Opioid Discharge Research Articles

Hospital discharge opioid guidelines and policies: a Victorian survey

AbstractBackgroundOpioid prescribing has increased over the past two decades in Australia and has been associated with a rise in opioid‐related harm, including hospitalisations. Guidelines for supplying opioids at discharge from hospitals may reduce these associated risks. Examples of these guidelines exist worldwide, but it is unknown what strategies Victorian hospitals are using.AimThe aim of the present study was to discover what strategies, if any, Victorian hospitals are using to decrease risk associated with opioids prescribed on discharge and the perceived barriers to implementing these strategies.MethodsAn online survey was sent to each Victorian hospital. Participants were asked questions about whether their service was using an opioid discharge guideline, the barriers to using these guidelines and whether they would use industry‐ or peer‐developed guidelines if available.ResultsStaff from 41 (19.62%) hospitals responded to the survey. Ten hospitals reported having a guideline. Nearly half (41.5%) of the hospitals that did not have a guideline reported that they would consider using an industry‐ or peer‐developed guideline. Time, funding, collaboration between stakeholders and staffing inconsistencies were reported as barriers to development and implementation.ConclusionOnly a small number of Victorian hospitals are using opioid discharge prescribing guidelines. Development of industry‐ or peer‐developed guidelines may bypass many of the barriers to development and implementation.

Clinical Factors Associated With Practice Variation in Discharge Opioid Prescriptions After Pancreatectomy.

To characterize opioid discharge prescriptions for pancreatectomy patients. Wide variation in and over-prescription of opioids after surgery contribute to the United States opioid epidemic through persistent use past the postoperative period. Objective strategies guiding discharge opioid prescriptions for oncologic surgery are lacking, and factors driving prescription amount are not fully delineated. Characteristics of pancreatectomy patients (March 2016-August 2017) were retrospectively abstracted from a prospective database. Discharge opioids prescriptions were converted to oral morphine equivalents (OME). Regression models identified variables associated with discharge OME. In 158 consecutive patients, median discharge OME was 250 mg (range 0-3950). Discharge OME was labeled "low" (<200 mg) for 33 patients (21%) and "high" (>400 mg) for 38 (24%). Only shorter operative time (odds ratio [OR]-0.14, P = 0.004) and inpatient team (OR-15.39, P < 0.001) were independently associated with low discharge OME. Older age was the only variable associated with high discharge OME. Fifty-seven patients (36%) used zero opioids in the last 24-hours predischarge, yet 52 of 57 (91%) still received discharge opioids. Older age (OR-1.07), grade B/C pancreatic fistula (OR-3.84), and epidural use (OR-3.12) were independently associated with zero last-24-hours OME (all P ≤ 0.040). The wide variation in discharge opioid prescriptions is heavily influenced by provider routine/bias and not by objective criteria such as last-24-hours OME. Quality improvement strategies could include aggressive weaning protocols to increase the proportion of patients with zero/near-zero last-24-hour OME and limiting prescriptions to a conservative multiplier of the last-24-hour OME.

Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery.

The aim of this study was to conduct a prospective, multicenter survey of patients regarding postoperative opioid use to inform development of standardized, evidence-based, procedure-specific opioid prescribing guidelines. Previous work has shown significant variation in the amount of opioids prescribed after elective procedures, calling for optimization of prescribing. Adults (n = 3412) undergoing 25 elective procedures were identified prospectively from 3 academic centers (March 2017 to January 2018) to complete a 29-question telephone interview survey 21 to 35 days post-discharge (n = 688 not contacted, n = 107 refused). Discharge opioids were converted into Morphine Milligram Equivalents (MMEs). Of the 2486 patients who completed the survey, 91.2% received opioids at discharge [median 225 (interquartile range, IQR 125 to 381) MME]. A median of 43 (0 to 184) MMEs were consumed after discharge with 77.3% of patients having leftover opioids at the time of the survey. In total, 61.5% of prescribed opioids were unused; 31.4% of patients used no opioids, and 52.6% required <50 MME. Overall, 90.6% of patients were satisfied with their postdischarge pain control. While 28.3% reported being prescribed too many opioids, 9.0% felt they were not prescribed enough. Only 9.6% of patients disposed of remaining opioids. Of the 2068 opioid-naive respondents (83.2%), 33.6% consumed no opioids (range 5.2% to 80.0% by procedure) and 57.0% (65.7% nonorthopedic) consumed <50 MME. Utilization data and predictors of low/high opioid consumption informed development of postoperative prescribing guidelines. A large proportion of postoperative patients reported using no or few opioids following discharge. Guidelines were developed to minimize opioid prescribing and identify patients requiring low doses or additional multimodal pain control.

Opioid Prescribing: Where Should Academic Emergency Departments Focus Their Efforts?

BackgroundOpioid prescriptions from the emergency department (ED) are being heavily scrutinized. This has resulted in prescribing guidelines and laws. ObjectiveWe analyzed the “current state” of opioid prescribing practices by emergency medicine (EM) trainees to gain understanding where operational, educational, or supervisory efforts should be directed to comply with current guidelines and future legislation. MethodsOur retrospective, observational, study was performed at an academic ED with an annual census of 61,289 visits. We extracted all 6962 opioid prescriptions attributed to the ED during calendar year 2015 from the electronic health record. Error prescriptions were excluded from the analysis. Overall prescribing by opioid class was performed. Prescriptions written by EM trainees were categorized by postgraduate year and compared with other prescribers. Prescribing patterns for recurrent visits were also analyzed. ResultsOf the 6962 opioid discharge prescriptions, 5515 were written by EM providers. No refills were provided. A mean of 15.4 pills (95% confidence interval 13.9–16.9) were prescribed. Analysis of variance did not detect a significant difference between mean numbers of pills prescribed by EM providers. However, there was a significant difference between EM and non-EM prescribers. Less-experienced EM providers exhibited greater variability with regard to class and preparation. There were 389 prescriptions written for patients who received at least one other opioid prescription in the preceding 30 days. The number of pills dispensed decreased with increasing prior visits. ConclusionEM providers prescribe short courses of opiates regardless of postgraduate year. Patients returning to the ED received fewer pills on subsequent visits. Non-EM providers prescribe larger numbers of pills per prescription. This information will help focus future operational efforts and educational efforts to comply with guidelines and laws.

Guideline for Discharge Opioid Prescriptions after Inpatient General Surgical Procedures

There is a paucity of data to inform appropriate opioid prescribing for patients who are discharged after a hospital admission for a surgical procedure. We studied 333 inpatients discharged to home after bariatric, benign foregut, liver, pancreas, ventral hernia, and colon surgery. Chronic opioid users or patients who had complications were excluded. Home opioid usage was quantified in 90% of the remaining patients by questionnaires and phone surveys. Eighty-five percent of patients were prescribed an opioid and 38% of prescribed opioid pills were taken. Fifteen opioid pills satisfied the opioid needs of 88% of patients discharged on postoperative day (POD) 1. For patients discharged after POD 1, in multivariate analysis, the number of opioid pills used at home was associated with the number taken the day before discharge (p < 0.0001) and patient age (p= 0.006), but not the type of surgery. Forty-one percent of patients took no opioids the day before discharge, 33% took 1 to 3, and 26% took more than 4 pills. Eighty-five percent of patients' home opioid requirements would be satisfied using the following guideline: if no opioid pills are taken the day before discharge, no prescription is needed; if 1 to 3 opioid pills are taken the day before discharge, then a prescription for 15 opioid pills is given at discharge; and if 4 or more pills are taken the day before discharge, then a prescription for 30 opioid pills is given at discharge. If these guidelines were used, the number of opioid pills prescribed would decrease by 40%. For patients admitted after surgical procedures, post-discharge opioid use is best predicted by usage the day before discharge. Use of this guideline could decrease opioid prescriptions substantially and effectively treat patients' pain.

Patterns of Opioid Prescribing for an Orthopaedic Trauma Population.

To determine opioid-prescribing practices to the orthopaedic trauma (OT) population at one Level I trauma center. A retrospective study of discharge prescriptions for adult patients with OT. Prescription details, injury burden, and patient demographics were abstracted for patients from initial injury through a 2-month follow-up. Level I trauma center. Adult patients with OT admitted over a 30-day period (n = 110). All discharge and follow-up opioid prescriptions were recorded. Morphine milligram equivalents (MMEs) per day, number of opioid prescriptions, type/dose of medication prescribed. One hundred thirty-five discharge prescriptions were written for 110 patients with orthopaedic injuries during the review period. All patients received opioids at the time of discharge. The MMEs prescribed at the time of discharge was 114 mg (54-300 mg) for a mean of 7.21 days (2-36.7 days). Although patients with preinjury risk factors were prescribed discharge opioids for a similar duration (7.00 days vs. 7.30 days, P = 0.81) than those without risk factors, they were prescribed significantly more MMEs than those without (130 vs. 108, P < 0.05) and were more likely to receive extended-release and long-acting opioids than those without (42.11% vs. 21.98%). Pain management after OT continues to be opioid-centric despite involving a population at risk. Further focus on prescriber and patient education, risk evaluation with mitigation, guideline development, and comprehensive pain management strategies are warranted in the OT population. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

(234) Examination of opioid discharge prescriptions, consumption and disposal in an orthopedic population

(234) Examination of opioid discharge prescriptions, consumption and disposal in an orthopedic population

Opioid exit plan: A pharmacist's role in managing acute postoperative pain

ObjectivesThe benefits of a pharmacist's involvement in medication reconciliation and discharge counseling are well documented in the literature as improving patient outcomes. In contrast, no studies have focused on the initiation of a pharmacist-led opioid exit plan (OEP) for acute postoperative pain management. This paper summarizes a pharmacist-led OEP practice model and the potential role that pharmacists and student pharmacists can have at the point of admission, during postoperative recovery, and on discharge in acute pain management patients. SettingThe pain management team at St. Joseph Mercy Hospital in Ann Arbor, MI, has developed and implemented a pharmacist-led OEP to better manage acute postoperative pain in neurosurgery and orthopedic and colorectal surgery in an effort to ensure appropriate patient and provider education and understanding of pain management. Practice descriptionOEP is a tool with the potential to expand the role of pharmacists in managing acute pain in postoperative patients at the point of admission, during the postoperative inpatient stay, and on discharge. Its benefits include medication reconciliation review and prescription drug–monitoring program search before admission, interdisciplinary rounds with the medical team to provide optimal inpatient postoperative pain management, clinical assessment of outpatient prescriptions with opioid discharge counseling, and medication evaluation of prescribed pain regimen and opioid discontinuation status at the post-discharge follow-up appointment. ConclusionA hospital pain management team operating a pharmacist-led OEP can be key to guiding the appropriate prescribing practice of opioids and assisting with transitions of care on discharge. Further outcomes-based evaluations of the practice model are planned and encouraged to validate and improve the pharmacist-led OEP practice.

Changes in Provider Prescribing Patterns After Implementation of an Emergency Department Prescription Opioid Policy

BackgroundPrescription opioid-associated abuse and overdose is a significant cause of morbidity and mortality in the United States. Opioid prescriptions generated from emergency departments (EDs) nationwide have increased dramatically over the past 20 years, and opioid-related overdose deaths have become an epidemic, according to the Centers for Disease Control and Prevention. ObjectiveOur aim was to determine the effectiveness of implementing a prescription policy for opioids on overall opioid prescribing patterns in a hospital ED. MethodsThe ED provider group of an academic, non-university–affiliated urban hospital with 23,000 annual patient visits agreed to opioid prescribing guidelines for chronic pain with the goal of limiting prescriptions that may be used for abuse or diversion. These guidelines were instituted in the ED through collaborative staff meetings and educational and training sessions. We used the electronic medical record to analyze the number and type of opioid discharge prescriptions during the study period from 2006–2014, before and after the prescribing guidelines were instituted in the ED. ResultsThe number of patients discharged with a prescription for opioids decreased 39.6% (25.7% to 15.6%; absolute decrease 10.2%; 95% confidence interval [CI] 9.6–10.7; p < 0.001) after the intervention. The improvements were sustained 2.5 years after the intervention. Decreases were seen in all major opioids (hydrocodone, oxycodone, hydromorphone, and codeine). The number of pills per prescription also decreased 14.8%, from 19.5% to 16.6% (absolute decrease 2.9; 95% CI 2.6–3.1; p < 0.001). ConclusionsImplementation of an ED prescription opioid policy was associated with a significant reduction in total opioid prescriptions and in the number of pills per prescription.

Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain.

Over recent years there has been a growing need for patients to be sent home from hospital with prescribed opioids for ongoing management of their acute pain. Increasingly complex surgery is being performed on a day-stay or 23-hour-stay basis and inpatients after major surgery and trauma are now discharged at a much earlier stage than in the past. However, prescription of opioids to be self-administered at home is not without risk. In addition to the potential for acute adverse effects, including opioid-induced ventilatory impairment and impairment of driving skills, a review of the literature shows that opioid use continues in some patients for some years after surgery. There are also indications that over-prescription of discharge opioids occur with a significant amount not consumed, resulting in a potentially large pool of unused opioid available for later use by either the patient or others in the community. Concerns about the potential for harm arising from prescription of opioids for ongoing acute pain management after discharge are relatively recent. However, at a time when serious problems resulting from the non-medical use of opioids have reached epidemic proportions in the community, all doctors must be aware of the potential risks and be able to identify and appropriately manage patients where there might be a risk of prolonged opioid use or misuse. Anaesthetists are ideally placed to exercise stewardship over the use of opioids, so that these drugs can maintain their rightful place in the post-discharge analgesic pharmacopoeia.

Multidisciplinary intervention decreases the use of opioid medication discharge packs from 2 urban EDs

IntroductionPrescription opioid overdoses and deaths constitute a public health epidemic, and recent studies show that emergency department (ED) prescribers may contribute to this crisis. We hypothesized that a multidisciplinary educational intervention would decrease ED opioid packs dispensed at discharge. MethodsThis prospective study implemented a “bundle” of interdisciplinary educational modalities: lectures, journal clubs, case discussions, and an electronic medical record decision support tool. Implementation occurred in 2 urban EDs in the same health system at different times (“affiliate,” September 2011; “primary,” January 2012) to better distinguish its effects. The primary outcome was preintervention/postintervention change in opioid discharge packs dispensed to all patients treated and discharged through August 2012 and was assessed by 2-way analysis of variance. The secondary outcome was bivariate analysis (using Fisher exact test) of change in opioid dispensing among patients with known risk factors for prescription opioid dependence: age less than 65 years, history of substance abuse, chronic pain, or psychiatric disorders. ResultsA total of 71,512 and 45,746 patients were evaluated and discharged from primary and affiliate EDs, respectively. Orders for opioid discharge packs decreased from 13.9% to 8.4% and 4.7% to 1.9% at the primary and affiliate hospitals (P < .0001). Dispensing among individuals at risk for opioid dependence at the primary ED decreased from 21.8% to 13.9%. ConclusionsA staged, multidisciplinary intervention targeting nurses, residents, nurse practitioners, and attending physicians was associated with decreased orders for opioid discharge packs in 2 urban EDs. Opioid discharge pack orders decreased slightly more among patients with risk factors for prescription opioid dependence.