Respiratory Depression Associated with Opioids: A Narrative Review.

All opioids have a risk of causing respiratory depression and reduced cerebral circulation. Fentanyl has the greatest risk of causing both. This is particularly a concern when combined with illicit opioids such as diamorphine (also known as heroin).

Implementation of a Pilot PharmD Medication Optimization Telehealth Clinic Within a Veterans Affairs System.

Patients older than 65 years of age with an anticipated life-expectancy of 12 months or less may have complex medication regimens and an increased risk of adverse drug reactions, and drug-drug interactions. Within the Department of Veterans Affairs, a commonly used medication optimization model is known as the VIONE methodology. This project aimed to pilot implementation of board-certified clinical pharmacist practitioners utilizing the VIONE model within a patient-aligned care team targeting patients 65 years of age and older.

The Impact of a Clinical Pharmacist Practitioner on Perioperative Pain Management for Orthopedic Surgeries.

The objective of this quality improvement (QI) project was to assess the impact of an evidence based clinical pharmacist practitioner (CPP) model applied to perioperative pain management by integrating a CPP into the perioperative orthopedic surgery clinical pathway. Secondary objective was to assess the effect of CPP pain management service on surgical team satisfaction. This QI project expanded CPP pain management services for patients who were scheduled for an orthopedic surgery.

Management of Critical Glucose Values in Hospice.

: This quality improvement (QI) project was to lean the process for managing critical high and low glucose levels in the hospice unit and to simplify the pharmacologic options for hypoglycemic management for nursing staff. : The process for developing and refining the recommendations involved a modified Delphi approach with a team of key stakeholders with overlapping expertise in hospice care practice. Recommendations were based on literature review, judgement of experts, and clinical experience.

Medication Use Evaluation of Docusate Sodium in Constipation Prophylaxis and Opioid Induced Constipation at the WPB VA HCS Community Living Center.

Introduction: Docusate sodium's efficacy is widely debated. Several studies on opioid induced constipation (OIC) concluded that docusate sodium vs either placebo or in combination with sennosides provided no benefit.

Objective: This medication use evaluation aimed to investigate constipation treatment trends within the West Palm Beach VA Healthcare System Community Living Center, and to assess the therapeutic effectiveness of docusate sodium.

Prescription drug monitoring program (PDMP) utilization and outcomes within the West Palm Beach Veterans Affairs (VA) healthcare system.

Objective: Prescription drug monitoring programs (PDMPs) can identify patients at risk of controlled substance (CS) polypharmacy and accidental poisoning.

Design: A retrospective pre-/post-intervention review of a random sample of provider notes with documentation of PDMP outcomes was completed before and after the enactment of a Florida law mandating PDMP queries.

Setting: West Palm Beach Veterans Affairs Health Care System, which provides inpatient and outpatient services.

Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists.

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed.

Impact of Clinical Pharmacist Practitioner-Driven High Opioid Dose Reevaluation in Veterans with Chronic Non-Cancer Pain.

Veterans Health Administration implemented the Opioid Safety Initiative (OSI) in 2013 to promote safe/rational opioid prescribing. West Palm Beach VA Healthcare System (WPBVAHCS) has been an outlier for the percentage of Veterans with chronic non-cancer pain receiving ≥90 mg Morphine Equivalent Daily Dosing (MEDD) in Veterans Integrated Service Networks (VISN) 8 since the 2016 fiscal year. The purpose was to determine the utility of a Pain Clinical Pharmacist Practitioner (CPP) identifying, reviewing, and approaching Veterans utilizing high-dose opioids for dose reevaluation and the impact on OSI metric post-opioid reevaluation.

Development of Entrustable Professional Activities for Specialist Hospice and Palliative Care Pharmacists.

Context: Entrustable professional activities (EPAs) translate competencies into explicit, practical terms that clearly state the expected roles and responsibilities of clinicians who have achieved proficiency and expertise in a field. EPAs are defined for Hospice and Palliative Medicine physicians but not for other members of Hospice and Palliative Care (HAPC) interprofessional teams, including pharmacists.

Objectives: The objective of this study was to develop EPAs for HAPC pharmacists.

Retrospective Review of Perioperative Multimodal Analgesia for Orthopedic Patients in a Veterans Affairs Setting.

Objectives: To determine adherence of perioperative knee/hip arthroplasties and hip fracture repairs to the American Pain Society (APS) guideline recommendations for perioperative pain control. One secondary objective was to perform an internal quality audit on the use of enhanced recovery after surgery (ERAS) protocols; another secondary objective was to design an evidence-based, multi-modal perioperative quick-order menu (if warranted).

Design/patients: A retrospective quality improvement (QI) review of uncomplicated knee/hip replacement and hip fracture repairs from January 2018 through March 2018.

Spiritual Healing in a Hospice Veteran Led to a Successful Opioid Taper: A Case Report.

Addressing "total pain" is a concept commonly practiced in palliative care. Spiritual healing in a Navy Veteran led to a significant improvement in pain allowing a voluntary taper of opioid medication. The Veteran was able to reconcile his faith in God and participated in several spiritual practices daily.

Pharmacy-Led Quality Improvement Project on Pain Control Using Continuous Subcutaneous Infusion of Opioids in an Inpatient Hospice Unit.

Objectives: The purpose of this quality improvement (QI) project was to improve the overall process of implementing continuous subcutaneous infusion of opioids (CSCIOs) at the West Palm Beach Veterans Affairs Medical Center and characterize their use in the hospice unit.

Methods: A retrospective chart review from July 2014 to August 2017 was conducted to identify patients who had received CSCIO. Results were analyzed with descriptive statistics.

Managing Cancer Pain, Monitoring for Cancer Recurrence, and Mitigating Risk of Opioid Use Disorders: A Team-Based, Interdisciplinary Approach to Cancer Survivorship.

Palliative care (PC) teams increasingly care for patients with cancer into survivorship. Cancer survivorship transcends distinctions between acute, chronic, malignant, and nonmalignant pain. Partnering with oncologists, PC teams manage pain that persists after disease-directed treatment, evaluate changing symptoms as possible signs of cancer recurrence, taper opioids and mitigate risk of opioid misuse, and manage comorbid opioid use disorder (OUD).

Analysis of Inpatient Hospice Pharmacist Interventions Within a Veterans Affairs Medical Center.

Clinical pharmacy interventions have been shown to improve medication therapy, prevent undesirable side effects, and improve patients' clinical outcomes in a number of settings; however, limited data exist to characterize clinical pharmacy specialist (CPS) providers' interventions in an inpatient hospice Veteran Affairs (VA) setting. The primary objective of this quality improvement (QI) project was to quantify the number and types of pharmacy interventions implemented from the Pharmacists Achieve Results with Medications Documentation (PhARMD) tool for inpatient hospice patient encounters in a VA medical center. A total of 453 interventions during 185 patient care encounters were documented by CPS providers between September 1, 2016, and December 31, 2016.

Pilot Inpatient Pain Pharmacist Consult Service at the West Palm Beach VA Medical Center.

An inpatient pain pharmacist consult service may help manage the complex issues associated with medications for patients with pain.

Use of Topical Morphine to Relieve Painful Pressure Ulcers.

Introduction: Topical morphine is a potential treatment option for painful pressure ulcers in hospice and palliative care patients who favor avoidance of systemic opioid therapy.

Case: A 65-year-old male African-American veteran with a painful stage 3 sacral pressure injury was hesitant to take systemic opioids to control his pain, as he wished to stay alert for family and friends. Topical morphine was initiated, and within 24 hours the patient reported a significant reduction in pain on the numeric rating scale.

Integration of a Clinical Pharmacist into an Interdisciplinary Palliative Care Outpatient Clinic.

Objectives: The primary objective of this quality improvement (QI) project was to determine if the Interdisciplinary Palliative Care Outpatient Clinic (IPCOC) at the West Palm Beach Veterans Affairs Medical Center offered improved symptom assessment and palliative care treatment outcomes. Secondary objectives were to identify, classify, and resolve medication problems and calculate the number of pharmacist recommendations accepted by prescribing providers.

Methods: An IPCOC was created by selecting disciplines for a core group including a nurse practitioner, clinical pharmacist, social worker, chaplain, and physician.

The Use of Transdermal Buprenorphine in Complex Regional Pain Syndrome: A Report of Two Cases.

Management of complex regional pain syndrome (CRPS) can be challenging. Various pharmacological approaches have produced mixed results. Buprenorphine activates mu-opioid receptors and antagonizes kappa and delta receptors, acts at N-methyl-d-aspartate (NMDA) receptor, and is an orphan-related ligand-1 receptor agonist.

Opioid-Induced Androgen Deficiency in Veterans With Chronic Nonmalignant Pain.

Patients on chronic opioid therapy or considering it should be counseled about the risks associated with opioid-induced androgen deficiency.

Clinical decision support tools: personal digital assistant versus online dietary supplement databases.

Background: Clinical decision support tools (CDSTs) on personal digital assistants (PDAs) and online databases assist healthcare practitioners who make decisions about dietary supplements.

Objective: To assess and compare the content of PDA dietary supplement databases and their online counterparts used as CDSTs.

Methods: A total of 102 question-and-answer pairs were developed within 10 weighted categories of the most clinically relevant aspects of dietary supplement therapy.

Clinical decision support tools: focus on dietary supplement databases.

Objective: To assess the content of dietary supplement databases used for clinical decision support.

Methods: Four online dietary supplement databases were assessed according to scope, completeness, and ease of use. Additionally, a composite score integrating all 3 criteria was determined.