any opioids in the hospital setting but naloxone was given soon after admission, most likely due to concerns about medications taken prior to admission.

Ultimately, reviewing naloxone use can serve as a starting point for monitoring opioid safety. Combining the results of the review of inpatient naloxone use with the organizational assessments performed during HEN projects, we have been able to increase the safety of our medication-use process. Improvements have been made in our education efforts, including instructing patients on avoiding sedatives while using opioids. In addition, we discovered some cases wherein multiple prescribers were ordering opioids for the same patient; in these cases we work with the appropriate teams to correct this pattern.

Addressing Addiction Risk
Just as recent media scrutiny has brought an increased focus to addiction risk and opioid abuse, this subject has come into strong focus by the Acute Pain Service. Our pharmacists and nurses are currently working on implementing methods throughout the hospital to identify patients most at risk of abuse. In the past year, we have been able to utilize drug and alcohol counselors to evaluate patients and discuss substance abuse programs for patients with known opioid abuse issues. In addition, the pain team endeavors to incorporate non-opioid options into treatment whenever possible, and we continue to emphasize this approach.

Following the publication of the CDC Guidelines for Prescribing Opioids for Chronic Pain in 2016,1 the pain team increased its efforts to educate patients and the community, and continues to provide recommendations for individuals with chronic pain seen in the inpatient setting, including discussing with patients the risk of using opioids for treatment of chronic pain (not related to cancer). Patients with acute pain in addition to chronic pain can be particularly difficult to manage, due to increased opioid tolerance at baseline caused by previous opioid exposure. We make education available to providers and nurses specific to pain control in these patients, as both parties are often concerned that patients requesting higher doses of opioids and with a frequent need for medication may have addiction issues.

We provide education to nurses and patients about realistic expectations of pain control in the hospital setting. The team explains that the baseline requirements for pain medication are higher in chronic opioid users than other patients, and if there is an separate acute pain issue, they may require medications more often and in higher doses. The team also works with these patients to decrease medications as the issue resolves. Some patients with chronic pain may have unrealistic expectations of experiencing no pain in the hospital. For example, patients who have had open-heart surgery may report their chronic back pain as their main postoperative complaint. Another issue arises when patients are taking pain medication in excess of what they were prescribed prior to admission. In these cases, we emphasize safe prescribing and the proper use of these medications with the patient.

Future directions for our group include preoperative collaboration for patients with chronic pain issues, especially in the neurosurgery population. With the implementation of a new EMR this year, we are exploring opportunities to improve opioid safety via the EMR system capabilities. Some areas of focus are adding dosing alerts, including pertinent lab results on the ordering screen for certain medications, and utilizing documentation systems to assess the risk of substance abuse. Finally, as billing opportunities evolve for pharmacist-provided services, we will incorporate this functionality into our services as well.

Final Thoughts
Creating a pharmacist-driven Acute Pain Service was an important step in the development of clinical pharmacist services at our institution. We have been able to expand services to other collaborative practice agreements and work closely with physicians. In addition to providing one-on-one education to nurses and physicians, it has proven beneficial for patients to see pharmacists in the hospital more often. Though not our primary objective in creating this service, patients have expressed increased satisfaction with their care, which is attributable to having a pharmacist specifically assigned to monitoring their pain control. While some areas of pain management are becoming more challenging due to abuse issues, the long-standing role of our pharmacists in this practice area allows pharmacy to have a voice in the future directions of our hospital practice.

Reference

1. Dowell D, Haegevich TM, Chou R. CDC Guidelines for Prescribing Opioids for Chronic Pain—United States, 2016. MMWR Recommendations and Reports (March 18, 2016). www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Accessed August 23, 2017.

Nancy Love, PharmD, BCPS, serves as a clinical pharmacist in the Acute Pain Service at Conemaugh Memorial Medical Center in Johnstown, Pennsylvania. Nancy is a graduate of the University of Pittsburgh School of Pharmacy and completed her pharmacy residency at Conemaugh Memorial Medical Center. Since 2008, she has worked on the inpatient pain team, rounds daily on active pain consults, reviewing naloxone use and working with the nursing staff to review pain satisfaction scores for the hospital. In addition, Nancy serves as a faculty member for the pharmacy residency program. She has spoken at multiple conferences, and her clinical group won the Innovative and Collaborative Practice Award from the Pennsylvania Society of Health System Pharmacists for the work they have done in pain management.