The Pharmacist Perspective

Re-adding EXPAREL to Formulary

System Overview

Small, physician-owned surgical center, operating as a hospital outpatient department (HOPD), that had removed EXPAREL from its formulary for approximately 5 years based on cost concerns

Strategic Goal:

Leverage separate Medicare reimbursement for EXPAREL (NOPAIN Act) to create an opportunity for adding EXPAREL back onto formulary in order to reduce opioid use in the community surrounding the health system

Approach

Established positive rapport with cross-functional partners

The Director of Pharmacy engaged physicians and surgeons who had experience with EXPAREL at other facilities to understand their perspectives and kickstart the conversation
Engaged leadership

Key members of system leadership—including the medical executive team—were educated on the potential benefits of EXPAREL prior to presenting the full plan to the Pharmacy & Therapeutics committee
Started with few indications to monitor closely

EXPAREL usage was initially granted for only 2 indications—interscalene and adductor canal blocks—based on high usage in orthopedic procedures and was provided on a case-by-case basis after anesthesiologists proved that the patient use case met preidentified criteria for approval
Ensured appropriate implementation

Surgeons and anesthesiologists were trained to ensure that EXPAREL was tracked and charted appropriately (in milligrams), and office managers were engaged to ensure that the J-code was used for billing
Regularly analyzed cost benefits and clinical outcomes

Leadership met quarterly to review the economic benefits and clinical outcomes, including postoperative pain scores and opioid use compared with patients not receiving EXPAREL

Key Considerations

Start small with clear criteria

Establishing the benefit in select indications can help gain a controlled assessment for the potential of EXPAREL

Have a vision

Mapping out the proposed plan and the potential impact can help gain buy-in from colleagues and leadership

Collect and assess data

Using health system data and patient feedback is critical to determining success and guiding future decisions

Leverage manufacturer support

Maintaining a strong relationship with the Pacira representative helped connect the system with medical science liaisons and nurse educators

Reported Impact at This Health System*

By adding EXPAREL back onto formulary with clear controls and a controlled population, the system was able to see reductions in spending compared with their original experience 5 years prior
The Director of Pharmacy and their team were able to elevate the standard of care for the health system while helping reduce opioid use and providing greater overall patient satisfaction
The success of the initial rollout has allowed the facility to expand the use of EXPAREL to more indications while maintaining control and minimizing the financial impact
The Director of Pharmacy was able to establish strong lines of communication between clinicians and pharmacy to support future collaborations in advancing patient care

*Based on data reported by the Chief Pharmacy Officer interviewed for this case. Results reflect the experiences of one health system. Results at other health systems may vary.

NOPAIN, Non-Opioids Prevent Addiction in the Nation.

See real-world approaches that may align with your system’s goals.

Additional Studies and Materials

The Chief Pharmacy Officer Perspective

View the study

The Anesthesiologist Perspective

View the study

Resources

Learn about adding EXPAREL to your health system

Back to Case Studies Selection

Important Safety Information

Indication

EXPAREL® (bupivacaine liposome injectable suspension) is indicated to produce postsurgical local analgesia via infiltration in patients aged 6 years and older and regional analgesia in adults via an interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and an adductor canal block.

Important Safety Information

EXPAREL is contraindicated in obstetrical paracervical block anesthesia
Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation
Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia

Important Safety Information

Important Safety Information

Indication

Important Safety Information

EXPAREL is contraindicated in obstetrical paracervical block anesthesia
Adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via infiltration were nausea, constipation, and vomiting; adverse reactions reported in adults with an incidence greater than or equal to 10% following EXPAREL administration via nerve block were nausea, pyrexia, headache, and constipation
Adverse reactions with an incidence greater than or equal to 10% following EXPAREL administration via infiltration in pediatric patients six to less than 17 years of age were nausea, vomiting, constipation, hypotension, anemia, muscle twitching, vision blurred, pruritus, and tachycardia
Do not admix lidocaine or other non-bupivacaine local anesthetics with EXPAREL. EXPAREL may be administered at least 20 minutes or more following local administration of lidocaine
EXPAREL is not recommended to be used in the following patient populations: patients <6 years old for infiltration, patients younger than 18 years old for nerve blocks, and/or pregnant patients
Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease

Warnings and Precautions Specific to EXPAREL

Avoid additional use of local anesthetics within 96 hours following administration of EXPAREL
EXPAREL is not recommended for the following types or routes of administration: epidural, intrathecal, regional nerve blocks other than interscalene brachial plexus nerve block, sciatic nerve block in the popliteal fossa, and adductor canal block, or intravascular or intra-articular use
The potential sensory and/or motor loss with EXPAREL is temporary and varies in degree and duration depending on the site of injection and dosage administered and may last for up to 5 days, as seen in clinical trials

Warnings and Precautions for Bupivacaine-Containing Products

Central Nervous System (CNS) Reactions: There have been reports of adverse neurologic reactions with the use of local anesthetics. These include persistent anesthesia and paresthesia. CNS reactions are characterized by excitation and/or depression
Cardiovascular System Reactions: Toxic blood concentrations depress cardiac conductivity and excitability, which may lead to dysrhythmias, sometimes leading to death
Allergic Reactions: Allergic-type reactions (eg, anaphylaxis and angioedema) are rare and may occur as a result of hypersensitivity to the local anesthetic or to other formulation ingredients
Chondrolysis: There have been reports of chondrolysis (mostly in the shoulder joint) following intra-articular infusion of local anesthetics, which is an unapproved use
Methemoglobinemia: Cases of methemoglobinemia have been reported with local anesthetic use

Please refer to full Prescribing Information.