Clinicians United to Resolve the Epidemic (CO's CURE)
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Colorado’s Opioid Solution: Clinicians United to Resolve the Epidemic (CO’s CURE) Obstetrics and Gynecology 2020 Opioid Prescribing and Treatment Guidelines Developed by the Colorado Section of the American College of Obstetricians and Gynecologists in partnership with Colorado Hospital Association, Colorado Medical Society and Colorado Consortium for Prescription Drug Abuse Prevention CO’s CURE is a proud collaboration of the following sponsoring and participating societies and organizations. The CO’s CURE initiative’s leadership thanks each for its contributions, expertise and commitment to ending the opioid epidemic together. SPONSORING ORGANIZATIONS COLORADO EST. 1871 MEDICAL SOCIETY PARTICIPATING ORGANIZATIONS FUNDED BY Colorado Department of Human Services, Office of Behavioral Health SPECIAL THANKS TO Support for Hospital Opioid Use Treatment (Project SHOUT) and BridgetoTreatment.org Dedicated to the clinicians across Colorado and the patients for whom they care © 2021 CHA Page 1 Contributors Editors-in-Chief Section Editors Elizabeth Esty, MD Robert Valuck, PhD, RPh, FNAP Donald E. Stader III, MD, FACEP Introduction: The Opioid Epidemic Elizabeth Esty, MD Obstetric and Gynecologic Specialty Editors Limiting Opioid Use in Obstetric and Amy Adelberg, MD Gynecologic Practice Julie C. Gelman, MD, FACOG Rachael Duncan, PharmD, BCPS, BCCCP Jill H. Liss, MD, FACOG Rachael Rzasa Lynn, MD Brandi N. Ring, MD, FACOG, FAWM Cristina Wood, MD, MS Maridee D. Shogren, DNP, CNM, CLC Multimodal Analgesia in Obstetric and Marcela C. Smid, MD, MA, MS, FACOG, FASAM Gynecologic Practice Mishka Terplan, MD, MPH, FACOG, DFASAM Martin Krsak, MD Cristina Wood, MD, MS Donald E. Stader III, MD, FACEP Harm Reduction Associate Editors Elizabeth Esty, MD Brian T. Bateman, MD, MSc Mishka Terplan, MD, MPH, FACOG, DFASAM Jonathan Clapp, MD Steven G. Young, MD, FASAM Rachael Rzasa Lynn, MD Treatment of Opioid Use Disorder Steven G. Young, MD, FASAM Debra Parsons, MD, FACP Donald E. Stader III, MD, FACEP Darlene Tad-y, MD, SFHM Robert Valuck, PhD, RPh, FNAP The Future and Ending the Opioid Epidemic in Colorado Contributing Editors Julie Denning Nathan Novotny John Spartz Ryan Rotanz Tsipis, MPH Helena Winston, MD Narin Wongngamnit, MD Task Force Members and Volunteers Kevin Boehnke, PhD Kenneth Finn, MD Indra Wood Lusero, Esq, MA Page 2 Table of Contents Introduction ................................................................................................................................................................. 4 The Origins of the Opioid Epidemic The Opioid Epidemic in Colorado CO’s CURE Limiting Opioid Use in Obstetric and Gynecologic Practice ............................................................................................ 9 Practice Recommendations Practice Recommendations to Reduce the Risks Associated with Opioid Therapy Practice Recommendations for Hospitalized Patients Practice Recommendations for Surgical Patients Practice Recommendations for Discharge Prescribing Policy Recommendations Multimodal Analgesia in Obstetric and Gynecologic Practice ...................................................................................... 28 Practice Recommendations Multimodal Pain Management for Obstetric and Gynecologic Surgeries Multimodal Analgesia for Common Gynecologic Conditions Multimodal Pain Management in Nonsurgical Obstetric Care Nonopioid Pharmacologic Agents for Multimodal Analgesia Nonpharmacologic Interventions Policy Recommendations Harm Reduction ......................................................................................................................................................... 74 Stigma and Bias as Obstacles to Health Care Practice Recommendations Policy Recommendations Treatment of Opioid Use Disorders ............................................................................................................................. 89 Opioid Use Disorder in Pregnancy Neonatal Opioid Withdrawal Syndrome Practice Recommendations Policy Recommendations The Future and Ending the Opioid Epidemic in Colorado .......................................................................................... 113 Appendices .............................................................................................................................................................. 114 I. The Clinically Aligned Pain Assessment (CAPA) II. Risk Index for the Prediction of Chronic Postsurgical Pain III. Understanding Pain: A Complex Biopsychosocial Phenomenon IV. Cannabinoids and Pain V. Risks, Benefits and Contraindications of Peripheral Nerve and Plane Blocks VI. Peripheral Nerve and Plane Blocks for Common Obstetric and Gynecologic Surgical Procedures VII. Primary and Adjunctive Pharmacologic Agents for Regional Anesthesia VIII. Map and List of Syringe Access Programs in Colorado IX. Intimate Partner Violence Screening Questions X. Urine Toxicology Screening XI. Characteristics of Medications Used for Addiction Treatment XII. Patient-Centered Decision Considerations when Selecting an Opioid Agonist Medication for a Pregnant Patient XIII. Quick Start Guide for Methadone XIV. Buprenorphine Quick Start Guide in Pregnancy References ............................................................................................................................................................... 146 Page 3 Introduction Clinicians across Colorado and the nation are facing one become an increasingly common part of medical practice. of the most devastating public health crises in decades. The number of lives impacted by the crisis is astonishing. Opioids, both prescription and illicit, have become the The Centers for Disease Control and Prevention (CDC) leading cause of death in the United States for adults 50 reports that opioid overdose killed nearly 400,000 years of age or younger.1 Opioid-related adverse drug Americans between 2000 and 2017, and currently an events (ORADEs), opioid overdose, physical dependence average of 130 Americans die every day of opioid overdose and the development of opioid use disorder (OUD) have (FIGURE 1).2,3 (FIGURE 1) Three Waves of the Rise in Opioid Overdose Deaths, 1999-2017 SOURCE: CDC MMWR3 More than 10.3 million people over the age of 12 years admission is an average of seven years. For patients who self-reported misusing opioids in 2018, with 9.9 million die of an overdose, the time between their first exposure misusing prescription pain relievers and 808,000 using to an opioid and death is between nine and 13 years.7,8 In heroin.4 The pharmaceutical use of opioids skyrocketed 2017, opioids were responsible for 34% of all substance between 1990 and 1996: prescriptions for fentanyl rose use disorder (SUD) treatment admissions for patients 1,000%, followed by morphine (49%), oxycodone (15%) aged 12 years and older.9 The economic implications of and hydromorphone (12%).5 The number of prescription this epidemic are staggering; the White House Council of opioids sold in the United States increased five-fold Economic Advisers estimates that the full economic cost between 1999 and 2017, and prescription opioids were of the opioid epidemic was $696 billion in 2018, a figure involved in 218,000 overdose deaths over this time period. that represents 3.4% of the gross domestic product of the In 2017, there were 58 opioid prescriptions written for United States.10 every 100 patients in the United States, with an average prescription length of 18 days.6 While a number of external factors have contributed to the liberal use of these potentially lethal drugs, the medical The dire consequences of the widespread availability community is compelled to acknowledge its role in creating of prescription opioids emerged over time. The “lag this crisis. Fortunately, clinicians and health care systems period” between a patient’s first exposure to an opioid also have the power to reverse these grim statistics by (either medical or nonmedical) and their first treatment reforming their practices with resolve and innovation. Page 4 Introduction continued The Origins of the Opioid Epidemic This shift in perspective was reinforced by the Veterans Concerned about potential adverse effects, including Health Administration, which adopted pain as the “fifth addiction and overdose, few physicians prescribed vital sign” in 1999.18 The Joint Commission, a governing opioids for chronic noncancer pain throughout most of body responsible for hospital accreditation, added the 20th century.11 That changed in 1986, however, when pain management as a requirement for accreditation pain expert Russell Portenoy published a limited case in 2000.2,11 During the same period, a report by the series of 38 hospital patients that suggested that chronic Institute of Medicine, Relieving Pain in America, painted noncancer pain could be managed safely with high doses pain management as a “moral imperative, a professional of opioids without posing a risk of addiction.12 Since then, responsibility, and the duty of people in the healing the scientific validity of Portenoy’s original work has professions.”19 In addition to these mounting institutional been called into question; in recent years, the researcher pressures, patient satisfaction surveys increasingly himself has publicly doubted the relative efficacy and compelled medical clinicians to place a premium on safety of long-term opioid use for the treatment of chronic pain management. These highly subjective scorecards, noncancer pain.12-15 Portenoy’s findings were endorsed which were