Evaluating a Pharmacist-Led Opioid Stewardship Initiative at an Urban Teaching Hospital

Abstract

Background: Deaths due to overdose from illicit drugs have risen in Canada, despite various community-led harm reduction programs. There have been limited pharmacist-led inpatient initiatives aimed at reducing opioid harm. The authors’ group recently developed and implemented the Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) tool, a systematic checklist designed to help pharmacists follow and enhance the safety of in-hospital opioid prescribing. Objectives: To evaluate the impact of a pharmacist-led opioid stewardship program utilizing the MORE tool in the care of patients at one tertiary teaching hospital. Methods: This study involved a review of health care records for patients admitted to general surgery and internal medicine clinical teaching units at a tertiary hospital between September 10 and December 31, 2018, for whom opioids were prescribed during the hospital stay. A descriptive data analysis was performed for patients who underwent assessment with the MORE tool. Results: Of the 210 patients who met the initial eligibility criteria, including in-hospital opioid therapy for at least 3 days, 50 were assessed by a pharmacist using the MORE tool. For 40 (80%) of these patients, the pharmacist recommended an intervention, and 35 (87.5%) of these interventions were accepted by the prescriber. Among all 50 patients, the most common pharmacist interventions were adding or optimizing non-opioid pain medications (23 patients [46%]), decreasing opioid dose or frequency (15 patients [30%]), and adding a bowel regimen (9 patients [18%]). Conclusions: Most patients who underwent assessment by a pharmacist had risk factors for adverse events from opioid prescriptions and/or suboptimal orders and drug combinations. The MORE tool provided a guided approach for pharmacists to make targeted interventions aimed at improving opioid safety. A dedicated opioid stewardship pharmacist might be able to provide additional benefit. RÉSUMÉ Contexte : Les décès provoqués par les surdoses de drogues illégales ont augmenté au Canada, malgré les divers programmes communautaires axés sur la réduction des risques. Le nombre d’initiatives menées par les pharmaciens auprès des patients hospitalisés visant à réduire les dommages causés par les opioïdes est limité. Le groupe d’auteurs de cette étude a récemment élaboré et mis en place l’outil Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) : une liste de contrôle systématique conçue pour aider les pharmaciens à respecter et à renforcer la sécurité de la prescription d’opioïdes en milieu hospitalier. Objectifs : Évaluer l’impact d’un programme de gestion des opioïdes dirigé par des pharmaciens à l’aide de l’outil MORE pour les soins des patients résidant dans un hôpital d’enseignement tertiaire. Méthodes : Cette étude impliquait l’examen des dossiers de santé des patients admis dans les unités d’enseignement clinique de chirurgie générale et de médecine interne d’un hôpital tertiaire entre le 10 septembre et le 31 décembre 2018. Des opioïdes ont été prescrits à ces patients lors de leur séjour hospitalier. Une analyse descriptive des données a été menée auprès des patients ayant fait l’objet d’une évaluation à l’aide de l’outil MORE. Résultats : Sur les 210 patients qui répondaient aux critères d’admissibilité initiaux, notamment à celui d’un traitement aux opioïdes à l’hôpital pendant au moins trois jours, 50 ont fait l’objet d’une évaluation à l’aide de l’outil MORE. Le pharmacien a recommandé une intervention auprès de 40 de ces patients (80 %), et le prescripteur a accepté 35 de ces interventions (87,5 %). Les interventions des pharmaciens les plus répandues réalisées auprès des 50 patients consistaient en l’ajout ou en l’optimisation des analgésiques sans opioïdes (23 patients [46 %]); en la diminution de la dose d’opioïdes ou de leur fréquence (15 patients [30 %]); et en l’ajout d’un régime d’hygiène intestinale (9 patients [18 %]). Conclusions : La plupart des patients ayant fait l’objet d’une évaluation menée par un pharmacien présentaient des facteurs de risque d’effets indésirables découlant des prescriptions d’opioïdes et/ou d’ordonnances et de combinaisons médicamenteuses sous-optimales. L’outil MORE a permis aux pharmaciens d’adopter une approche guidée pour qu’ils puissent effectuer des interventions ciblées visant à améliorer l’innocuité des opioïdes. Un pharmacien affecté spécifiquement à la gestion des opioïdes pourrait offrir des avantages supplémentaires.

Advancing opioid stewardship in low-middle-income countries: challenges and opportunities

“…Their roles have been reported to be key to substance abuse prevention and treatment programs, and they are known to collaborate with authorities as well as healthcare professionals on detoxification protocols and opioid overdose treatment (ASHP, 2014 ). Pharmacists have supported the provision of medication-assisted treatment with methadone, buprenorphine and naltrexone, which have the potential to reduce opioid addiction and mortality (Chen et al, 2021 ; Connery, 2015 ; Schwartz et al, 2013 ). However, some studies suggest that pharmacists in HICs may lack comprehensive clinical guidance on opioid-related interventions, highlighting the need for evidence-based support and collaborative practice models (Webb et al, 2021 ).…”

Cultivating optimal analgesic prescribing practices in a metropolitan hospital network: evaluating an analgesic stewardship program

“…11 Analgesic stewardship, also known as opioid stewardship, is defined as the implementation of coordinated interventions to enhance, monitor, and assess the use of analgesics to support and protect patients using these drugs. 16 Similar to other stewardship programs, an AGS program encompasses structured approaches to governance, policy, education, monitoring, and improvement activities. 17 The benefits of AGS programs include a reduction in the incidence and potential for opioid-related harm, along with a decrease in the healthcare and economic costs associated with inappropriate opioid analgesic use.…”

“…In 2018, less than 5% of Australian hospitals reported having a formal AGS program for managing opioid prescribing 11 . Analgesic stewardship, also known as opioid stewardship, is defined as the implementation of coordinated interventions to enhance, monitor, and assess the use of analgesics to support and protect patients using these drugs 16 . Similar to other stewardship programs, an AGS program encompasses structured approaches to governance, policy, education, monitoring, and improvement activities 17 .…”

Discerning Clinician Perceptions of an Established Opioid Stewardship (DISCLOSE) Program

“…4,5 In British Columbia, a similar OSP exists within a different health authority, incorporating an audit and feedback process led by a pharmacist and a physician. 6 Clinical work began in March 2019 at Surrey Memorial Hospital and June 2019 at Royal Columbian Hospital. The OSP pharmacists identified patients at high risk of opioid-related adverse outcomes using the following criteria: personal or family history of substance use disorder, psychiatric illness, opioid-related aberrant behaviour, increased risk of overdose (e.g., pulmonary disease), morphine milligram equivalent above 50 mg/day, concurrent use of opioid and benzodiazepines or other sedatives, long-acting opioid use by opioid-naive patients, escalating opioid use without apparent cause, and non-decreasing opioid requirements for management of acute pain.…”