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.

Improving Opioid Stewardship in Pediatric Emergency Medicine

OBJECTIVES

Poor opioid stewardship contributes to opioid misuse and adverse health outcomes. We sought to decrease opioid prescriptions in children 0 to 18 years treated for pain after fractures and cutaneous abscess drainage from 13.5% to 8%. Our secondary aims were to reduce opioid prescriptions written for >3 days from 41% to 10%, eliminate codeine prescriptions, increase safe opioid storage and disposal discharge instructions from 0% to 70%, and enroll all emergency department (ED) physicians in the state prescription drug monitoring program.

METHODS

We implemented an intervention bundle on the basis of 4 key drivers at a pediatric ED: ED-wide education, changes in the electronic medical record, discharge resources, and process standardization. Two plan-do-study-act cycles were performed. Interventions included provider feedback on prescribing, safe opioid storage and disposal instructions, and streamlined electronic medical record functions. Run charts were used to analyze the effect of interventions on outcomes. Our balance measure was return ED or clinic visits for inadequate analgesia within 3 days.

RESULTS

During the intervention period, 249 of 3402 (7.3%) patients with fractures and cutaneous abscesses were prescribed opioids. The percentage of opioid prescriptions >3 days decreased from 41% to 13.2% (P < .0001), codeine prescription dropped from 1.1% to 0% (P = .09), opioid discharge instructions increased 0% to 100% (P < .0001), and all physicians enrolled in the prescription drug monitoring program. There was no change in return visits for uncontrolled analgesia compared with the baseline (P = .79).

CONCLUSIONS

A comprehensive opioid stewardship program can improve opioid prescribing practices of ED physicians and deliver information on safe storage and disposal of prescription opioids with a negligible effect on return visits for uncontrolled pain.

A Systematic Review of Interventions to Improve Analgesic Use and Appropriateness in Long-Term Care Facilities

OBJECTIVES

To systematically review the effectiveness of interventions to improve analgesic use and appropriateness in long-term care facilities (LTCFs).

DESIGN

Systematic review.

SETTING AND PARTICIPANTS

MEDLINE, Embase, PsycINFO, and CINAHL Plus were searched from inception to June 2021. Randomized controlled trials (RCTs), controlled and uncontrolled prospective interventions that included analgesic optimization, and reported postintervention change in analgesic use or appropriateness in LTCFs were included.

METHODS

Screening, data extraction, and quality assessment were performed independently by 2 review authors.

RESULTS

Eight cluster RCTs, 2 controlled, and 6 uncontrolled studies comprising 9056 residents across 9 countries were included. The 16 interventions included education (n = 13), decision support (n = 7), system modifications (n = 6), and/or medication review (n = 3). Six interventions changed analgesic use or appropriateness, all of which included prescribers, 5 involved multidisciplinary collaboration, and 5 included a component of education. Education alone changed analgesic use and appropriateness in 1 study. Decision support was effective when combined with education in 3 interventions. Overall, 13 studies reported analgesic optimization as part of pain management interventions and 3 studies focused on medication optimization. Two pain management interventions reduced the percentage of residents reporting pain not receiving analgesics by 50% to 60% (P = .03 and P < .001, respectively), and 1 improved analgesic appropriateness (P = .03). One reduced nonsteroidal anti-inflammatory drugs (NSAIDs) (P < .001) and another resulted in 3-fold higher odds of opioid prescription in advanced dementia [95% confidence interval (CI) 1.1-8.7]. One medication optimization intervention reduced NSAID prescription (P = .036), and another reduced as-needed opioid (95% CI 8.6-13.8) and NSAID prescription (95% CI 1.6-4.2).

CONCLUSIONS AND IMPLICATIONS

Interventions involving prescribers and enhanced roles for pharmacists and nurses, with a component of education, are most effective at changing analgesic use or appropriateness. Interventions combining education and decision support are also promising. Medication review interventions can change analgesic prescription, although there is currently minimal evidence in relation to possible corresponding improvements in resident-related outcomes.