2025 Southeastern Residency Conference

Title: Implementation of a Pharmacist-Managed Buprenorphine Induction Protocol for Patients with Opioid Use Disorder (OUD) in the Inpatient Setting  


Authors: Madeline Lysogorski, PharmD, Charleen Melton, PharmD, BCCCP, Holly McLean PharmD, CPP, BCPS, BCCCP, Joe Norton PharmD, BCPS  
 
Background: 
In recent years, there has been an increase in research published discussing high-dose buprenorphine for induction of Medication-Assisted Therapy (MAT) in patients with Opioid Use Disorder (OUD), with the primary setting being inpatient induction. However, none of these studies specifically highlight interventions that can be made by a clinical pharmacist during the induction process. This study aims to evaluate the impact of a pharmacist-managed buprenorphine MAT- induction protocol in hospitalized patients with OUD. 
 
Methods:  
This study is being conducted as a prospective chart review at CaroMont Regional Medical Center, a 476-bed not-for-profit community hospital located in Gastonia, NC. Patients will be evaluated for withdrawal symptoms by an attending physician, who will subsequently order a pharmacy consult for patients to be initiated on buprenorphine. The patients will then be enrolled in the pharmacy protocol and followed until they are successfully maintained on their maintenance dose (Day 3 of the consult). Data will be collected utilizing the hospital’s electronic health record (EHR) and will evaluate patients that were initiated on the buprenorphine initiation protocol from November 1st, 2024, through March 31st, 2025. Those included in the study will be adult inpatients over 18 years old that are initiated on the pharmacist-managed buprenorphine protocol. Patients will be excluded if they are part of a vulnerable population (under 18 years old or incarcerated), if they are already established on a buprenorphine/naloxone regimen outpatient, or if they were initiated on buprenorphine in the emergency department (ED) and discharged to complete induction outpatient. The primary outcome to analyze in this study is the number of patients who had successful buprenorphine induction on the pharmacist-managed protocol, defined as the patient not leaving AMA, completing the induction protocol during their admission, and being successfully connected to care at discharge.  
 
Results: A total of 15 patients were enrolled in the study. 13/15 patients (86.66%) had successful induction, and met our primary endpoint . 2/15 patients left AMA prior to completion of the protocol, with the average hospital length of stay being 4.5 days. The average total daily dose of buprenorphine that patients received was 19.6mg, and the average total buprenorphine dose received during admission was 58.3mg. The majority of patients (8/15) were connected to care with a local health department that provides MAT services with a bridge prescription until they were able to be seen by a provider. 
 
Conclusions: High dose buprenorphine induction in the inpatient setting is the ideal environment, due to consistent monitoring for withdrawal management. No patients in this study failed induction due to adverse events. Addressing institutional barriers can make the protocol more successful and increase recruitment. 

Title: 
Prevalence, Incidence, and Outcomes of Selective-Serotonin Reuptake Inhibitor (SSRI) and Serotonin-Norepinephrine Reuptake Inhibitor (SNRI) Duplication of Therapy 


Authors:
Gabrielle E. Hall, Aaryn Brewster, Cameron Lanier


Objective:
Identify the prevalence, incidence, and associated outcomes of duplicative prescribing and ordering of SSRI and SNRI therapy at three regional hospitals within a regional health system. 


Self Assessment Question:
What percentage of patients on SSRI or SNRI therapy at baseline were prescribed or ordered duplicative therapy while admitted to a study hospital during the research period?


Background: 
Multiple patients have been identified as having been prescribed or ordered duplicative SSRI and SNRI therapy. This is not a guideline recommended therapy due to the increased risk for adverse events, specifically serotonin syndrome, resulting from using multiple serotonergic agents in combination. Our goal is to identify how often these duplications are occurring and to promote patient safety through recommending appropriate prescribing practices.  


Methods:
This is a retrospective chart review with subgroup analysis. The patient population consists of patients exposed to either two SSRIs, two SNRIs, or an SSRI and SNRI combination while inpatient. Patients were divided into two groups based on those on duplicative therapy prior to admission and those who started on duplicative therapy during admission.  
The primary outcome for this study is prevalence of duplications of therapy as compared to those on SSRI or SNRI at baseline. The secondary outcome is incidence of duplications of therapy as compared to those on an SSRI or SNRI at baseline. Further secondary outcomes of the study include a logistic regression analysis comparing the exposure group to the control group to assess outcomes including similarities and differences in their baseline demographics and reported adverse events. 


Results:
The primary outcome for this study was prevalence of duplications of therapy where out of 7545 patients on an SSRI or SNRI at baseline 152 patients (2%) were on duplicative therapy. The secondary outcome of incidence of duplications of therapy revealed 81of the of 7545 patients (1%) on an SSRI or SNRI at baseline were started on duplicative therapy inpatient. Of the 152 patients on duplicative therapy, 81 patients (53%) were initiated on those duplicate agents while inpatient. Another finding includes 588 patients out of 7545 patients (8%) on an SSRI or SNRI at baseline were on multiple serotonergic agents.  Frequently duplicated medications include escitalopram with duloxetine (40/152, 26%), sertraline with duloxetine (40/152, 26%), and fluoxetine with duloxetine (19/152, 12.5%). Duloxetine was found to be a duplicated medication in 111 of 152 patients (73%).

Title: Initiative To Improve Lithium Safety Monitoring at Veterans Affairs Medical Center

Authors: Cydney Smalls, Carrie Sartin, William Erwin

Objective: To evaluate the effectiveness of recommendations provided by a pharmacist via chart review regarding lithium therapeutic drug levels and safety monitoring for Veterans.

Self-Assessment Question:

Background: Lithium is a well-established therapy for mood disorders, known for its effectiveness in mood stabilization and significant reduction in suicide risk. Despite its clinical benefits, lithium therapy is challenging due to its narrow therapeutic index, making patients susceptible to toxicity. Consequently, frequent monitoring of serum lithium levels and organ function (Scr, ECG, TSH, electrolytes, CBC) is critical. This quality improvement initiative aims to evaluate the impact of clinical pharmacist recommendations provided via chart notifications on enhancing lithium monitoring practices.

Methodology: This quality improvement project is designed as a multi-center, prospective cohort analysis, exempt from Institutional Review Board approval. It investigates provider responses to clinical pharmacist recommendations made through a chart-based review for Veterans on lithium therapy at the Fayetteville NC VA Coastal Health Care System (FNCVACHCS). Participants were identified using the Veterans Affairs Lithium Lab Monitoring Dashboard. Recommendations were communicated to providers using a standardized note template embedded within the computerized patient record system (CPRS). The primary outcome measures the percentage of recommendations accepted by prescribers, determined by new orders placed within one week of the note's documentation. Secondary outcomes include evaluating the average duration between note documentation and completion of recommended safety monitoring tests, incidence rates of supra-therapeutic lithium levels along with associated side effects, and the proportion of accepted recommendations not carried out by patients.

Results: Forty-six notes were entered to communicate recommendations to prescribers. Regarding the primary outcome, providers accepted 37% (17) of these recommendations. The average time from note entry to completion of recommended safety monitoring tests was 13 days. Notably, no supratherapeutic lithium levels were reported during the observation period. However, 47.1% (8) of provider-accepted recommendations were not completed by patients, indicating a significant gap between provider acceptance and patient adherence.

Conclusions: Despite the inconsistent laboratory monitoring parameters for Veterans on lithium therapy, the results showed that Veterans for whom lab values were reviewed showed no significant concerns. There were limitations with the initiative which included providers not acknowledging the recommendation within the computerized patient record system (CPRS), resulting in variability in the implementation of recommended monitoring practices. Identified barriers, including time constraints and alert fatigue, likely contributed to this inconsistency. Addressing these challenges through targeted education, streamlined workflows, and supportive feedback is essential to enhancing provider adherence, thereby ensuring consistent patient safety practices. Efforts to mitigate these barriers are crucial to sustaining the initiative without placing undue burden on healthcare providers.