55 - Opioid Stewardship MATters: Addressing Opioid Use Disorder across the Continuum of Care
Michelle Busch, Todd Walroth
Eskenazi Health, Indianapolis, IN, USA
Purpose More than 2 million patients suffer from opioid use disorder in the United States resulting in a vulnerable population in need of targeted treatment efforts. Our health-system has addressed this need by implementing opioid stewardship efforts related to medication assisted treatment (MAT) led by an oversight committee and clinical pharmacist. A clinical pharmacist position dedicated to pain and opioid stewardship initiatives was created in March 2019 with the main objective to implement an opioid stewardship program across inpatient and outpatient services. Alongside developing a new service, this pharmacist focuses on process improvement activities related to opioids, maintaining regulatory readiness, tracking and reporting various metrics related to opioid prescribing and pain management, policy and procedure development, leveraging the electronic health record to support pain management and opioid use, ensuring legal compliance, and the development of a controlled substance diversion detection and prevention program. This pharmacist also serves as the co-chair for a newly formed interdisciplinary pain management oversight committee for the institution. Led by the oversight committee, strategies for addressing pain management in patients receiving MAT have been designed and implemented, such as: policy development, implementation of assessment tools, electronic order sets, patient and provider education, and alignment of treatment agreements for controlled substances and buprenorphine across specialties. Methods In October 2019, process mapping was completed by the pain management oversight committee to identify gaps and needs in current clinical pathways and workflows related to treatment and access for opioid use disorder across the continuum of care. This gap-analysis reviewed opioid use disorder from all perspectives of patient interactions (i.e., ED, inpatient, PCP, OB, teen, MAT, transitions, etc.) from initial presentation through follow-up. A questionnaire was distributed to interdisciplinary committee members from various departments, both inpatient and outpatient, to outline baseline screening, treatment, and referral practices for patients with opioid use disorder prior to the discussion. Responses were recorded and distributed to committee members to facilitate discussion. Current state processes were analyzed in order to develop inefficiencies and variation in practice, in order to develop a more streamlined future state process that would meet the needs of the multiple service lines involved. Following this work, updates needed for various order sets, policies, screening tools, and education were identified. Results Results from this gap-analysis led to the identification and prioritization of various projects related to opioid use disorder and its treatment at our organization. In early 2020, a formalized clinical opiate withdrawal scale (COWS) assessment was implemented in combination with an inpatient MAT initiation electronic order set to facilitate appropriate dosing and monitoring of buprenorphine/naloxone. Prior to this, a discrete order for a COWS assessment did not exist in the electronic health record (EHR) and could only be ordered through a generic nursing communication order. MAT initiation was at the discretion of the ordering provider with no direction or dosing support in the EHR. This effort required collaboration between inpatient hospitalists, pharmacists, information services (IS) support, nurses, and clinical education team members. Specialty-specific education was created for providers, nurses, and pharmacists prior to the COWS and MAT order set implementation. Providers were given an hour of live continuing education (CE) to review opioid use disorder, associated stigma, MAT options, COWS assessment, and EHR changes. Pharmacists were provided similar live education while nurses completed education electronically. After all clinical education was complete, the COWS assessment and MAT order set went live in February 2020 and its use in the first month was evaluated. From 02/11/2020 to 03/08/2020, the new order set was utilized for 79 individual orders on 13 unique patients. We are working with our informatics team to obtain necessary data to conduct a pre and post implementation analysis; endpoints collected will be inpatient buprenorphine/naloxone prescribing, orders for COWS assessment, and nursing documentation related to COWS. Results from the initial walkthrough also prompted the creation of a website with provider access to answers to frequently asked questions about opioid use disorder and associated treatment to be prioritized. Pain recommendations before, during, and after surgery concentrated on guidance for surgeons managing acute pain in patients receiving MAT have been developed. Additional projects that were identified for future initiatives include educational materials for MAT products and naloxone, targeted education to providers and nurses, naloxone access and supply, identification of metrics specific to MAT, assessment of the referral process, and inpatient consult services. Conclusions A pain management oversight committee and clinical pharmacy specialist dedicated to opioid stewardship play integral roles in the prioritization of initiatives to address identified gaps in workflows related to opioid use disorder and MAT. Oversight committees promote interdisciplinary collaboration across the organization. Other health-systems are encouraged to evaluate their own processes in order to identify opportunities for improvement in caring for these patients across the continuum of care.