Current state of opioid stewardship

National Trends and Predictors of Opioid Administration in Patients Presenting With Abdominal Pain to the Emergency Department (2010-2018)

Given the current opioid crisis, in this study, we assess the national trend and factors associated with opioid administration for patients presenting to the emergency department with abdominal pain. This is a retrospective cross-sectional study conducted using the National Hospital Ambulatory Medical Care Survey from 2010 to 2018. Weighted multiple logistic regression was applied to assess the independent factors associated with opioid administration in the emergency department. Trends of opioid administration were evaluated using the linear trend analysis. There were an estimated total of 100,925,982 emergency department visits for abdominal pain. Overall, opioid was administered in 16.8% of visits. Age less than 25 years was associated with lower odds of receiving opioids. Patients living in the Northeast had the lower odds of receiving opioids (odds ratio [OR] = 0.82, p = .006) than patients living in the Midwest. Patients in the West had the highest odds of receiving opioids (OR = 1.16, p = .01). Non-Hispanic White patients had higher odds of opioid administration (OR = 1.29, p < .001). Trend analysis demonstrated a statistically significant reduction in opioid administration. From 2010 to 2018, opioid administration has approximately decreased in half. Living in the West and the non-Hispanic White racial group were the significant factors associated with a higher risk of opioid administration.

Opioid stewardship program implementation in rural and critical access hospitals in Arizona

OBJECTIVE

The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments.

DESIGN

Health administrator survey to identify the number and type of OSP elements that each hospital has implemented.

SETTING

Arizona critical access hospitals (CAHs).

PARTICIPANTS

ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments).

MAIN OUTCOME MEASURES

Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary).

RESULTS

The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD.

CONCLUSIONS

Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Adverse Events of the Long-Term Use of Opioids for Chronic Non-cancer Pain: A Narrative Review

BACKGROUND

The long-term use of opioids for chronic non-cancer pain (CNCP) has drawn more attention and debate. Although opioids are frequently used to treat chronic pain, their effectiveness and safety over extended periods are still unknown.

OBJECTIVES

The purpose of this review is to provide an overview of what is currently known about the adverse events of long-term use of opioids in CNCP. It also delivers patient-centered strategies designed to mitigate these risks.

METHODS

We conducted a literature search in PubMed, MEDLINE, EMBASE, and Web of Science databases. Search terms included CNCP, pain pathophysiology, opioid pharmacodynamics, opioid prescribing trends, guidelines for opioid use, and opioid side effects.  Results: Our review highlights that while opioids may provide short-term relief from CNCP, their effectiveness diminishes over time due to the development of opioid tolerance. This tolerance often leads to increased dosages, which can subsequently result in opioid dependence. Additionally, long-term opioid therapy is associated with a spectrum of adverse effects, including constipation, drowsiness, respiratory depression, and potential for drug interactions. Furthermore, our review indicates that alternative pain management strategies play a crucial role in controlling CNCP. They offer significant benefits with fewer adverse events. These strategies include non-opioid medications, physical therapy, cognitive-behavioral therapy (CBT), various interventional procedures, injection therapy, and acupuncture.

CONCLUSION

Using opioids to manage CNCP presents several challenges. Given these challenges, alternative treatments are being considered as viable options. Moreover, it is crucial to customize treatment plans to align with the patients' specific health requirements, existing conditions, and potential risks to ensure the best possible outcomes.

Trends of Opioid Usage in Surgical Patients in a Small Community Hospital: Analysis of Patient Data Between 2017 and 2021

Purpose: The purpose of our study was to quantify and analyze the annual opioid usage in surgical patients at Wood County Hospital (WCH) between 2017 and 2021. Methods: In this retrospective study, patient data between 2017 and 2021 was analyzed to determine the oral morphine milligram equivalent (MME) of opioids used in surgical patients at WCH. Annual MME prescribed per admission was compared each year using one-way ANOVA followed by Tukey post hoc test. Similarly, the annual use of intravenous (IV) acetaminophen for surgical patients per admission was also calculated and analyzed using the one-way ANOVA followed by Tukey post hoc test. Results: Compared to the year 2017 (42.0 ± 3.6), a statistically significant decrease in opioid usage per surgical admission (mean±SEM of MME) was observed during the years 2018 (32.6 ± 1.4; P = .04), 2019 (30.4 ± 1.2; P = .01), and 2021 (30.8 ± 1.9; P = .01). An analysis of individual opioid use revealed a trend toward lower fentanyl and hydromorphone usage each year since 2017. A significant decrease in the annual morphine usage (mean±SEM of MME) for surgical patients was observed during both 2020 (14.4 ± 0.9; P = .05) and 2021 (14.0 ± 0.7; P = .05) compared to the year 2017 (22.1 ± 2.4). Finally, compared to the year 2017, a statistically significant decrease (P < .05) in the annual use of oxycodone (MME) and IV acetaminophen (mg) for pain management in surgical patients was observed from 2018 to 2021. Conclusion: Our analysis reveals a significant decrease in opioid usage per surgical admission at WCH over 2017 to 2021 indicating a positive impact of the various opioid stewardship measures implemented at the hospital.

Evaluation of Discharge Opioid Prescribing in Coronary Artery Bypass Patients Following an Opioid Stewardship Intervention for Providers

Introduction: Opioid stewardship efforts can promote safe and effective use of opioids to optimize pain control and minimize unintended consequences. The purpose of this study is to assess the difference in post-operative opioid discharge prescribing in patients undergoing coronary artery bypass graft (CABG) surgery following implementation of a tripartite opioid stewardship intervention. Methods: This was a single-center, quality improvement study at a large, quaternary academic medical center. Adult patients undergoing CABG from July 2019 to June 2020 (pre-intervention) and November 2020 to February 2021 (post-intervention) were included. The intervention included adopting hospital-wide post-surgical opioid discharge prescribing guidelines, discharge prescriber education, and electronic medical record changes. The primary outcome was the proportion of patients receiving an opioid prescription at discharge. Secondary outcomes included total morphine milligram equivalents (MME) prescribed and non-opioid analgesics prescribed at discharge. Results: A total of 200 patients were included in the study; 100 pre- and 100 post-intervention. There was no difference in opioid discharge prescribing at discharge (74% pre-intervention vs. 72% post-intervention; P = .87). There was no difference in MMEs prescribed at discharge (145.6 ± 57 pre- vs. 162.2 ± 95 post-; P = .202). No difference was seen in non-opioid analgesic prescriptions prescribed at discharge (35% pre- vs. 40% post-; P = .56). Conclusion: A multipronged opioid stewardship intervention did not lead to a reduction in opioid prescribing at discharge. Post-intervention, there was a non-statistically significant increase in the proportion of patients who received non-opioid analgesics discharge. Future studies should assess the effect of different stewardship interventions on prescribing and patient outcomes.

Polypharmacy stewardship: a novel approach to tackle a major public health crisis

With growing global concern regarding medication-related harm, WHO launched a global patient safety challenge, Medication Without Harm, in March, 2017. Multimorbidity, polypharmacy, and fragmented health care (ie, patients attending appointments with multiple physicians in various health-care settings) are key drivers of medication-related harm, which can result in negative functional outcomes, high rates of hospitalisation, and excess morbidity and mortality, particularly in patients with frailty older than 75 years. Some studies have examined the effect of medication stewardship interventions in older patient cohorts, but focused on a narrow spectrum of potentially adverse medication practices, with mixed results. In response to the WHO challenge, we propose the novel concept of broad-spectrum polypharmacy stewardship, a coordinated intervention designed to improve the management of multimorbidities, taking into account potentially inappropriate medications, potential prescribing omissions, drug-drug and drug-disease interactions, and prescribing cascades, aligning treatment regimens with the condition, prognosis, and preferences of the individual patient. Although the safety and efficacy of polypharmacy stewardship need to be tested with well designed clinical trials, we propose that this approach could minimise medication-related harm in older people with multimorbidities exposed to polypharmacy.

Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.

Evaluation of Policies Limiting Opioid Exposure on Opioid Prescribing and Patient Pain in Opioid-Naive Patients Undergoing Elective Surgery in a Large American Health System

OBJECTIVES

Overprescribing to opioid-naive surgical patients substantially contributes to opioid use disorders, which have become increasingly prevalent. Opioid stewardship programs (OSPs) within healthcare settings provide an avenue for introducing interventions to regulate prescribing. This study examined the association of OSP policies limiting exposure on changes in surgery-related opioid prescriptions and patient pain.

METHODS

We evaluated policies implemented by an OSP in a large American healthcare system between 2016 and 2018: nonopioid medication during surgery, decrease of available opioid dosage vials in operating rooms, standardization of opioid in-patient practices through electronic health record alerts, and limit to postsurgery opioid supply. Generalized linear mixed effects models examined the association of interventions with outcome changes in 9262 opioid-naive patients undergoing elective surgery. Outcomes were discharge pain, morphine milligram equivalent in the first prescription postsurgery, and opioid prescription refills.

RESULTS

Decreases in all prescription outcomes and discharge pain were observed following onset of OSP interventions ( P 's < 0.001). Among individual policies, standardization of in-patient prescribing practices was associated with the strongest decrease in prescribed morphine milligram equivalent. Importantly, there was no evidence of an increase in discharge pain related to any intervention.

CONCLUSIONS

This study promotes the potential of OSP formation and policies to reduce opioid prescribing without compromising patient pain. The most effective policy, standardization of in-patient prescribing practices through alerts, suggests that reminding prescribers to re-evaluate the patient's need is effective in changing behavior. The findings offer considerations for OSP formation and policy implementation across health systems to improve quality and safety in opioid prescribing.

What is "Opioid Stewardship"? An Overview of Current Definitions and Proposal for a Universally Acceptable Definition

Introduction

Opioid stewardship has been widely used to promote rational use, monitoring and discontinuation of opioid therapy; however, its definition and scope of practice remain unclear.

Objective

To synthesize definitions of opioid stewardship proposed by clinical practice guidelines and professional societies, and to offer a proposal for a universally acceptable definition.

Methods

Systematic literature searches were performed (earliest records to May 2022) in six databases (MEDLINE, EMBASE, APA PsycINFO, Scopus, and CENTRAL) and grey sources guidelines development bodies and professional societies through Google. The conventional but widely applied content analysis and word frequencies were used to analyze the definitions and scope of practice.

Results

After removing duplicates, 449 articles were retrieved (439 databases and registers and 11 from other sources), 19 of which included a definition of "opioids stewardship". A total of 12 themes was identified in the definitions, including 1) improvement or appropriateness of prescribing opioids use, 2) mitigation of risk from opioids, 3) monitoring opioid use, 4) evaluation of opioid use, 5) judicious opioid use, 6) appropriateness of opioid disposal, 7) identification and treatment of opioid use disorder, 8) reduction in mortality associated with opioid overdoses, 9) appropriate procurement practices, 10) appropriate storage, 11) promoting better communications between patients and prescribers including education provision and 12) patient-centered decision-making.

Conclusion

Opioid stewardship is inconsistently defined across professional and research literature. While there is a greater focus on appropriateness and need for improvement of prescribing and monitoring of opioid use, the importance of communications between patients and prescribers, and patient involvement in both prescribing and deprescribing decision-making remains sparse. A comprehensive definition has been proposed as part of the work. There is a need to develop and validate the proposed definition and scope of practice to promote rationale for opioid prescribing, use and attainment of favourable outcomes through international consensus involving practitioners, researchers, and patients.

Minimally invasive, benign foregut surgery is not associated with long-term, persistent opioid use postoperatively: an analysis of the IBM® MarketScan® database

BACKGROUND

It is unknown if opioid naïve patients who undergo minimally invasive, benign foregut operations are at risk for progressing to persistent postoperative opioid use. The purpose of our study was to determine if opioid naïve patients who undergo minimally invasive, benign foregut operations progress to persistent postoperative opioid use and to identify any patient- and surgery-specific factors associated with persistent postoperative opioid use.

METHODS

Opioid-naïve, adult patients who underwent laparoscopic fundoplication, hiatal hernia repair, or Heller myotomy from 2010 to 2018 were identified within the IBM® MarketScan® Commercial Claims and Encounters Database. Daily drug logs of the preoperative and postoperative period were evaluated to assess for changes in drug use patters. The primary outcome of interest was persistent postoperative opioid use, defined as at least 33% of the proportion of days covered by opioid prescriptions at 365-day follow-up. Patient demographic information and clinical risk factors for persistent postoperative opioid use at 365 days postoperatively were estimated using log-binomial regression.

RESULTS

A total of 17,530 patients met inclusion criteria; 6895 underwent fundoplication, 9235 underwent hiatal hernia repair, and 1400 underwent Heller myotomy. 9652 patients had at least one opioid prescription filled in the perioperative period. Sixty-five patients (0.4%) were found to have persistent postoperative opioid use at 365 days postoperatively. Lower Charlson comorbidity index scores and a history of mental illness or substance use disorder had a statistically but not clinically significant protective effect on the risk of persistent postoperative opioid use at 365 days postoperatively.

CONCLUSIONS

Only half of opioid naïve patients undergoing minimally invasive, benign foregut operations filled an opioid prescription postoperatively. The risk of progression to persistent postoperative opioid use was less than 1%. These findings support the current guidelines that limit the number of opioid pills prescribed following general surgery operations.

Development and Implementation of a Neonatal Pain Management Guideline for Minor Surgeries

BACKGROUND

Although opioids are effective for neonatal postoperative pain management, cumulative opioid exposure may be detrimental. Pain management practices vary among providers, but practice guidelines may promote consistency and decrease opioid use.

PURPOSE

To develop a pain management guideline (PMG) for neonates undergoing minor surgical procedures with the overarching goal of reducing opioid use without compromising the pain experience. The specific aim was for neonatal intensive care unit providers to adhere to the PMG at least 50% of the time.

METHODS

An interdisciplinary pain and sedation work group in a large level IV neonatal intensive care unit developed an evidence-based PMG for minor surgical procedures. Nurses and providers were educated on the new guideline, and rapid cycle quality improvement methodology provided an opportunity to adjust interventions over 3 months.

RESULTS

The PMG was used for 32 neonates following minor surgical procedures: 18 (56%) of the neonates received only acetaminophen and no opioids, 32% required 0.15 mg/kg dose equivalent of morphine or less, and only 9% required more than 0.15 mg/kg dose equivalent of morphine. Overall, opioid use decreased by 88% compared with rates before implementation of the PMG. Providers adhered to the PMG approximately 83.3% of time.

IMPLICATIONS FOR PRACTICE

A PMG is a systematic approach to direct nurses and providers to appropriately assess, prevent, and treat neonatal pain following minor surgery while alleviating opioid overuse.

IMPLICATIONS FOR RESEARCH

Future research should focus on determining and mitigating barriers to nurse/provider use of the PMG and developing and implementing a PMG for major surgical procedures.

Gabapentin initiation in the inpatient setting: A characterization of prescribing

Disclaimer

In an effort to expedite the publication of articles related to the COVID-19 pandemic, AJHP is posting these manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

Purpose

Gabapentin is a widely prescribed analgesic with increased popularity over recent years. Previous studies have characterized use of gabapentin in the outpatient setting, but minimal data exist for its initiation in the inpatient setting. The objective of this study was to characterize the prescribing patterns of gabapentin when it was initiated in the inpatient setting.

Methods

This was a retrospective cohort study of a random sample of adult patients who received new-start gabapentin during hospital admission. Patients for whom gabapentin was prescribed as a home medication, with one-time, on-call, or as-needed orders, or who died during hospital admission were excluded. The primary outcome was characterization of the gabapentin indication; secondary outcomes included the starting and discharge doses, the number of dose titrations, the rate of concomitant opioid prescribing, and pain clinic follow-up. Patients were stratified by surgical vs nonsurgical status.

Results

A total of 464 patients were included, 283 (61.0%) of whom were surgical and 181 (39.0%) of whom were nonsurgical. The cohort was 60% male with a mean (SD) age of 56 (18) years; surgical patients were younger and included more women. The most common indications for surgical patients were multimodal analgesia (161; 56.9%), postoperative pain (53; 18.7%), and neuropathic pain (26; 9.2%), while those for nonsurgical patients were neuropathic pain (72; 39.8%) and multimodal analgesia (53; 29.3%). The mean starting dose was similar between the subgroups (613 mg for surgical patients vs 560 mg for nonsurgical patients; P = 0.196). A total of 51.6% vs 81.8% of patients received gabapentin at discharge (P &lt; 0.0001), while referral/follow-up to a pain clinic was minimal and similar between the subgroups (1.1% vs 3.9%; P = 0.210).

Conclusion

Inpatients were commonly initiated on gabapentin for generalized indications, with approximately half discharged on gabapentin. Further studies are needed to assess the impact of this prescribing on chronic utilization.

Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: a pre- and postimplementation analysis of 268 patients

OBJECTIVE

Opioid stewardship programs combine clinical, regulatory, and educational interventions to minimize inappropriate opioid use and prescribing for orthopedic and spine surgery. Most evaluations of stewardship programs quantify effects on prescriber behavior, whereas patient-relevant outcomes have been relatively neglected. The authors evaluated the impact of an opioid stewardship program on perioperative opioid consumption, prescribing, and related clinical outcomes after multilevel lumbar fusion.

METHODS

The study was based on a retrospective, quasi-experimental, pretest-posttest design in 268 adult patients who underwent multilevel lumbar fusion in 2016 (preimplementation, n = 141) or 2019 (postimplementation, n = 127). The primary outcome was in-hospital opioid consumption (morphine equivalent dose [MED], mg). Secondary outcomes included numeric rating scale pain scores (0-10), length of stay (LOS), incidence of opioid-induced side effects (gastrointestinal, nausea/vomiting, respiratory, sedation, cognitive), and preoperative and discharge prescribing. Outcomes were measured continuously during the hospital admission. Differences in outcomes between the epochs were assessed in bivariable (Wilcoxon signed-rank or Fisher's exact tests) and multivariable (Wald's chi-square test) analyses.

RESULTS

In bivariable analyses, there were significant decreases in preoperative opioid use (46% vs 28% of patients, p = 0.002), preoperative opioid prescribing (MED 30 mg [IQR 20-60 mg] vs 20 mg [IQR 11-39 mg], p = 0.003), in-hospital opioid consumption (MED 329 mg [IQR 188-575 mg] vs 199 mg [100-372 mg], p < 0.001), the incidence of any opioid-related side effect (62% vs 50%, p = 0.03), and discharge opioid prescribing (MED 90 mg [IQR 60-135 mg] vs 60 mg [IQR 45-80 mg], p < 0.0001) between 2016 and 2019. There were no significant differences in postanesthesia care unit pain scores (4 [IQR 3-6] vs 5 [IQR 3-6], p = 0.33), nursing floor pain scores (4 [IQR 3-5] vs 4 [IQR 3-5], p = 0.93), or total LOS (118 hours [IQR 81-173 hours] vs 103 hours [IQR 81-132 hours], p = 0.21). On multivariable analysis, the opioid stewardship program was significantly associated with decreased discharge prescribing (Wald's chi square = 9.45, effect size -52.4, 95% confidence interval [CI] -86 to -19.0, p = 0.002). The number of lumbar levels fused had the strongest effect on total opioid consumption during the hospital stay (Wald's chi square = 16.53, effect size = 539, 95% CI 279.1 to 799, p < 0.001), followed by preoperative opioid use (Wald's chi square = 44.04, effect size = 5, 95% CI 4 to 7, p < 0.001).

CONCLUSIONS

A significant decrease in perioperative opioid prescribing, consumption, and opioid-related side effects was found after implementation of an opioid stewardship program. These gains were achieved without adverse effects on pain scores or LOS. These results suggest the major impact of opioid stewardship programs for spine surgery may be on changing prescriber behavior.

Feasibility of Opioid-Free Anesthesia for Cervical Rib Excision: A Case Series and Review of Literature

Background Perioperative pain management following cervical rib excision can be compounded in the background of chronic pain disorder caused by the neurovascular compression. The former mandates an enhanced analgesic requirement wherein the perioperative opioid use, in particular, can be associated with a peculiar adverse-effect profile and abuse potential. Appropriate to the context, an opioid-free anesthesia (OFA) protocol can be instrumental in minimizing the incidence of the aforementioned.

Case Series While two patients necessitated OFA owing to opioid contraindication, the formulated protocol was evaluated in another six consecutive patients posted for elective cervical rib excision. A combined paravertebral block and superficial cervical plexus block was employed alongside general anesthesia. Intravenous dexmedetomidine and lignocaine assisted the conduct of OFA, and paracetamol dosing was continued into the postoperative period. Intraoperative rescue analgesia was ensured by a ketofol bolus (1:1 mixture of ketamine and propofol) whereas intravenous diclofenac was used for postoperative rescue analgesia.

Results OFA could be successfully contemplated in all eight patients. A single bolus rescue dose of ketofol had to be administered in two patients intraoperatively and diclofenac had to be administered as postoperative rescue analgesic in two patients. There was no incidence of postoperative nausea/vomiting or any block-related complications. The postoperative stay was uneventful with an acceptable patient satisfaction.

Conclusion The index experience reiterates the fact that a prudent combination of nonopioid multimodal analgesics with case-based locoregional techniques can feature as a successful OFA protocol, albeit mandating future prospective studies in this novel area of clinical interest.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Do we still need to be concerned about postsurgical opioid prescribing?

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

A pharmacist-led intervention to improve the management of opioids in a general practice: a qualitative evaluation of participant interviews

Background Opioid prescribing has escalated, particularly long-term in chronic noncancer pain. Innovative models of care have been recommended to augment regulatory and harm-minimisation strategies and to review the safety and benefits of opioids for the individual patient. Medication stewardship and pharmacist integration are evolving approaches for general practice. Aim To explore enablers, barriers, and outcomes of a pharmacist-led intervention to improve opioid management in general practice, from the perspectives of general practitioners (GPs) and practice personnel. Method The study was part of a mixed-methods investigation into a general practice pharmacist pilot. Qualitative data relevant to opioids were analysed. Data from 13 semi-structured interviews were coded, analysed iteratively and thematically, and interpreted conceptually through the framework of Opioid Stewardship fundamentals proposed by the National Quality Forum. Results Seven themes and 14 subthemes aligned with stewardship fundamentals. Participants considered organisational policy, supported by leadership and education, fostered collaboration and consistency and improved practice safety. Patient engagement with individualised resources, 'agreements' and 'having the conversation' with the pharmacist enabled person-centred opioid review and weaning. GPs reported greater accountability and reflection in their practices, in the broader context of opioid prescribing and dilemmas in managing patients transitioning through care. Receiving feedback on practice deprescribing outcomes encouraged participants' ongoing commitment. Patient communication was deemed an early barrier; however, learnings were applied when transferring the model to other high-risk medicines. Conclusion Improved opioid management was enabled through implementing pharmacist-led coordinated stewardship. The findings offer a practical application of guideline advice to individualise opioid deprescribing.

Moving Away From a "One Size Fits All" Model: Ensuring Opioid Stewardship Includes People Who Use Drugs

The opioid-driven overdose crisis has had devastating effects across North America, resulting from a complex interplay between individual, social-structural, and environmental factors. Changing approaches to pain management, increased heroin use, and potent synthetic opioids infiltrating the drug supply are compounded by both lack of access to opioid use disorder treatment and surrounding stigma. Inappropriate opioid prescribing practices in healthcare settings have played a central role, and in recent years, there has been increasing interest in implementing hospital-based opioid stewardship programs aimed at improving safety and monitoring opioid prescribing. There is a range of approaches taken by these programs, ranging from audit and feedback to consult services; however, a significant focus of many of these programs is on medication restriction. Such measures stand to negatively impact the care of people with complex healthcare needs, including those currently on long-term opioid therapy, and those with increased opioid tolerance. In this commentary, we emphasize the importance of creating opioid stewardship programs focused on appropriate pain treatment rather than solely on medication restriction to both appropriately prescribe to and manage pain in people who use illicit drugs. This population faces many barriers to care, such as unique dose requirements and high interpatient variability that "one size fits all" stewardship cannot appropriately address. Additionally, opioid stewardship programs that use patient-centered strategies such as multidisciplinary consult services have been shown to lead to positive health outcomes and have significant potential to address the current shortcomings in pain management for people who use illicit drugs.

[Consumption of narcotics, substances assimilated to narcotics and psychotropic drugs in health establishments: Profile of a hospital from France and a hospital from Quebec]

OBJECTIVES

The objective was to describe the trends in the consumption of narcotic drugs, substances related to narcotic drugs (SAS) and psychotropic drugs between a French hospital and a Quebec hospital between 2013 and 2017.

METHODS

This is a retrospective descriptive study. The consumption data was obtained from the pharmacy management software and was extracted by financial year (January 1st, 2013 to December 31st, 2017 for the French hospital and April 1st, 2013 to March 31st, 2018 for the Quebec hospital). For each drug considered to be narcotics, SAS and psychotropic drugs in France or subject to the legislation on designated substances in Quebec, we identified the quantities consumed from 2013 to 2017. The data werepresented according to the following therapeutic classes: opioids (N02A), other analgesics (N02B), anxiolytics (N05B), hypnotics and sedatives (N05C), general anesthetics (N01A), psychostimulants (N06B), androgens (G03B) and antagonists peripheral opioid receptors (A06A). The data were expressed as a defined daily dose (DDJ) for 1000 patient-days (PDs).

RESULTS

In the French hospital, the consumption of narcotics, SAS and psychotropic drugs varied from 676 to 560 DDJ per 1000 PDs between 2013 and 2017. While it varied from 1019 to 756 DDJ per 1000 PDs between 2013 and 2017 in the Quebec hospital. In 2017, the most widely used therapeutic classes in French hospitals were, in decreasing order, anxiolytics (211 DDJ per 1000 PDs) (i.e. alprazolam), opioids (205 DDJ per 1000 PDs) (i.e. tramadol, morphine injectable) and hypnotics and sedatives (64 DDJ per 1000 PDs) (i.e. midazolam injectable). In Quebec hospitals, the three therapeutic classes the most used in 2017 were, in decreasing order, opioids (314 DDJ per 1000 PDs) (i.e. hydromorphone injectable, morphine injectable), anxiolytics (221 DDJ per 1000 PDs) (i.e. clobazam) and hypnotics and sedatives (108 DDJ per 1000 PDs) (i.e. midazolam injectable).

CONCLUSION

This study notes a decrease in the consumption of opioids and other substances in both the French and Quebec establishments between 2013-2017. More work is needed to better describe the differences observed between the profile of each establishment. This is why monitoring consumption trends, therapeutic indications and preventive measures are essential.

Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities

To undertake a scoping review of pharmacist activities in opioid medicines management in primary care settings, including those developed or led by pharmacists, or in which pharmacists were members of broader multidisciplinary teams, and to collate the activities, models of care and settings, and reported outcomes. The bibliographic databases MEDLINE, EMBASE, International Pharmaceutical Abstracts, CINAHL, SCOPUS and Web of Science were searched. Studies with quantitative evaluation and published in English were eligible. Participants were patients with any pain category or an opioid use disorder, and healthcare providers. Studies originating in hospitals or involving supply functions were not included. Screening of literature and data charting of results were undertaken by two researchers. The 51 studies included in the scoping review occurred in primary care settings collated into four categories: general practice or primary care clinics, healthcare organisations, community pharmacies and outreach services. Studies were primarily of opioid use in chronic, noncancer pain. Other indications were opioid use disorder, cancer and dental pain. Pharmacist activities targeted risk mitigation, patient and provider education and broader, strategic approaches. Patient-related outcomes included reduced opioid load, improved functionality and symptom management, enhanced access to services and medication-assisted treatments, and engagement in risk-mitigation strategies. Behaviour change of providers was demonstrated. The review has identified the significant contribution that pharmacists working in primary care settings can make to minimise harm from opioids. Strategies implemented in isolation have the potential to further reduce adverse clinical outcomes with greater collaboration and coordination, such as opioid stewardship.

A Quality Improvement Pilot of Pharmacist-Led Identification of an Inpatient Population for Opioid Stewardship and Pain Management

The Joint Commission standards now include identification and monitoring patients at high-risk for adverse outcomes of opioid use. Our institution does not have a method to identify at-risk patients. This pilot aimed to assess feasibility of pharmacist-led identification of a population for pain management and opioid stewardship. All patients admitted to the hospital were screened; electronic health record reports identified all opioid, antidepressant, and benzodiazepine administrations within the previous 24 hours, and pertinent family and social history risk factors for Opioid Use Disorder (OUD) and opioid-induced respiratory depression (OIRD). Data were exported to spreadsheets and calculated risk scores for OUD and OIRD, and opioid utilization and morphine milligram equivalents (MME) were tabulated. Chart reviews were completed on patients identified as high risk for OUD or OIRD, if MME was 90 or greater, or those receiving four or more "as needed" opioid doses in the previous 24 hours. Potential regimen adjustments based on the primary investigator's judgment were categorized. Mean number of patients identified per day to receive stewardship was 13, and 18.6 potential interventions per day were identified. Based on results of this pilot, pharmacist-led identification of inpatients warranting pain and opioid stewardship is feasible at our institution.

Perioperative Pain Management and Opioid Stewardship: A Practical Guide

Surgical procedures are key drivers of pain development and opioid utilization globally. Various organizations have generated guidance on postoperative pain management, enhanced recovery strategies, multimodal analgesic and anesthetic techniques, and postoperative opioid prescribing. Still, comprehensive integration of these recommendations into standard practice at the institutional level remains elusive, and persistent postoperative pain and opioid use pose significant societal burdens. The multitude of guidance publications, many different healthcare providers involved in executing them, evolution of surgical technique, and complexities of perioperative care transitions all represent challenges to process improvement. This review seeks to summarize and integrate key recommendations into a "roadmap" for institutional adoption of perioperative analgesic and opioid optimization strategies. We present a brief review of applicable statistics and definitions as impetus for prioritizing both analgesia and opioid exposure in surgical quality improvement. We then review recommended modalities at each phase of perioperative care. We showcase the value of interprofessional collaboration in implementing and sustaining perioperative performance measures related to pain management and analgesic exposure, including those from the patient perspective. Surgery centers across the globe should adopt an integrated, collaborative approach to the twin goals of optimal pain management and opioid stewardship across the care continuum.