Author: David Wild
Anesthesiology News
Educating inpatient prescribers on the benefits of oral and subcutaneous administration of opioids versus IV administration can markedly reduce the amount of opioids dispensed, researchers at Yale New Haven Hospital have found. Over a three-month period of rolling out a new standard of opioid administration and educating providers, they found a 31% drop in morphine milligram equivalents (MMEs) per patient-day and a 55% reduction in parenteral opioid use (JAMA Intern Med 2018;178[6]:759-763).
The impetus for addressing opioid prescribing at Yale New Haven Hospital came after lead researcher Adam Ackerman, MD, a clinical instructor of general internal medicine at Yale School of Medicine, and the medical director of East Pavilion 4-7 at Yale New Haven Hospital, in Connecticut, and his colleagues informally polled their colleagues. They found “a general lack of awareness of the good evidence that subcutaneous opioid administration is safer than IV administration and has proven efficacy,” Dr. Ackerman said.
“We wanted to test whether increasing that awareness among prescribers and nurses could lead to decreased exposure to IV opioids,” he continued.
The investigators compared the prescription of opioids for 287 inpatients treated during a six-month control period and for 127 inpatients treated during the three-month period following education on opioid routes of administration, for a total of 4,500 and 2,459 patient-days, respectively.
The bulk of patients had gastrointestinal conditions, infectious illness, and neurologic, hematologic/oncologic, orthopedic, pulmonary or endocrine-related conditions.
Opioids Reduced While Pain Levels Steady
Mean daily parenteral opioid exposure also decreased by 49% (5.67 [±1.14] to 2.88 [±0.72] MMEs per patient-day), and the daily number of patients administered any parenteral opioid fell by 57% (14%-6%; P<0.001).
Additionally, opioid use, whether oral or parenteral, was reduced by 23% (0.95-0.73 doses per patient-day; P=0.02), and mean daily overall opioid exposure decreased by 31% MMEs (9.11 [±7.34] vs. 6.30 [±4.12] MMEs per patient-day).
There were also no significant changes in patient-reported pain scores on days 1 through 3 of hospitalization (day 1: –0.19 [95% CI, –0.94 to 0.56]; day 2: –0.49 [95% CI, –1.01 to 0.03]; and day 3: –0.54 [95% CI, –1.18 to 0.09]). However, scores on a 10-point Likert pain scale in the intervention group were roughly 1 point lower on days 4 and 5 than those reported in the control group during the same time period (day 4: –1.07 [95% CI, –1.80 to –0.34]; day 5: –1.06 [95% CI, –1.84 to –0.27]).
Raising awareness of opioid prescribing practices also may have led to greater use of multimodal analgesic regimens, which would have reduced overall opioid prescribing, Dr. Ackerman explained.
According to Dr. Leibowitz, in addition to a slower onset and longer duration of subcutaneous injections, “administering injections that themselves are painful to persons with intravenous access may on the face of it seem improper, but it could actually lead to an additional ‘placebo’ effect from the drug administered in a manner that’s painful.
Whatever the causes for the protocol’s success, Dr. Ackerman said it is now being rolled out across the entire Yale New Haven Health System.
“It’s been widely embraced by the internal medicine community at our hospital, and our anesthesia colleagues have expressed interest in studying the approach further,” he added.
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