Opioid Stewardship in PALTC Settings: Raising the Bar

Stewardship is defined as the “the careful and responsible management of something entrusted to one’s care” (Merriam-Webster). Providers in post-acute long-term care have thoughtfully embraced concept stewardship, providing direction, guidance, oversight for a variety clinical, social, regulatory initiatives.The residents patients our are offered an opportunity live under umbrella which affords greater protection, supervision, attention detail where critically necessary. A recent, widely adopted example would be antimicrobial stewardship programs, led by data-driven analyses evidence-based revelations. This initiative has been out medical necessity, with prodding partners Department Health Human Services, Centers Disease Control Prevention, Medicare & Medicaid Services.Opioids another area matters. According CDC, more than 100,000 died from overdoses during year ending April 2021, increase 56,064 deaths previous (“Drug Overdose Deaths U.S. Top Annually,” Nov. 17, 2021; https://bit.ly/3JeY4NY). Included increases synthetic opioids (primarily fentanyl), psychostimulants (e.g., methamphetamine), cocaine, natural semisynthetic prescription pain medication). The we provide among those who may not counted statistics — must recognize this issue help prevent these happening.Recalling Recent HistoryOpioid use was encouraged “revelation” infamous extended release formulation, marketed “non-addicting” forms existing opioids. As prescriptions increased all name improved patient suffering chronic cancer pain, palliative, or end-of-life regulators professionals alike were slow understand ramifications.Expanded types both acute (>3 months), well expanded coverage insurance plans later Part D program, greatly influenced ease became pervasive. demand also fueled manufacturing importing illicit street substitutes, only addiction, disorder, death.Unintended Consequences Opioid PrescribingOpioids highly addictive, even at low doses prescribed short duration. First-time exposure remains leading driver cascade dependence substance disorder. Researchers found that half overdose had active time death (Pain Med 2016;17:85–98).Adverse drug events (ADEs) considered cause hospital admissions. In 2014, hospitals 280,000 admissions ADEs, including opioid (Office Prevention Promotion, National Action Plan Adverse Drug Event 2014; https://bit.ly/3utLIO6).Although often associated young middle-aged individuals, crisis affects PALTC settings. recent study community-based occurrences opioid-related ADEs after hospitalization indicated 7% risk ADE 65 older discharged prescription, excluding hospice transferred facility (J Am Geriatr Soc 2022;70:228–234).Strategies Incorporate StewardshipHow addressing epidemic? provided on regular basis should give us pause prompt focus some larger issues hand:•Assessing approach prescribing.•Using nonpharmacological treatment options.•Creating actionable goals.•Recognizing necessity disorders, especially being denied access living facilities.•Collaborating members teams individual corporate levels.As directors, advanced practice providers, consultant pharmacists, nurses, pharmacy collaborate appropriate structure their ramifications.Quality Measures PrescribingQuality measures used CMS benchmark quality Advantage Plans plans. plan sponsors incorporate into workflow, report interventions, rated annually. Pharmacy Quality Alliance (PQA), “national organization dedicated improving medication safety, adherence, use” medications across health settings, (https://www.pqaalliance.org/opioid-measures). These, together measures, play important role how dispensed communities.Although facilities receiving palliative care, therapy exempt, assisted independent facilities. become familiar sets measures.More Than Reducing Prescribing: Systems ApproachOrdering fewer one-dimensional countering crisis. collaborative educational techniques communication other clinical administrative team essential achieving goals.Screening tools available can integrated admission discharge assessments. These identify disorders ideal candidates avoidance tapering For information, see Substance Abuse Mental Services Administration (SAMHSA) program “Screening, Brief Intervention, Referral Treatment” (SBIRT) (https://www.samhsa.gov/sbirt).Connecting community resources partner organizations resident referral follow-up reduce potential transitioning residents’ needs. Education disciplines about dangers disorder could carry keep organization’s goals high priority (Healthc Exec 2020;35[3]:50–52).Overdose Treatment Options AvailabilityNaloxone, antagonist, gold standard treating overdoses, it finally taken prominent place emergency protocols. Although 50 states Washington, DC, laws naloxone (https://legislativeanalysis.org/naloxone-summary-of-state-laws/), there still challenges regarding its availability prescribing Some require co-prescribing prescribed, providers gatekeeper requirement. At minimum, included every facility’s kit.Clinical Practice Guidelines, Pain Management, OpioidsAMDA – Society Post-Acute Long-Term Care Medicine recently released guideline (CPG) “Pain Management Setting.” extensive document provides in-depth review options, pearls setting. It uniquely presents material stepwise practical application along many useful tables medications, pharmacological classes, dosing, adjuvant management, risk-mitigating strategies table 31 CPG).PALTC Partnership, Collaboration Members Interprofessional TeamConsultant pharmacists frequently board certified geriatric regimen reviews education facilities’ staff areas provision services. Consultants, conjunction director improvement team, take lead activities.•Communication provider monthly activities usually includes:•Reviewing scale documentation, assesses response scheduled as-needed (PRN) regimens.•Questioning need PRN orders transition facility.•Monitoring evidence such sedation constipation.•Reviewing combinations sedation, orthostatic hypotension, falls.•Recommending efforts taper discontinue before home when regimens ineffective unnecessary.•Advising prescribers patterns dispensing quantity hand mitigation strategy diversion.Pharmacy PALTC, living, residential ideally positioned real-time support specialized software alert systems interactions, contraindications. addition alerts generated electronic records enter orders.Best practices encourage three-way system: nursing staff, prescriber, sharing information prescribing, clarifications, side effects, stop orders, morphine milligram equivalent (MME) edits concerns, pertinent matters.Preparation SurveysBest include preparation surveys. “State Operations Manual Appendix PP: Guidance Surveyors Long Term Facilities” (https://www.hhs.gov/guidance/document/guidance-surveyors-long-term-care-facilities) most with. concern, relative opioids, following sections F-tags:483.12 Freedom Abuse, Neglect, ExploitationF 608: Reporting Reasonable Suspicion Crime;Concerns: care; diversion personal drugs483.25 CareF 697: Management;Concern: inadequate substandard relief483.45 ServicesF 757: Regimen Free Unnecessary Drugs;Concern: assessing medicationsAdditional Resources:•AMDA. “Fifteen Things Physicians Patients Should Question.” Updated July 6, 2021. https://www.choosingwisely.org/societies/amda-the-society-for-post-acute-and-long-term-care-medicine/•AMDA. “Opioids Nursing Homes.” Resolution Position Statements. December 4, 2018. https://paltc.org/opioids%20in%20nursing%20homes•American Consultant Pharmacists (ASCP). “Opioid Toolkit: Pharmacist’s Guide Older Adults.” 2020. (For purchase.) https://www.ascp.com/page/opioid•American “Policy Statement: Appropriate Analgesics Facilities.” June 23, https://bit.ly/34LDuWQ•Centers Prevention. “CDC Guidelines Prescribing Opioids Chronic United States 2016.” Morbidity Mortality Weekly Report (MMWR) 2016;65(1):1–40. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htmRobert C. Accetta, RPh President/Owner Rivercare Consulting, LLC, Strategy Consulting business rehabilitation, long term, group home, organizations. Board-Certified Geriatric Pharmacist, he serves Educator roles. Rob currently Board Directors American He graduate St. John’s University College Sciences New York. initiatives. Services. happening. Recalling death. ramifications. Expanded Unintended 2022;70:228–234). 2016;17:85–98). https://bit.ly/3utLIO6). Strategies How levels. measures. communities. More 2020;35[3]:50–52). Ordering goals. Screening (https://www.samhsa.gov/sbirt). Connecting kit. Naloxone, Clinical CPG). AMDA diversion. orders. Best Preparation F-tags: 483.12 Exploitation F Crime; Concerns: drugs 483.25 Management; Concern: relief 483.45 Drugs; Additional •AMDA. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm Robert