New recommended guidelines expand the recommendations and reflects developments in best practices for physicians hospital-wide.

Lake Regional Hospital is joining other Missouri hospitals in combatting the opioid abuse problem with new prescribing guidelines as well as a new opioid stewardship program.

In November 2015, the Missouri Academy of Family Physicians, Missouri Association of Osteopathic Physicians and Surgeons, Missouri College of Emergency Physicians, Missouri Dental Association, Missouri Hospital Association, and Missouri State Medical Association jointly recommended a set of hospital emergency department guidelines to reduce variation in opioid prescribing practices. New recommended guidelines expand the recommendations and reflects developments in best practices for physicians hospital-wide.

According to a press release from a coalition of health care policy and advocacy organizations, the revised guidance reflects evolving best practices in the use of opioids for pain management and changes in the law designed to reduce the opioid addiction crisis.

“The guidelines serve to assist physicians in following best opioid prescribing practices while still allowing for individual autonomy and judgement,” said Evan Schwarz, M.D., MOCEP President and Assistant Professor of Emergency Medicine at Washington University School of Medicine in St. Louis.

The new recommendations are consistent with guidance from the Centers for Disease Control and Prevention and update prescribing limits for first-time acute pain management to synchronize with Missouri’s new law.

“Opioid abuse prevention is the primary goal,” said Leslie Porth, R.N., Ph.D., MHA Senior Vice President of Strategic Quality Initiatives. “When providers have the knowledge and tools to make informed decisions about patients’ pain management options, patients get better, safer care.”

Here at Lake of the Ozarks, Lake Regional has initiated an opioid stewardship program in addition to following the prescribing guidelines outlined in the Guidance for Physicians, according to Tony Kauten, RPh, Lake Regional pharmacy manager. Lake Regional Emergency Department physicians and orthopedic surgeons will screen all patients for high risk of adverse drug events and addiction upon admission.

Substance abuse is one of the top three health priorities for the area, according to the 2018 Community Health Needs Assessment produced by Lake Regional Health System and collaborating community partners. (The entirety of this assessment report will be released soon, according to hospital staff.) 

With the breadth of the problem, Lake Regional has joined the Camden County Health Department and Central Ozarks Medical Center to work on this issue. 

“Together, the Ozarks Rural Health Network will work to reduce opioid misuse in our high-risk rural communities,” said Michael Burcham, Lake Regional vice president of physician practices.

Throughout the next three years, Lake Regional will align community outreach activities to address these issues while partnering with community organizations, according to information provided by the hospital.

Kauten will provide community education on the risks and side-effects of prescription and illicit opioids and how to respond to an overdose in a health talk, “Fighting the Opioid Epidemic,” on March 14, 2019, at Lake Regional Hospital. He also is available to speak to community groups on this topic.

According to the press release from the statewide health care coalition, the new guidance includes a new recommendation encouraging physicians to consider prescribing naloxone upon discharge to patients at risk of overdose. Naloxone, an overdose rescue medication, can be used by patients or bystanders to reverse an opioid overdose.

“Missouri's family physicians continue to implement evidence-based strategies that both prevent opioid misuse and reduce harm associated with opioid use,” said Sarah Cole, D.O., Fellow of the American Academy of Family Physicians and MAFP President. “These recommendations are clear and succinct for all physicians who care for people in the emergency department and hospital settings.”

The recommendations are being implemented now.

Revised guidelines effective November 2018

•A focused pain assessment prior to determination of treatment plan should be conducted. If the patient’s pain prohibits a comprehensive assessment, then judicious use of opioids to alleviate pain is suggested. While the pain assessment should include risk factors for addiction and the incorporation of non-narcotic analgesics, a specific written, comprehensive assessment is not required.

•The Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain should serve as a primary resource. e clinical decision to prescribe opioids in excess of, or for longer duration than the guidelines suggest, should be documented.

•Diagnoses based on evidence-based guidelines and appropriate diagnostics whenever possible.

•Non-narcotic treatment of symptomatic, non-traumatic tooth pain should be utilized when possible.

•Treatment of patients with acute exacerbation of existing chronic pain should begin with an attempt to contact the primary opioid prescriber or primary care provider, if circumstances are conducive.

•In the emergency department, opioid analgesic prescriptions for chronic conditions, including acute exacerbation of existing chronic pain management, should be limited to no more than 72 hours, if clinically appropriate and a er assessing the feasibility of timely access for follow-up care.

•For new conditions requiring narcotics, the length of the opioid prescription should be limited to the shortest duration needed, but not to exceed seven days. Outpatient access to follow-up care should be taken into consideration regarding the length of the prescription.

•Emergency department physicians and providers should not provide prescriptions for controlled substances that are claimed to be lost or destroyed.

•Unless otherwise clinically indicated, emergency department physicians and providers should not prescribe long-acting or controlled release opioids. If indicated, prescribers should provide tamper-resistant, or abuse deterrent, forms of opioids.

•When narcotics are prescribed, emergency department staff should counsel patients on proper use, storage, and disposal of narcotic medications.

•Health care providers should evaluate and consider discharging patients at risk of overdose with prescriptions for naloxone.