Background/Purpose: With the evolution of DMARDs, the need for opioids in the treatment of rheumatic diseases has decreased. However, rheumatology professionals are often presented with patients in whom chronic opioid therapy was started prior to the availability of newer DMARDs.  Current guidelines suggest opioid tapering should be considered in patients with chronic noncancer pain on ≥90 mg morphine equivalent dose (MED) daily or in combination with other high-risk medications. The aims of our project are to assess provider perspective and baseline knowledge on opioid taper regimens, provide education and support related to opioid management, and demonstrate improved patient outcomes when a pharmacist is part of the multidisciplinary team in a rheumatology practice.

Methods: The pharmacy team at a private rheumatology practice developed a three phased program including provider and staff education, updates to office workflows, and implementation of individualized patient taper plans.  A baseline survey was administered to providers to characterize current practices and perspectives regarding practice-wide opioid use and confidence in managing opioids. The pharmacy team held training sessions to teach providers to appropriately identify circumstances when opioid tapering is indicated, develop individualized opioid taper regimens, recognize and manage withdrawal symptoms, and apply risk mitigation strategies during a chronic opioid therapy taper. Patients identified by providers as candidates are enrolled in the pharmacy service. The pharmacy team serves as a continuous resource to providers and works directly with patients enrolled in the service. Baseline characteristics, historical data on opioid related efficacy and side effects, and daily morphine equivalents are collected and tracked for each patient.

Results: All providers (n=10) reported having patients on chronic opioids; 70% felt they had at least one patient who would benefit from tapering. Reported barriers to tapering included time, comfort, and lack of confidence in managing withdrawal. Eighty percent of providers rated their comfort level a 5 or lower in tapering or discontinuing an opioid, on a scale of 0 to 10, with 0 being not comfortable at all and 10 being very comfortable. Nine providers stated they were hesitant or very hesitant in developing an opioid tapering plan. As of June 2020, 16 patients have been enrolled in the opioid taper service, and 2 withdrew.  Five have reduced their daily MED somewhere between 25 and 100%. The remainder of patients are at stage where the focus is optimizing non-opioid analgesics, limiting high-risk concomitant medications, and minimizing use of existing opioids.  A follow-up provider survey is planned. Patient survey data will also be collected.

Conclusion: Successful opioid tapering is a time intensive process and requires a multidisciplinary approach.  This provides an opportunity for pharmacists to play an essential role as part of a team-based approach to ensure a successful opioid taper or discontinuation while minimizing adverse events. Our pharmacist-led opioid taper protocol can serve as an innovative model for rheumatology practices to include a clinical pharmacist as part of their healthcare team.

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ACR Meeting Abstracts - https://acrabstracts.org/abstract/pharmacist-led-multidisciplinary-approach-to-opioid-tapering-in-a-large-private-rheumatology-practice/