Closing a Door to Opioid Addiction
Transplant pharmacy team at UI Health spurs effort to minimize the use of opioids following surgery.
Five years before the U.S. Department of Health and Human Services declared the opioid crisis a public health emergency in 2017, Dr. Maya Campara, PharmD ’06, noticed kidney donors at UI Health Hospital struggling with the ill effects of the commonly prescribed pain management drugs.
During morning rounds, she witnessed kidney donors — otherwise young and healthy people by design — dealing with postsurgical pain. The universal antidote? Opioids.
And far too often, Campara observed, the opioids sparked vomiting, constipation, and potentially preventable patient suffering in addition to longer hospital stays.
“This was the way it was done,” says Campara,a clinical transplant pharmacist since 2008 who, along with her team, was tasked to manage pain for organ recipients and donors through medication therapy management protocols with UI Health surgeons.
Well-intentioned as the prescription of opioids might have been, the routine practice also opened the door to opioid abuse and misuse.
And that reality did not sit well with Campara.
SEEKING A BETTER WAY
For Campara and colleagues like Dr. Jamie Benken, PharmD ’08, opioids in the postoperative setting seemed to drive unnecessary harm. Though medications such as morphine, hydrocodone, and oxycodone were regarded as effective therapeutics to manage pain, the drugs carried a litany of potential consequences. Alternatives, meanwhile, were seldom offered.
“We got used to the assumption that everyone would need opioids at discharge and that became our culture,” says Benken, a clinical assistant professor in the Department of Pharmacy Practice. “We needed to reflect on what we were doing.”
With surgery being identified as the top doorway to opioid addiction — one study, in fact, showing that one in seven postoperative patients would become addicted to opioids — Campara and her PharmD team stood eager to investigate other treatment options.
“We were exposing people at such a high rate to develop side effects and possibly risk dependence,” says Campara, also a clinical associate professor in the Department of Pharmacy Practice. “Our organ donors were doing something altruistic, yet far too many were paying a big price for their effort.”
Together, Campara, Benken, and pharmacy colleagues, including residents and PharmD students, began exploring opioid use in the postoperative setting, specifically looking at kidney donors. The group reviewed patient charts, consulted partners, and began to examine the efficacy of opioid alternatives to pain management, namely ketorolac and acetaminophen.
“A lot of addiction starts with the first prescription, so we wanted to know if we could change the likelihood of addiction to opioids while still controlling pain,” Benken says.
Specifically, Campara’s retrospective chart review of 277 robot-assisted, laparoscopic, living-donor nephrectomies between 2009 and 2012 helped the team determine that scheduled ketorolac was a safe, effective alternative to opioids. It was an important conclusion and one the PharmD transplant team touted with UI Health’s surgeons and anesthesiologists.
“This was a way to get away from the opioids while still providing great care to patients,” Campara says.
In March 2014, the transplant group implemented a new ketorolac-based pain management protocol for kidney donors. After two years of tracking the results, Campara and her project team reported positive results: the shift to ketorolac had produced no harm to patients’ kidney function and the average length of stay for donors had dropped nearly one full day.
Inspired by those findings, the pharmacy transplant team began seeking even greater gains at UI Health, which handles approximately 200 kidney transplants each year.
INVOLVING NURSES AND RECIPIENTS
Viewing nurses as critical frontline partners, though ones that had not necessarily embraced the new pain-management protocols, the PharmD transplant group held two nursing in-services in 2016 to educate nursing staff about the changes and the rationale guiding the shift.
“Nothing works without the nurses,” Campara acknowledges. “A dramatic change in pain management approach requires all hands on deck.”
During the in-services, the pharmacists and nurses reviewed existing pain assessment tools, equianalgesic doses, and opioid side effects, a collaborative endeavor designed to help nurses select the appropriate medication for pain and to view nonopioid therapies like ketorolac and acetaminophen as valid alternatives. Those efforts sparked deeper understanding and, more importantly, positive results.
“We learned a lot from each other about what pain strategy should be and how and when different medications might be administered,” Benken says, noting that length of stay for donors following the nursing in-services dropped to 2.6 days in 2017 before falling to 2.2 days in both 2018 and 2019.
Alongside nursing education, the transplant pharmacy group also began shifting its attention from the donor population to kidney recipients, often a more medically fragile group. For decades, recipients were immediately given morphine, hydromorphone, or Norco upon leaving the operating room. The transplant team sought a move to acetaminophen or tramadol upon discharge, a decision fueled by increasing buy-in from care-team partners.
“The transplant team worked on minimalizing use of opioids for kidney donors and they showed clear advantages and positive results,” says Dr. Enrico Benedetti, professor and head of surgery at UI Health. “It only made sense to try it on the recipient side as well.”
The results, which the transplant pharmacists noted themselves in follow-up clinic visits, were clear as many kidney recipients were effectively recovering without the use of opioids. In 2018, fewer than nine percent of kidney transplant patients were discharged from the hospital with an opioid prescription, a nearly ten-fold decrease from 2015.
“We’re still achieving our goal of pain control without the need for opioids, while these patients are leaving the hospital faster as well,” Benken says. “It’s a real victory.”
CONFRONTING A NATIONAL EPIDEMIC
Powered by these outcomes, similar pain-management protocols are now being applied to other transplant patients at UI Health Hospital, while members of the transplant PharmD team are also involved in an ambitious, new hospital-wide effort to develop and implement opioid-free pain management for surgical patients.
“We’ve taken the initiative to be leaders on the healthcare team and responded to the opioid epidemic on our level,” Benken says, adding that one crucial component to the reduced opioid use has been open dialogue with patients both before and after surgery regarding pain management expectations and protocols.
Benedetti considers his department fortunate to have access to one of the world’s largest contingents of trained transplant PharmDs in a single surgical unit. He says the pharmacists’ work in clinic and at bedside, participation in regular meetings, and professional insights help ensure that UI Health transplant patients receive the safe, effective care they need and deserve.
“The PharmDs are integral members of our team, and there’s no question we benefit from their presence,” Benedetti says.
For her part, Campara is pleased that she and her PharmD colleagues led a multidisciplinary effort that has challenged the status quo of opioid prescription and helped to combat a still-pressing national epidemic.
“Because of our hands-on, collaborative practice model, we were not only able to better safety and care for patients, but to also improve key hospital outcomes like length of stay,” she says. “It’s been empowering to show how with well-executed intervention, pharmacists add value and make an impactful and lasting difference on a surgical team.”