Q&A: How Multidisciplinary, Patient-Centered Care Reduces Opioid Dependence

As pre-operative, operative, and post-operative approaches to care are often handled in silos, many experts believe all 3 transitions of care should be treated together. Throughout post-operative pain programs, like the incredibly valuable work at Johns Hopkins, patients experiencing pain need the proper support and education from providers in order to avoid the intense risks of opioids.

“If your patients are saying that they’re in more pain, maybe it’s because they’re on too much pain medication, and we need to start tapering them off,” Duane Jones, BS Pharm, regional pharmacy supervisor and clinical program director at Harps Food Stores, told Drug Topics®. “There’s a proper way to do that, and we’ve done it.”

In part 2, we explored the ins and outs of the Johns Hopkins Perioperative Pain Program, explaining the pharmacist’s ongoing role in managing a patient’s opioid or pain management regimen. Throughout this discussion, learn about the immense value of both a multidisciplinary and patient-focused approach to minimizing risks and maximizing successful outcomes in pain management.

READ MORE: Nonopioid Treatment Offers Safer, Effective Alternatives for Pain Management

Drug Topics: What is the mission of the Johns Hopkins Perioperative Pain Program and what specific goals does it set for patients on chronic opioid therapy?

Duane Jones: Perioperative, to define that or to understand it, it’s different. In the past, we were looking at pre-op, operative, and post-op, and then treating that separately. Today, they treat it all together. [They] educate the patient, do an assessment first to see where they are. If we have patients that are on a chronic opioid now, how do we taper them before surgery? How do we educate them to what to expect after the surgery? What do we do during the surgery that’s going to also lead into the post-op treatment as well?

It’s a multidisciplinary approach to treating this patient’s pain. We incorporate several different professions in this, even psychiatrists, because if you have somebody that has an underlying psychiatric condition that’s going to make them more exposed to addiction, we need to know that and we need to be able to be aware of that going into it. Then, we can prepare pre-op, op, and post-op, and then we can triage them accordingly.

That’s the beauty of their program; it’s a multidisciplinary approach to that pain. Here again, the patient becomes a center of care. We look at this patient; we work with the patient as according to their needs. It’s what we think they need as this standardized patient. We treat them as an individual, and that’s the beauty of their program. And it’s been extremely effective.

Drug Topics: How does the program utilize a multidisciplinary transitional care model to coordinate patient care?

Duane Jones: Then, you have transitions of care. Within their multidisciplinary approach, they’ll actually follow this patient post-op from up to 6 months to make sure that they’re rehabbing properly, making sure that they’re actually going through with their physical therapy. They make sure that they’re actually getting their joints, their body back to the condition where it was before the surgery. That takes some time, some education with that patient. As we look at that approach, we’ve looked at transition of care for many years within our practices: How we can help [patients] as pharmacists, how we can help them to understand what’s happening, and how they can help themselves to heal better.

The worst thing we can do is give them medication and tell them to go home and sit. I had my knee surgery; I’m up walking on it 2 hours afterwards because we need to condition your body. We’ve got to have that blood flow. We’ve got to have oxygen flow into that area for your body to heal. Your body wants to heal anyway. If we give you medication that prevents that, then it’s counterproductive. We don’t want that to happen. It’s an individualized approach.

They actually now have developed an entire chronic pain management system within Johns Hopkins, where they manage these patients, help taper them off opioids if they’re on them, and then give them alternative means of handling that pain and treating that pain and successfully doing it. Acupuncture can even come into play within this multidisciplinary approach. We’re looking at that patient and what the cause is. You have situations where people have had tremendous trauma; they’ve had accidents, they’ve had multiple surgeries. There are really issues there that we need to deal with [for] that particular individual. As we put that patient back at the center of care, we can do that. But we don’t treat every patient that way, and that’s why we’re in the problem we’re in. Every patient’s been treated the same.

Lack of knowledge of opioids and the effect on opioids has caused this problem. There is a clinical entity out there; it’s called opioid-induced hyperalgesia, which most people don’t understand. I remember whenever I was in our clinical group in our residency, I mentioned this one day, and one of the clinical people told me that they thought I was just making this term up because they hadn’t heard this. They didn’t teach us that in school. They started looking it up and said, “It’s real.” What happens is, the more opioids you give them, the more sensitive they become to pain, and their pain actually grows.

We have had many instances where we’ve had patients that we started to taper them off of their opioids. They start feeling better, and then they say, “I want to get off of these completely.” We’re able to help them taper their dose down. Sometimes you have to have a substance abuse therapy involved with them, they have to go to counseling, but then we can get them completely off of it. Now, they’re completely functional in society again. I can’t say how many people have come up and said, “Thank you very much; I feel so much better.” That is because that knowledge is not out in the marketplace—in the marketplace, I say, but in our profession [too], to understand that that’s a real entity. If your patients are saying that they’re in more pain, maybe it’s because they’re on too much pain medication, and we need to start tapering them off. There’s a proper way to do that, and we’ve done it.

We had a lot of pushback in our company whenever we established our opioid policy. I said we are going to follow CDC guidelines and we’re going to reduce people down below 90 morphine milligram equivalents because we had so many that were above it. I had physicians call me, one wrote me a letter and another one called me, and said, “Thank you for taking a stand.” We need some guidance and direction, and that’s what I love about the Johns Hopkins program.

READ MORE: Nonopioid Pain Management Resource Center