A call for opioid stewardship

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.