Evaluate opioid prescribing trends for ElderPlace, a Program for All-inclusive Care for the Elderly (PACE)

Background • Providence ElderPlace in Oregon is the fifth-largest PACE program in the country that offers wraparound nursing home-eligible medical and social services to over 1600 community-dwelling seniors who are medically frail with complex medication regimens. • Many elderly patients suffer from chronic nonmalignant pain which may affect their function and quality of life. • The Centers for Disease Control and Prevention (CDC) reports a 7.7% increase in drug overdoses and opioid deaths in the aging population from 2013 to 2014. • In 2015-2016 elderly adults obtained an annual average of 774 Morphine Milligram Equivalents (MME) of outpatient prescriptions for chronic & acute pain. • Multiple comorbidities and age-related changes may affect distribution, metabolism, and elimination, older adults are at increased risk of adverse drug events and reactions. • Physician prescribing practices has been shown to play an important role in high rates of prescription opioid use and misuse. Purpose To determine trends in opioid prescribing for chronic pain in geriatric patients enrolled with Providence ElderPlace in Oregon Objectives Discuss trends in opioid prescribing for chronic pain in geriatric patients at Providence ElderPlace • Determine if opioids are being safely prescribed at Providence ElderPlace • Identify potential gaps that can be addressed to improve opioid prescribing safety Methodology • Institutional Review Board (IRB) exempt • Retrospective electronic health record (EHR) based study of multiple ElderPlace clinic sites in Oregon. • All patients meeting inclusion criteria were included • Study population: • Providence ElderPlace participants on routine opioids for chronic pain only (\u3e6 months). • Study period: • March 1, 2020 – October 1, 2020 • Exclusion criteria: • Palliative care Stage 2 and Stage 3 • Outcomes: • Primary: Trends in opioid prescribing using surrogate markers such as: • Average MEDD • Functional goals of therapy • Alternative therapy offered/provided • Informed consent • ElderPlace protocol use • Safety: Falls and opioid-related hospitalizations Discussion Patient Population • Total of 610 people were originally enrolled in the study. After screening, 168 patients were utilized to determine the clinical and safety outcomes. • At baseline, patients were of average of geriatric age (≥65 years old) • Mean age was 76 years (range 57-97 years). • Majority of patients were not of palliative care status. • Opioid use prior to joining ElderPlace was 69.6% of the study population with majority of use being scheduled narcotics. • The most used opioid medications were oxycodone and hydrocodone-acetaminophen followed by morphine. • Additional opioid medications used chronically were tramadol, codeine, fentanyl, hydromorphone, and methadone. Outcomes • The average morphine equivalent daily dose was 33.6 mg per day. • 91, 53, 17 and 7 patients required \u3c25 MEDD, 25-49 MEDD, 50-119 MEDD, and ≥120 MEDD respectively. • Only 41.7% of the patient population had defined functional goals. • 95.8% of patients had alternative forms of pain management (non-controlled medications, topicals, physical therapy, acupuncture, etc.) in addition to opioids. • 23 (13.7%) patients provided informed consent and 10 followed the current ElderPlace protocol. • Total of 78 falls occurred in 49 different patients. Of those patients 89.8% had 1-2 falls, 8.2% had 3-4 falls, & 2% had \u3e5 falls. • Total of 67 hospitalizations occurred in 37 different patients- - of those, only 18 were opioids related. • Falls were more frequent in Palliative Care Stage 1 patients. Study Limitations • Retrospective, non-randomized study • Risk of information bias since clinical outcomes determined via chart review • Short study time frame • Unable to assess compliance, efficacy of current therapy, and use of PRN medications • Did not assess cause of falls • Specific goals were not defined to determine success Conclusions This study was performed to evaluate trends in opioid prescribing for chronic pain at Providence ElderPlace in Oregon. • Overall, ElderPlace has high compliance at providing alternative therapy in addition to opioids for pain management, but minimal compliance with following the PACE guideline • Low percentage of patients on opioids experienced falls or hospitalizations during the study period. No clear correlation between average MEDD and safety outcomes. • Room for improvement includes determining clear functional goals in relation to pain and obtaining a signed material risk notice (which will enhance ElderPlace protocol use).https://digitalcommons.providence.org/oaa_ppmcstvin_21/1005/thumbnail.jp