The Impact of a Clinical Pharmacist Practitioner on Perioperative Pain Management for Orthopedic Surgeries.

The objective of this quality improvement (QI) project was to assess the impact of an evidence based clinical pharmacist practitioner (CPP) model applied to perioperative pain management by integrating a CPP into the perioperative orthopedic surgery clinical pathway. Secondary objective was to assess the effect of CPP pain management service on surgical team satisfaction. This QI project expanded CPP pain management services for patients who were scheduled for an orthopedic surgery. Surgical provider satisfaction of CPP pain management services was assessed through a provider survey. Pain management recommendations by the Pain CPP were implemented 61% (n = 23/38) of the time by the orthopedic surgeon. The impact of the Pain CPP on perioperative pain management was demonstrated by improvement in the Clinically Aligned Pain Assessment Tool, which was similar in patients where CPP recommendations were accepted compared to surgeon only recommended regimens (p = 0.048). Five orthopedic surgical providers responded to our satisfaction survey, 80% (n = 4/5) strongly agree that a pain management CPP should become a permanent member of the care team. Through an evidence-based CPP model we observed a reduction in quantity of opioid prescribed and morphine equivalent daily dose utilized in patients who underwent an orthopedic surgery.

Management of Critical Glucose Values in Hospice.

Objectives: This quality improvement (QI) project was to lean the process for managing critical high and low glucose levels in the hospice unit and to simplify the pharmacologic options for hypoglycemic management for nursing staff. Methods: The process for developing and refining the recommendations involved a modified Delphi approach with a team of key stakeholders with overlapping expertise in hospice care practice. Recommendations were based on literature review, judgement of experts, and clinical experience. Stakeholders ranked six potential solutions and two were prioritized within the scope of this project. Results: From 1/1/21 - 12/31/21, there were 48 veterans with insulin sliding scale orders in the hospice unit, of which there were six critical values acted on. A standard operating procedure (SOP) for the management of critical glucose values in hospice was developed based on updated processes. In addition, hospice patient specific insulin sliding scale order sets were created and endorsed for utilization and dissemination. Following implementation on 3/1/22, no critical values were found in the hospice unit from 3/1/22 - 6/1/22 during the sustainment period. Conclusions: The implementation of hospice insulin sliding scale order sets and SOP on the management of critical glucose values in hospice reduced the number of critical glucose values.

Prescription drug monitoring program (PDMP) utilization and outcomes within the West Palm Beach Veterans Affairs (VA) healthcare system.

OBJECTIVE: Prescription drug monitoring programs (PDMPs) can identify patients at risk of controlled substance (CS) polypharmacy and accidental poisoning. DESIGN: A retrospective pre-/post-intervention review of a random sample of provider notes with documentation of PDMP outcomes was completed before and after the enactment of a Florida law mandating PDMP queries. SETTING: West Palm Beach Veterans Affairs Health Care System, which provides inpatient and outpatient services. PARTICIPANTS: Reviewed a random sample of 10 percent of progress notes documenting PDMP outcomes between September and November 2017 and the same timeframe of 2018. INTERVENTIONS: Florida enacted a law in March 2018 requiring PDMP queries to be completed for all new and renewed CS prescriptions. MAIN OUTCOME MEASURED: The primary outcome was to compare PDMP utilization and prescribing decisions based on query results before and after the enactment of the law. RESULTS: The number of progress notes documenting PDMP queries increased by over 350 percent from 2017 to 2018. In 2017 and 2018, 30.6 percent (68/222) and 20.8 percent (164/790) of PDMP queries found non-Veterans Affairs (VA) CS prescriptions, respectively. Providers decided to avoid prescribing CS prescriptions in 23.5 percent (16/68) of patients with non-VA CS prescriptions found in 2017 and 11 percent (18/164) in 2018. Overlapping or unsafe combinations were identified in 10 percent (7/68) of queries with non-VA prescriptions found in 2017 and 14 percent (23/164) in 2018. CONCLUSIONS: Mandating PDMP queries resulted in an increase in the total number of queries, positive findings, and overlapping CS prescriptions. Outcomes of PDMP mandate impacted prescribing by discontinuation and avoidance of CS initiation in 10-15 percent of patients.

Impact of Clinical Pharmacist Practitioner-Driven High Opioid Dose Reevaluation in Veterans with Chronic Non-Cancer Pain.

Veterans Health Administration implemented the Opioid Safety Initiative (OSI) in 2013 to promote safe/rational opioid prescribing. West Palm Beach VA Healthcare System (WPBVAHCS) has been an outlier for the percentage of Veterans with chronic non-cancer pain receiving ≥90 mg Morphine Equivalent Daily Dosing (MEDD) in Veterans Integrated Service Networks (VISN) 8 since the 2016 fiscal year. The purpose was to determine the utility of a Pain Clinical Pharmacist Practitioner (CPP) identifying, reviewing, and approaching Veterans utilizing high-dose opioids for dose reevaluation and the impact on OSI metric post-opioid reevaluation. Pain CPP opioid education resulted in 28% (11/39) of Veterans undergoing an average 17.7 mg MEDD opioid dose reduction. For Veterans evaluated by Pain CPP, 83% (15/18) reported no change or improvement in average pain and PEG score. Pain CPP's implemented 48 interventions outside of opioid dose reduction, the most common related to naloxone. No documented opioid overdose events, hospitalizations for uncontrolled pain or mental health, suicide attempts or pain-related crisis interventions were reported. Pain CPP's are equipped to provide opioid education, address risk mitigation strategies, reassess pain regimens, and refer for non-pharmacologic modalities. Utilization of Pain CPP resources helps improve OSI metrics while providing safe comprehensive medication management (CMM) for chronic pain.

A Survey on Opioid Tapering Practices, Policies, and Perspectives by Pain and Palliative Care Pharmacists.

Opioid tapering is an essential clinical tool to utilize for a variety of reasons, including safety and analgesic optimization. The need for individualized regimens reveals a corresponding need for healthcare providers who can actively manage patients throughout the process. Pharmacists have taken on an integral role for achieving success in opioid tapering. This survey was conducted to describe the current opioid tapering practices of pain and palliative care pharmacists. A Qualtrics survey was offered to the Society of Pain and Palliative Care Pharmacist members. The majority (87%) indicated they specialized in pain management. Almost all respondents (98%) reported providing tapering recommendations and 82% reported being involved with patient monitoring throughout the taper. The majority (multiple responses could be chosen) noted that the indication for initiating an opioid taper was due to abuse/misuse (91%), reduced overall efficacy (89%), and adverse drug reactions (78%). The most common follow-up intervals during tapering were weekly (15%), every 2 weeks (22%), and every 4 weeks (44%). This practice-based survey, though small, showed that pharmacists in pain management and palliative care are actively involved in opioid tapering. This survey will hopefully serve as a foundation for continuing research into opioid tapering and the pharmacist's role therein.

Retrospective Review of Perioperative Multimodal Analgesia for Orthopedic Patients in a Veterans Affairs Setting.

OBJECTIVES: To determine adherence of perioperative knee/hip arthroplasties and hip fracture repairs to the American Pain Society (APS) guideline recommendations for perioperative pain control. One secondary objective was to perform an internal quality audit on the use of enhanced recovery after surgery (ERAS) protocols; another secondary objective was to design an evidence-based, multi-modal perioperative quick-order menu (if warranted). DESIGN/PATIENTS: A retrospective quality improvement (QI) review of uncomplicated knee/hip replacement and hip fracture repairs from January 2018 through March 2018. SETTING: West Palm Beach Veterans Affairs Medical Center (WPB VAMC) including acute care, subacute rehabilitation, and outpatient setting. MAIN OUTCOME MEASURE: Analgesic use in the perioperative setting via electronic health record review. RESULTS: Forty-seven patients were retrospectively reviewed. Perioperative multi-modal analgesia was used in 85% of patients. Eighty-seven percent were discharged on multi-modal analgesia. There was a 67% response rate to the internal quality audit on ERAS protocol usage from the orthopedic team. CONCLUSION: A retrospective QI review completed approximately two years after APS guideline publication showed that compliance with these recommendations for multi-modal analgesia (consisting of the use of at least two medication classes) at the WPB VAMC in the postoperative setting for knee/hip arthroplasties and hip fracture repairs was 85%. This indicated potential for improvement in achieving a pharmacologic multimodal and ERAS intervention. The authors developed an evidence-based quick-order menu to further reinforce adherence to the APS perioperative guidelines.

Spiritual Healing in a Hospice Veteran Led to a Successful Opioid Taper: A Case Report.

Addressing "total pain" is a concept commonly practiced in palliative care. Spiritual healing in a Navy Veteran led to a significant improvement in pain allowing a voluntary taper of opioid medication. The Veteran was able to reconcile his faith in God and participated in several spiritual practices daily. The palliative care pharmacist assisted the team in developing an opioid taper process per Veteran's request as he had a strong conviction that he was spiritually healed. A reduction in opioid morphine equivalent daily doses (MEDD) were 87.5% without any symptoms from the clinical opioid withdrawal scale (COWS). The Veteran died peacefully during an opioid taper in hospice care.

Use of Topical Morphine to Relieve Painful Pressure Ulcers.

INTRODUCTION: Topical morphine is a potential treatment option for painful pressure ulcers in hospice and palliative care patients who favor avoidance of systemic opioid therapy. CASE: A 65-year-old male African-American veteran with a painful stage 3 sacral pressure injury was hesitant to take systemic opioids to control his pain, as he wished to stay alert for family and friends. Topical morphine was initiated, and within 24 hours the patient reported a significant reduction in pain on the numeric rating scale. DISCUSSION: Palliative pharmacotherapy is focused on reducing the symptoms of disease while avoiding side effects that impair quality of life. Evidence suggests topical morphine can be an effective treatment option for painful pressure ulcers and can reduce the need for systemic opioids in select patients. CONCLUSION: In the palliative care setting, topical morphine may be considered for compassionate use when treatment with systemic analgesics is undesired, inadequate, or poorly tolerated.

Implementation and evaluation of an opioid overdose education and naloxone distribution (OEND) program at a Veterans Affairs Medical Center.

BACKGROUND: In recognition of the importance of safe and effective pain management, the Department of Veterans Affairs and the Office of the Under Secretary for Health have encouraged implementation of opioid overdose education and naloxone distribution (OEND) programs at Veterans Affairs Medical Centers (VAMCs). METHODS: An OEND program was developed in August 2015 and implemented in September 2015 at a VAMC which allowed for pharmacist-lead individual and group patient education. An OEND consult service was developed to streamline referrals of patients for naloxone education and distribution. At the conclusion of the class, participants were ordered a naloxone auto-injector or nasal spray kit. To evaluate the utility of this quality-improvement initiative, data was collected from September 2015 until May 2016. Examples of data collected included participant satisfaction with education, risk for accidental overdose, and number of naloxone kits dispensed to participants. RESULTS: Of a total of 243 consults placed, 71 individuals participated in OEND education. A large quantity of consults were discontinued due to patients no-showing education. Sixty-four consult referrals were identified to have a mental health diagnosis. Most participants who received education had a risk for accidental opioid overdose of 14%. Sixty-nine education participants were provided a naloxone kit. Based on the OEND class survey, participants felt that their knowledge of accidental opioid overdose increased and were generally satisfied with the education. CONCLUSION: OEND educated 30% of the Veterans referred into the program via the consult service, the majority of whom were at a relatively low risk for opioid overdose.

Analysis of Inpatient Hospice Pharmacist Interventions Within a Veterans Affairs Medical Center.

Clinical pharmacy interventions have been shown to improve medication therapy, prevent undesirable side effects, and improve patients' clinical outcomes in a number of settings; however, limited data exist to characterize clinical pharmacy specialist (CPS) providers' interventions in an inpatient hospice Veteran Affairs (VA) setting. The primary objective of this quality improvement (QI) project was to quantify the number and types of pharmacy interventions implemented from the Pharmacists Achieve Results with Medications Documentation (PhARMD) tool for inpatient hospice patient encounters in a VA medical center. A total of 453 interventions during 185 patient care encounters were documented by CPS providers between September 1, 2016, and December 31, 2016. These interventions were documented across 32 unique patients, with an average of 14.2 interventions made per patient during this period. CPS providers frequently intervened to optimize pharmacotherapy for the treatment of pain (42.38%), terminal agitation (5.08%), and nausea (3.97%). Additionally, CPS providers played a significant role in the deprescribing of medication by discontinuing drugs no longer indicated (18.3%). These results substantiate the valuable contribution to patient care that the CPS providers make in optimizing symptom management and deprescribing at end-of-life. Future studies are needed to characterize the potential cost savings of CPS provider services in the inpatient hospice setting.

The Use of Transdermal Buprenorphine in Complex Regional Pain Syndrome: A Report of Two Cases.

Management of complex regional pain syndrome (CRPS) can be challenging. Various pharmacological approaches have produced mixed results. Buprenorphine activates mu-opioid receptors and antagonizes kappa and delta receptors, acts at N-methyl-d-aspartate (NMDA) receptor, and is an orphan-related ligand-1 receptor agonist. It is available in transdermal patches that last for up to 7 days. This report describes two patients with refractory CRPS who were treated with transdermal buprenorphine. The patients experienced approximately 50% reduction in pain intensity scores. Application site rash that occurred was managed with topical steroid spray used before applying the patch.

Evaluation of clinical pharmacy interventions in a Veterans Affairs medical center primary care clinic.

PURPOSE: The development of an electronic tool to quantify and characterize the interventions made by clinical pharmacy specialists (CPSs) in a primary care setting is described. SUMMARY: An electronic clinical tool was developed to document the clinical pharmacy interventions made by CPSs at the Veterans Affairs Medical Center in West Palm Beach, Florida. The tool, embedded into the electronic medical record, utilizes a novel reminder dialogue to complete pharmacotherapy visit encounters and allows CPSs to document interventions made during patient care visits. Interventions are documented using specific electronic health factors so that the type and number of interventions made for both disease-specific and other pharmacotherapy interventions can be tracked. These interventions were assessed and analyzed to evaluate the impact of CPSs in the primary care setting. From February 2011 through January 2012, a total of 16,494 pharmacotherapy interventions (therapeutic changes and goals attained) were recorded. The average numbers of interventions documented per patient encounter were 0.96 for the management of diabetes mellitus, hypertension, dyslipidemia, and heart failure and 1.36 for non-disease-specific interventions, independent of those interventions being made by the primary physician or other members of the primary care team. CONCLUSION: A clinical reminder tool developed to quantify and characterize the interventions provided by CPSs found that for every visit with a CPS, approximately one disease-specific intervention and one additional pharmacotherapy intervention were made, independent of those interventions being made by the primary physician or other members of the primary care team.

Risk of venous thromboembolism with drospirenone-containing oral contraceptives.

PURPOSE: The risk of venous thromboembolism (VTE) with drospirenone-containing oral contraceptives (OCs) is reviewed. SUMMARY: Increasing attention and media have raised awareness and concern about whether drospirenone-containing OCs increase the risk of VTE. Two studies found that when compared with nonuse of OCs, use of drospirenone-containing OCs was associated with a fourfold to over sixfold increased risk of having a thrombotic event. One of these studies found an increased risk associated with short-term use of drospirenone-containing OCs; however, this study was limited by the small number of participants taking drospirenone despite the large number of study participants. The cohort study that found a higher rate of VTE among drospirenone users was only able to indicate an association between drospirenone use and VTE, not a cause-and-effect relationship. Three studies concluded that drospirenone-containing OCs did not appear to cause an increased risk of VTE. The hemostatic studies found no difference in the various variables assessed between drospirenone- and desogestrel-containing OCs or between cyclic and continuous administration of drospirenone-containing OCs. These results should be interpreted cautiously, as each study had limitations, such as not controlling for confounders (e.g., recent surgery, immobility, obesity), not providing p values to assess homogeneity between treatment groups, and not providing total numbers of participants or specific types of OCs. Patients who receive drospirenone-containing OCs should be educated regarding the signs and symptoms of VTE, along with an appropriate action plan. CONCLUSION: The majority of available data does not support the conclusion that drospirenone-containing OCs pose an increased risk of VTE compared with other OCs.