Pharmacist-Led Pathways Help Health Systems Balance Opioid Stewardship, Acute Pain Relief

In an interview with Pharmacy Times, Tanya J. Uritsky, PharmD, BCPP, FPPCP, FASHP, opioid stewardship coordinator at the Hospital of the University of Pennsylvania, discussed how health systems can strengthen acute pain management through evidence-based multimodal analgesia, standardized pathways, patient-centered outcomes, and pharmacist-led opioid stewardship.

Uritsky emphasized that opioid stewardship should not be defined solely by reducing opioid prescribing or lowering morphine milligram equivalents. Instead, she said successful programs should reduce unnecessary opioid exposure while ensuring that patients continue to receive appropriate analgesia. She also discussed challenges in implementing multimodal acute pain pathways across large health systems, the need to measure outcomes beyond opioid use, considerations for patients receiving buprenorphine or methadone, and how pharmacy and therapeutics committees may evaluate newer nonopioid analgesics such as suzetrigine.

Pharmacy Times: Opioid stewardship is sometimes measured primarily by reductions in prescribing. How should health systems define successful opioid stewardship in acute pain care, and how can they reduce unnecessary exposure without creating barriers to appropriate analgesia or leaving pain undertreated?

Tanya J. Uritsky, PharmD, BCPP, FPPCP, FASHP: Stewardship is not about decreasing opioid prescribing alone. Lowering morphine milligram equivalents is important whenever possible and appropriate, but the consequence can sometimes be patient harm and undertreated pain, which is not what we are trying to accomplish.

Successful stewardship, at least in my experience, consists of system-level approaches to addressing pain. That includes access to standardized, evidence-based multimodal analgesia. On the other side of the spectrum is risk reduction or harm reduction, so ensuring things like access to naloxone is also important.

There are other ways of doing this as well. Some of our dashboards monitor for patients who are being too rapidly tapered, so we try to identify that up front because rapid tapering can have significant adverse effects for patients. We also look at patients who are being admitted or readmitted to the hospital for pain. That is a less specific measure, so it is a little harder to interpret, but it can help identify a population that needs closer review.

It is also really important to include the patient perspective. We try to make sure we have a patient representative on our committees, especially when we are working on efforts that are looking at optimizing analgesia, decreasing opioids, or changing pain management in some way. That helps make sure the patient perspective is captured within those efforts.

Pharmacy Times: What are the greatest challenges to implementing consistent multimodal acute pain pathways across emergency, surgical, and inpatient settings? How can health systems standardize care while preserving the flexibility needed to address individual patient risks, preferences, and treatment goals?

Uritsky: The most notable challenge is the number of stakeholders. At our health system, we have 7 hospitals, so getting everyone from each department on board can be very challenging. Identifying the right stakeholders and then getting stakeholder buy-in is a big challenge, and in a multihospital system, it is definitely a larger task.

There are also so many different settings—inpatient, ambulatory, emergency care, same-day surgeries—and so many clinicians to get on board. We take advantage of the electronic health record, which is really critical to making things happen, but sometimes the EHR itself can present unexpected hurdles.

For example, in our case, we allow providers to personalize their own notes. They do not have to use a system-level standard template. When you want to embed a best practice into an admission or discharge template, that becomes really hard to do because everyone has their own template. We specifically saw this when we tried to embed prescription drug monitoring program documentation into admission templates. It did not work the way we expected because everyone had their own template.

On the other hand, through our EHR, we are fortunate that we are able to integrate pathways, and we use those pathways to help drive frontline care. There are not enough specialists to go around, and every patient experiencing pain cannot talk to a specialist. We are in a 1000-bed hospital, so that is not possible. We need some level of expert, evidence-based guidance that people can use, especially for patients who may have complexities such as opioid use disorder or sickle cell disease, where pain can be more challenging to manage.

We use pathways to help standardize our approaches to those patients. We also remind people that pathways are not policies. They allow room, and they should allow room, for clinical judgment. Clinicians should always exercise clinical judgment whenever they are using a guideline or pathway. It is important to provide people with a framework to work within while also allowing them the leeway to make patient-specific decisions.

Pharmacy Times: Beyond opioid consumption or morphine milligram equivalents, which outcomes should hospitals measure to determine whether an acute pain program is actually improving care? Should programs place greater emphasis on physical function, recovery, adverse effects, length of stay, patient experience, or the risk of persistent opioid use?

Uritsky: We need more ways to get at the patient experience. Since the HCAHPS survey removed pain from the equation, it has been harder to capture the patient experience in a standardized way. HCAHPS was a survey used to capture patient experience in the hospital, and once pain was removed, it became more difficult for pain committees to use that as a consistent measure.

We try to incorporate patients into our work and get their input in different ways. We also use Press Ganey reports and try to identify trends from what patients report through those surveys. That has been somewhat helpful, but it is still not ideal. Ideally, we would capture patient experience through surveys, outreach, or other direct methods.

In addition to patient experience, return to function after surgery is really important. We need to look at recovery time and how long it takes patients to return to function postoperatively. The risk of persistent opioid use is also important. Of course, we need to provide analgesics and pain medications for patients, but we also need to ask how well we are managing the acute pain period.

Length of stay is another important outcome. It can be a buzzword, and it is important to payers and to the hospital because it is important to payers. We want to right-size length of stay, but we do not want to push people out too soon. Finding ways to get patients home and recovering more efficiently is important for the patient, because patients often do better when they are safe at home, and it is also important for the health system.

Although length of stay can be a triggering term, it is important to everyone because, overall, patients are better off when they do not have to remain in the hospital for extended periods of time.

Pharmacy Times: Patients who are opioid-tolerant or receiving buprenorphine or methadone may be particularly vulnerable to undertreated acute pain, withdrawal, and stigma. What should clinicians understand when managing acute pain in these populations, and which common practices or institutional policies should be reconsidered?

Uritsky: The patients you are describing are very opioid tolerant. That means they are not going to respond to opioids in the same way, and increasing opioid doses will have diminishing returns. That does not mean they should not receive opioids, but we need to make sure we are using multiple analgesics, including things like nonsteroidal anti-inflammatory drugs, acetaminophen, ketamine, and other options, so that we are approaching pain from different angles because opioids are not going to work as well on their own.

We also need to make sure opioid dosing is correct. A lot of times, these patients are underdosed. If a patient is that opioid tolerant, they may need a higher dose in order to achieve an analgesic effect. At the same time, clinicians should not escalate to extreme doses because, again, there are diminishing returns when patients are very tolerant.

If patients are using illicit fentanyl in addition to medications for opioid use disorder, they need to be treated for withdrawal and monitored for withdrawal from fentanyl as well as from adulterants in the drug supply, such as medetomidine or xylazine. If they are actively using, they need more attention to the risk of withdrawal.

For any patient who is receiving medications for opioid use disorder, we should make sure we are providing adequate doses of opioids when opioids are indicated, and we should monitor them closely for withdrawal. Clinicians can also adjust the dosing intervals for medications like buprenorphine and methadone so they are given more frequently for analgesic benefit. Methadone is often given once daily for patients with opioid use disorder, but for analgesia, it may be reasonable to dose it every 8 hours or even every 6 hours for a short period of time.

We should also ensure that we are providing standardized best practices. Examples include multimodal analgesia, potentially splitting doses, and continuing medications like buprenorphine during the acute pain period. If we develop standardized protocols and pathways for these patients, then all patients will hopefully receive that level of evidence-based care.

Providing best practices can help reduce stigma. It does not eliminate stigma, but it can decrease the impact of stigma by ensuring we are providing best practices for everyone, rather than only for certain subsets of the population.

Pharmacy Times: As newer nonopioid analgesics, including suzetrigine, enter clinical practice, how should pharmacy and therapeutics committees determine whether they add meaningful value to existing multimodal acute pain pathways? Which factors—including efficacy, safety, drug interactions, patient selection, cost, access, and real-world outcomes—should guide formulary and protocol decisions?

Uritsky: I really struggled with this question myself. There is a hang-up on the types of procedures that are used to get drugs approved. The inclination is to say, “This was not studied in this procedure, so it does not have a place in the treatment of that procedure.” The issue is that certain procedures are used to get a drug approved because they produce a certain level of pain severity.

That is why a drug is approved for moderate to severe pain: it was studied in procedures that produce moderate to severe pain. There is no way we can approve a drug and study it in every single procedure. That is not possible.

In my experience, that has been one of the hang-ups. A P&T committee may say, “We do not have evidence in orthopedics. We do not have evidence in gynecology. We do not have evidence in this subspecialty or that subspecialty.” They may say the evidence is only in the procedures that were studied, so they want more evidence before approving broader use. That is reasonable because it is a new drug, but we also have not had a new pain medication in a long time. I think people are still figuring out how to apply the data.

They are getting very focused on the specific procedures used in the trials, rather than zooming out to the severity of pain in which the drug was used. That is how these studies work. That has been a rate-limiting step to getting it approved: focusing on which procedures were studied rather than on the broader pain context. There are efforts to get wider data and wider use data, but that takes time.

There is also a very legitimate concern that once a drug is on formulary, use will run rampant. Even if you approve it only for orthopedics, podiatry, or another specific area, once it is on formulary, it can bleed out, and others can access it. That is a real concern.

Hospitals want to make sure that, from a sustainability standpoint, they are using medications based on efficacy, safety, and cost. Those are the important things to consider because that is what matters most to patients: Does it work? Are they tolerating it? Can they afford it? Those are also the factors that matter most to the sustainability of the health system.

I do think P&T committees are trying to do that. We are just not used to having new pain medications, so we have to think a little differently.

Pharmacy Times: Which health-system interventions have the greatest potential to improve acute pain care—such as pharmacist-led consultation, standardized order sets, electronic prescribing defaults, clinician feedback, discharge protocols, or patient education—and where do you believe the most significant gaps in opioid stewardship remain?

Uritsky: In my experience, moving the needle on improving care is really multifaceted. It takes many different approaches to provide holistic pain care.

We use a combination of basically everything you listed. Where I practice, we have a pharmacist consultation model, and we have specialist pharmacists embedded in our consulting teams for palliative care, addiction, and acute pain.

We have addressed our prescribing defaults, which resulted in a significant drop in opioid prescribing. To look at the impact of that change, researchers texted patients to ask whether they needed refills, how severe their pain was, and whether they had medications left. Patients still seemed to have medication left even after we reduced our defaults, so we determined that we were not leaving patients without medication options and that the approach was working effectively.

We also have standardized pathways that guide ordering and best practices. We provide academic detailing based on dashboard metrics, and we have best-practice alerts that guide discharge prescribing, as well as formal and standardized patient education.

We are always working on more things and on optimizing or updating what we already have. It is an iterative process. One of the challenges is that there are so many competing priorities at the health-system level. Dedicating resources is hard, and resources are slim, so we have to choose where we invest.

It has been fruitful to provide standardized pathways because they provide clinical guidance as well as just-in-time education. The pathways include additional clinical decision support, so they marry 2 critical elements: standardization of best practices and education. They bring both to frontline staff.

I am also partial to this because of who I am and what I do, but pharmacists need to be included in the care of these patients and in all stewardship efforts. To optimize these approaches, the pharmacist needs to bring that medication-related perspective into the decision-making process and help make sure all the interdisciplinary stakeholders are coming together to make these decisions.