83 - Impact Of Inpatient Pain Pharmacists E-consults On Post-Discharge Morphine Equivalent Daily Doses

¹VA Long Beach Healthcare System, Long Beach, CA, USA. ²University of the Pacific, Stockton, CA, USA

Purpose
Overuse of opioids has shown to be particularly challenging in hospitals with no dedicated interdisciplinary pain team.^1,2 In the inpatient setting, studies suggest that more than 60% of inpatients experience incomplete or inadequate pain relief, despite extensive use of opioids.^1,2 Several studies have showed the benefit of pain pharmacist E-consult services at various VA institutions.^3,4
Between 2004 – 2012, the prevalence of opioid prescriptions among Veterans increased from 18.9% to 33.4%.⁵ In 2013, the Veterans Affairs Opioid Safety Initiative (OSI) was launched. Its goal was to help decrease opioid prescribing practices associated with adverse outcomes.⁶ In 2015, an outpatient pain clinic was established at the VA Long Beach Healthcare System (VALBHS), which comprised of a pain physician and pain pharmacist. However, there was no dedicated pain service in the inpatient setting. Inpatient pain management was primarily managed by Internal Medicine teams with consults to specialty services, and palliative care was at times inappropriately consulted for pain management for noncancer cases.
In 2018, the Joint Commission published updated recommendations regarding the use of opioids – suggesting that hospitals create and implement policies and procedures for review of pain regimens by pain specialists.7 In response to the Joint Commission mandates, the VALBHS established an Inpatient Pain Pharmacist electronic consult (E-consult) Service to address inappropriate acute care opioid prescribing. Its goal was to review patients’ electronic medical records and provide strategies to reduce high-dose opioid analgesics and recommendations for complex patient pain management cases. There are no set criteria required to submit an inpatient pain pharmacist E-consult. Although the recommendations made in the consult were available for providers to view, it was at the providers’ discretion as to whether the recommendations were accepted or rejected. This study was designed to describe the inpatient pain pharmacist E-consult service and evaluate its impact on changes in morphine equivalent daily dose (MEDD) at discharge and 90-days post-discharge from the VALBHS.
Methods
This study has two objectives: 1) to describe the inpatient pain pharmacist E-consults services at the VALBHS, and 2) to evaluate the clinical outcomes (therapy change, MEDD change) between patients who received an inpatient pain pharmacist E-consult and patients who did not.
This retrospective chart review study evaluated patients who received an inpatient pain pharmacist E-consult from January 1, 2018 to August 31, 2019. For the first objective, all patients who received an inpatient pain pharmacist E-consult (n=75) during the pre-specified index period were included in the analysis. For the second objective, patients who received an inpatient pain pharmacist E-consult (n=65) were matched to a cohort of patients receiving LA/ER opioids (fentanyl transdermal system, morphine sustained-release, methadone) who did not receive an E-consult (n=69) within the same time frame. These patients were included if they received at least one dose of LA/ER opioid during an inpatient hospitalization. These patients were excluded if they passed away within 90 days post-discharge, transferred their outpatient care to a facility other than VALBHS, or if they were continued on a LA/ER opioid initiated by a non-VA provider. Statistical analysis was performed using t-tests and Chi-Square tests for demographic variables. A two-factor repeated-measures ANOVA was conducted to evaluate MEDD difference from the admission, with Group (E-consult, Control) as the between-subjects factor and Time (discharge, 90-day post-discharge) as the within-subjects factor.
Results
A total of 75 patients received an inpatient pain pharmacist E-consult. 372 pharmacologic and 56 non-pharmacologic recommendations were made, with acceptance rates of 51.3% and 41.1%, respectively. The most common opioid therapy changes accepted by inpatient providers were as follows: IR opioid taper (76.2%), IR opioid titration (50%); and IR opioid initiation (46.2%). The most common non-opioid therapy changes were for NSAID discontinuation (71.4%), anticonvulsant initiation (67.5%), and topical analgesic initiation (61.3%). Pharmacologic recommendations not commonly accepted included antidepressant taper/discontinuation (0%), APAP/tramadol taper/discontinuation (0%), and NSAID initiation (25%). The top accepted recommendations for referrals were to Substance Abuse (84.6%) and Outpatient Pain Clinic (75%). Recommendations made to the following services were not commonly accepted: Physical Therapy (11.1%), Palliative Care (14.3%), and Psychiatry/Mental Health (20.0%).
After exclusion criteria, 65 patients in the E-consult group were randomly matched to a cohort of 69 patients in the Non E-consult group. The average MEDD for E-consult was 70.5 (at admission), 65.2 (at discharge), and 50.1 (at 90 days post-discharge), while the average MEDD for Non E-consult was 68.8 (at admission), 70.0 (at discharge), and 63.1 (at 90 days post-discharge).The outcomes from the two-factor repeated-measures ANOVA showed the significant main effect of Group (F_1,132 = 9.88, p = 0.002), Time (F_1,132 = 12.23, p = 0.001), but not Group X Time interaction (F_1,132 = 1.70, p = 0.19). These results indicate that regardless of the time point (discharge or 90 days post-discharge), the E-consult group showed significantly greater reduction in MEDD from admission. The average MEDD differences from admission for E-consult was -5.3 mg at discharge and -20.4 at 90-days post-discharge, whereas those for the control group were +1.2 mg at discharge and -5.8 at 90-days post-discharge. There were larger percentage increases in non-opioid prescriptions in the E-consult group for anticonvulsants, antidepressants, topical analgesics, and APAP/tramadol by discharge and 90-days post-discharge.
Conclusions
Inpatient pain pharmacist E-consult services resulted in an acceptance rate of 51.3% of pharmacologic recommendations. The most common opioid therapy changes included IR opioid taper, titration, and initiation, and the most common non-opioid therapy changes included NSAID discontinuation, anticonvulsant initiation, and topical analgesic initiation. Furthermore, this study showed significant reductions in MEDD at hospital discharge and post-discharge in patients who received inpatient E-consult services compared to the patients who did not receive the E-consult services. In the future, a dedicated inpatient pain pharmacy team should be constituted and the impact of their interventions on post-surgical opioids requirements should be evaluated.