The new era of pain management — & how hospital pharmacists can help usher it in

As healthcare continues its march toward value-based care, patient satisfaction, including how patients perceive the quality of their post-surgical pain care, is becoming more important. However, with the ongoing opioid epidemic, shifting the pain management paradigm away from the addictive drugs is also key — and pharmacists can play a significant role in that shift.

Amid rising numbers of opioid-related deaths, hospitals have been working to reduce opioid prescriptions, said Jawad Saleh, PharmD, in an April 21 webinar, hosted by Becker's Hospital Review and sponsored by Mallinckrodt Pharmaceuticals. Dr. Saleh is manager of clinical services and education and critical care coordinator at the Hospital for Special Surgery in New York City.

In 2018, the CDC reported that 70,237 people died from drug overdoses the year prior, and 68 percent of those involved an opioid.

"It is a serious issue," Dr. Saleh said. "And most of our institutions — no matter what type of patient population you treat or handle — are dealing with some sort of opioid usage and trying to minimize [it]."

Additionally, the healthcare industry has been moving toward value-based care for years. Incentives in the industry have become focused on enhancing the value of care, which means improving care quality and ensuring patient satisfaction, while lowering the cost of care.

"We want the best quality for our patients," Dr. Saleh said. "It used to be just wanting the best quality, and now what they are doing is tying a dollar sign to it."

CMS has introduced several mandatory programs tying reimbursement to care quality. About 6 percent of Medicare revenue can be withheld if hospitals do not meet certain quality metrics. There are also several voluntary programs that hospitals can participate in.

Patient satisfaction is also tied to reimbursement. For example, hospitals participating in CMS' Comprehensive Care for Joint Replacement, a bundled payment initiative that aims to improve care for hip and knee replacements by placing more financial risk in the hands of the hospitals, are assessed on quality performance, Dr. Saleh said. The composite quality score the hospitals receive is weighted, with 40 percent placed on their HCAPHS score. HCAHPS is a survey of patients' perspectives, and it includes questions on pain management.

Pain management: Then and now
For years, opioids were the predominant choice for pain management, with hospitals using the drugs primarily to treat all levels of pain and increasing the number of opioids used to manage greater pain levels. But that has changed.

Today, hospitals tend to use a multimodal analgesia approach to pain management, which combines two or more agents or techniques that act by different mechanisms and intervene at different pain points. A multimodal analgesia approach includes the use of COX-2 inhibitors, local anesthetics, gabapentinoids, nonsteroidal anti-inflammatory drugs, NMDA antagonists and the eventual use of opioids, if pain progresses, according to Dr. Saleh.

The multimodal analgesia approach is widely endorsed by several prestigious organizations, including the American College of Surgeons and Agency for Healthcare Research and Quality.

Using IV acetaminophen
Another pain relief weapon in clinicians' arsenal is intravenous acetaminophen. IV acetaminophen can be used as part of a multimodal analgesia, Dr. Saleh said.

IV acetaminophen can be particularly useful when patients are having trouble absorbing oral acetaminophen. According to Dr. Saleh, studies have also shown that IV acetaminophen is effective at reducing pain and opioid consumption.

How pharmacists can support the use of IV acetaminophen
Pharmacists play an important role in the effective and safe use of IV acetaminophen in hospitals and can help encourage its adoption. Dr. Saleh discussed the following ways in which pharmacists can support its use:

1. Become knowledgeable. Pharmacists need to educate themselves on the appropriate use of IV acetaminophen and help clinicians make informed medication decisions.

2. Identify an internal champion. Find someone to help engage stakeholders and encourage appropriate use of IV acetaminophen within your institution. Dr. Saleh suggested finding another pharmacist, or an anesthesiologist, surgeon or nurse.

"Sometimes it isn't the person with the biggest title," he said. "It's a personality…you have to be able to get the message across."

3. Monitor opioid usage in your institution. Data is everything, Dr. Saleh said. Pharmacists should help assess opioid use, identify trends and find ways to improve. Then disseminate that information in useful ways within the organization.

"[Pharmacists] are uniquely qualified because we're like a gel," he said. "We're a balance between cost, availability — meaning like what's the availability with purchasing, how much does it cost from an operational standpoint or workflow standpoint — and appropriate use from a clinical standpoint. And it's really important to be the gel in the multidisciplinary team."

Learn more about Mallinckrodt Pharmaceuticals here and view the webinar here.

 

 

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