In light of the ongoing opioid crisis, more hospitals are taking action to change their pain management protocols and reduce opioid prescriptions for inpatients.
According to a recent survey of 81 U.S. hospitals, 98% implemented changes to their opioid delivery practices between July 2017 and July 2018. The survey, published in October 2018 by health care solutions firm Vizient, found that prescriber education was the most common change, followed by new technologies to monitor opioid prescribing and alternative therapies for acute pain management.
“There has been a shift in opioid management in hospital settings,” said Susan Calcaterra, MD, MPH, an assistant professor at the University of Colorado School of Medicine in Aurora and a hospitalist who specializes in addiction medicine. “In response to the opioid epidemic, many health systems and health care professional organizations are implementing policies that reduce opioid prescribing and encourage nonopioid options.”
Hospitalists play an integral role in putting these policies into action, said Shoshana Herzig, MD, FACP, director of hospital medicine research at Beth Israel Deaconess Medical Center and an assistant professor at Harvard Medical School in Boston. She was also the lead author of an April 2018 Society of Hospital Medicine (SHM) statement on improving the safety of opioid use for acute noncancer pain in hospitalized patients.
“Hospitalists, at this point, care for the majority of hospitalized medical patients in the country and they also care for a lot of patients in the postoperative setting,” Dr. Herzig said. “If we were able to make prescribing practices more appropriate, I think we would be able to make a big impact on outcomes related to opioid therapy.”
Among the hospital initiatives are stewardship programs that seek to review current opioid practices and make improvements where necessary, Dr. Herzig said. At Beth Israel Deaconess Medical Center, for example, leaders are evaluating whether inpatients who are not receiving opioids during their final hospital days generally receive an opioid prescription at discharge.
“We're trying to better match the opioid prescriptions with what the patient's opioid needs actually are to try to prevent overprescription of opioids,” she explained. “That's just one initiative that we've taken on through our opioid stewardship program. Hospitals across the country have developed similar programs to try to target different prescribing practices across the continuum of care.”
One such opioid stewardship program at Scripps Health in San Diego reduced the average number of tablets per opioid prescription by 25% in its first year. The initiative, which started in 2017, includes online education modules for physicians about opioid prescribing and educational handouts for patients that explain how acute pain can be managed with nonopioid medication and pain relief techniques. Scripps also created new prescribing standards that restrict the number of opioid tablets prescribed and encourage tapering and partial prescription refills.
“We're pleased with the results from the first year of our program, and we believe this is just the tip of the iceberg; there is still a lot of opportunity for further improvement,” Valerie Norton, MD, physician operations executive at Scripps Mercy Hospital, San Diego, said in a November 2018 press release.
Limiting the use of opioids to patients who have severe pain or moderate pain that has not responded to nonopioid therapy or for whom nonopioid therapy is contraindicated was among the recommendations in the SHM statement. It also advised clinicians to use extra caution when administering opioids to patients with risk factors for opioid-related adverse events and to educate patients and families about the potential risks and side effects of opioid therapy.
Decreasing negative outcomes
Some hospitals are also focusing their efforts specifically on reducing certain opioid-related adverse events. Anne Arundel Medical Center in Annapolis, Md., set its sights on decreasing opioid-induced oversedation and respiratory depression events during hospitalization, which had been occurring more than five times a month.
“We were having a lot of patients having to be rescued with naloxone, and we didn't know if a single or multiple underlying problems [were] responsible for oversedation,” said Barry Meisenberg, MD, FACP, chair for quality and health systems research for Anne Arundel Health System. “We analyzed all the cases, looked for common themes, and then built educational and electronic tools to address that issue.”
When administrators surveyed staff hospitalists at the start of the effort, they found notable knowledge deficits regarding the definition of opioid tolerance, dosage adjustment strategies, and the value of monitoring sedation levels and respiratory rate, according to results published in the Feb. 1, 2017, American Journal of Health-System Pharmacy.
In response, the hospital enhanced sedation monitoring and made adjustments to dosing for high-risk patients. In addition, new clinical decision support and tools were integrated into the electronic health record, including a clearly displayed flowsheet to facilitate informed opioid prescribing.
“We made it easy for the physicians to see what had previously been administered,” said Dr. Meisenberg, who was the lead author of the American Journal of Health-System Pharmacy study. “That information was always in the electronic chart, but it was hard to find . . . The flowsheet was able to easily show how much drug was given and when. Particularly when you had a handoff, that information becomes extremely important. It made the transitions a lot safer.”
The series of interventions resulted in a fivefold reduction in oversedation and respiratory depression events, which has been maintained since 2015.
Managing postoperative pain at discharge with little to no opioid therapy was the focus of a multipronged approach at Roswell Park Comprehensive Cancer Center in Buffalo, N.Y. Roswell implemented an ultrarestrictive opioid prescription protocol for ambulatory patients and those undergoing minimally invasive surgery, limiting opioids at discharge unless patients had required more than five doses of oral or IV opioids while in the hospital.
The initiative included a preoperative counseling session for all surgical patients by physicians or nursing staff about postoperative pain management, including information about expected discharge pain medications, adverse effects of opioid pain medications, and alternative pain control methods. Patients leaving the hospital were prescribed a seven-day supply of ibuprofen and acetaminophen as needed.
The changes were linked to a significant reduction in opioids prescribed to patients at discharge, without changes in pain scores, complications, or refill requests, according to a study published Dec. 7, 2018, in JAMA Network Open. The mean number of opioid tablets for patients who underwent laparoscopic or robotic surgery decreased from 38.4 before the protocol to 1.3 after implementation, while the mean number of tablets given to ambulatory surgery patients went from 13.9 to 0.2.
The protocol illustrates a promising strategy for reducing postoperative opioid prescribing without increasing pain, said Jennifer Hah, MD, an anesthesiologist and pain medicine specialist at Stanford University Medical Center in Stanford, Calif. Dr. Hah, who wrote a commentary accompanying the study, emphasized the importance of patient counseling in the initiative.
“Preoperative counseling is extremely important for postoperative pain management for a number of reasons,” she said. “First, it's important for patients to understand how the protocol can improve their outcomes after surgery. Second, it is important to communicate what postoperative pain management will look like ahead of time. For example, it's important for patients to understand what their go-to pain medication should be after surgery. . . . Also, it's important for clinicians to emphasize that the focus is not simply to withhold or reduce opioid medications, but to improve postoperative pain management.”
Hospitals' efforts to decrease opioid prescribing are not without challenges.
In the Vizient study, the majority of hospitals that responded reported increasing their investment in opioid management in the last 12 months. For some, that investment meant a tradeoff, with nearly 30% of hospitals diverting resources from other areas to address the opioid epidemic and about 10% of hospitals reporting increased spending associated with the opioid crisis. While the majority of hospitals that reported adding staff to address the opioid epidemic said it was a very effective strategy, this solution was applied by only 7% of the survey respondents.
There's no doubt that changes to improve opioid management can be expensive, said Jim Lichauer, PharmD, a project manager for performance improvement collaboratives and advisory at Vizient. While some new technology may be integrated into existing electronic systems at fairly low expense, other changes such as expanding staff or utilizing pain management alternatives can mean significant cost for hospitals, he said.
“Unfortunately, the alternatives to solving this problem aren't inexpensive or free,” Mr. Lichauer said. “Alternatives, whether you're looking to improve your physical therapy or occupational therapy programs, offering acupuncture, or new psychosocial management programs, those resources do cost more money.” Changing the mindset of physicians and patients about pain and pain management can also be challenging, Dr. Calcaterra said. Frustration from patients who want more pain medication can create tension between doctors and patients, she said. At the same time, physicians who are used to more liberal prescribing of opioids may have difficulty modifying their practices.
“It can be challenging when we have patients who are wanting more or expecting more,” she said. “The goal is always to set clear expectations up front for pain management. Recognize that communication is really important and tak[e] that extra time in talking with a patient and letting them express their thoughts, which can be [difficult] but also important.”
There's also the challenge that the pendulum of opioid prescribing could swing too far in the other direction. “Finding the right balance in any given patient is tricky, and it's really a judgment call,” Dr. Herzig said.
Physicians must continue to reassess patients if they report ongoing pain and potentially change the treatment plan if severe pain persists and affects function, she added. Dr. Meisenberg noted that his health system kept an eye on this concern by tracking ED visits and patient satisfaction scores as part of the reduced prescribing initiative.
More research is also needed on the impact of conservative opioid prescribing on reducing opioid misuse and opioid use disorder, Dr. Hah added. “Randomized trials are always desirable to understand the true effects of any intervention. In addition, long-term outcomes and surveillance [data] is needed to assure the safety of these types of protocols to minimize the undertreatment of pain. The path to improving pain management while limiting opioid side effects will likely require moving towards more personalized care for each individual patient.”