Pharmacist Involvement in Opioid Stewardship and its Impact in a Small Community Health System

Pharmacist Involvement in Opioid Stewardship and its Impact in a Small Community Health System
Barbara Truskolawski, PharmD, CashWise Pharmacy 

BackgroundPenobscot Community Health Care (PCHC) is a system of Federally Qualified Health Centers (FQHC) stretching across much of rural central Maine.  In 2013, Maine as a state was in the midst of the opioid crisis.  From 2011 to 2014, Maine observed a 34% increase in the number of all drug related overdose deaths, and in 2014, 89% of drug overdose deaths involved pharmaceutical drugs.

During the same time, at PCHC, the average patient receiving an opioid prescription exceeded a dose equivalent to 290 morphine milligram equivalents (MMEs) per day. The health systems responded with a pharmacist led opioid stewardship program with a focus on population health management to impact the entire community. 

ObjectiveThe purpose of this study was to share the experiences of patient centered medical home that improved population health management through opioid stewardship, utilizing and leveraging internal resources and external partnerships to create a community-based approach to manage the opioid epidemic. 

Methods:  PCHC responded to the opioid epidemic by developing a comprehensive approach to controlled substance stewardship. Internally, this term was defined as a coordinated effort to promote the appropriate use of controlled substances, improve patient outcomes, reduce misuse and abuse, and decrease patient morbidity and mortality attributed to these high-risk medications.

Implementation of this program involved health system leadership revising policies and procedures in regards to controlled substances throughout the organization.  These policies require all patients who have been prescribed controlled substances to provide informed consent, acknowledging the high risks associated with these medications. Patients were also required to sign an annual contract, agreeing to random urine screening for drugs, and a random pill count to verify adherence to prescribed directions. The organization also decided to not prescribe controlled substances to patients using marijuana due to lack of safety support.

Apart from these new policies and procedures, a controlled substances initiative (CSI) committee was formed with the intent of improving safe medication usage and reducing opioid-related premature deaths, defined as patients who died before the age of 60 years old. This multidisciplinary committee consisted of physicians, nurse practitioners, a pain specialist, a psychiatrist, a care management social worker, pharmacists and pharmacy residents.

The electronic medical record was used to generate a report of patients on high dose opioids for the treatment of chronic pain (100 MME or more per day).  Pharmacy residents would review patient cases on a weekly basis and record pertinent information including appropriateness of therapy, previous treatment methods, concurrent mental health conditions, and other comorbid medical conditions in a standardized form. Evidence-based recommendations were made to primary care providers via email for intervention. These recommendations included opioid or benzodiazepine tapers, cognitive behavioral therapy, non-opioid pharmacologic treatment, and osteopathic manipulation.  Pharmacy residents would then follow up at 1 and 3 month intervals to assess the implementation of these recommendations.

ResultsSince the establishment of this program, 1,300 patient reviews have been completed. The number of patients receiving chronic opioids has decreased by 67.2% from October of 2013 to March of 2017. There was also a 65.6% decrease in the number of patients receiving benzodiazepines during a similar time period.  Premature deaths were reviewed to identify associations with opioids prescribed at the time of death. This revealed a decline of 50% (55 cases to 28 cases) between 2013 and 2015. 

DiscussionThis controlled substance stewardship program is a prime example of how health systems of all sizes can implement strong, evidence-based medicine in a protocol to improve patient outcomes and reduce opioid usage. Organizational involvement and investment into this program has led to significant achievements in the quadruple aim of improving health care delivery through enhanced patient experience, improved quality of care, reduced costs, and better provider satisfaction. The authors admit that this initiative was initially met with resistance from both patients and prescribers.  Providers that had difficulty bringing up controlled substance use now had tools to rely on; this eased implementation to provide evidence based medicine supported by organization wide policies. 

References:
1. Homsted FAE, Magee CE, Nesin N. Population health management in a small health system: Impact of controlled substance stewardship in a patient-centered medical home. Am J Health Syst Pharm. 2017;74(18):1468-1475. 

2. Diomede T. Department of Health and Human Services. SEOW Special Report: Heroin, Opioids, and Other Drugs in Maine. Published October 2015. Accessed November 19, 201. www.maine.gov/dhhs