Implementation of solutions to reduce opioid-induced oversedation and respiratory depression

Abstract

Purpose. The implementation of interventions to mitigate the causes of opioid-induced oversedation and respiratory depression (OSRD) is reported. Summary. A single-site retrospective review of eligible rescue naloxone cases was conducted to identify the causes of opioid-induced OSRD in a hospital as well as to identify risk factors. A survey was used to assess potential opioid knowledge deficits among hospitalist prescribers. Based on the findings of the case reviews and results of the opioid knowledge assessments, a series of interventions to address noted deficiencies was implemented over the ensuing months, including enhanced monitoring for sedation, improved clinical decision support in the electronic medical record (EMR), and various adjustments to dosing for high-risk patients. The primary endpoint of our analysis was naloxone use for documented cases of opioid-induced OSRD to determine the effectiveness of the interventions. A mean of 16 OSRD events occurred per quarter before intervention implementation. An average of five risk factors (range, two to six) was found among OSRD cases, most commonly age of >60, obesity, and comorbidities of the kidneys and lungs. Deficiencies of clinical care were found in four interrelated domains: knowledge deficits, inadequate monitoring, failure to leverage the EMR, and cultural issues regarding pain assessments and sedation management. Conclusion. Implementation of solution bundles that utilized an EMR to create meaningful clinical decision support and cultural changes related to pain goals and communication about sedation level at an acute care hospital resulted in a fivefold reduction in OSRD events that has been sustained for two years.

Impact of a Clinical Decision Support Tool on Cancer Pain Management in Opioid-Tolerant Inpatients

“…[9][10][11] Furthermore, clinical decision support tools (CDSTs) have demonstrated improvement in guideline adherence, pain relief, and safety, but studies supporting CDSTs have generally been methodologically weak with no focus on the impact of pharmacist-managed CDSTs. [12][13][14][15] Therefore, we set out to assess the impact of a pharmacist-managed PCDST on opioid-tolerant inpatient oncology patients at risk for uncontrolled pain.…”

Risk of respiratory depression with opioids and concomitant gabapentinoids

“…In a previous small cohort study of nine patients, 44% of patients experienced respiratory depression and/or sedation with the combination of gabapentinoids and opioids with dosages of gabapentinoids administered as high as 3,600 mg/d. 13 Therefore, higher dosages of gabapentinoids when concomitantly used with opioids may place the patient at a higher risk of developing respiratory depression than the lower dosages of gabapentinoids that were seen in this study. Beyond the scope of this study, it is noted that there have been recent reports of recreational use of gabapentinoids concomitantly with opioids to further enhance drug users’ high experience.…”

Opioid‐induced ventilatory impairment: current ‘track and trigger’ tools need to be updated

“…Consequently, there is a large discrepancy in the reported incidences of opioid‐induced ventilatory impairment which varies according to the population studied as well as the surrogate measured. An accepted rate does appear to be approximately ≤ 1% 6–8.…”

“…In addition, Ready's sedation score of ‘S’ (‘normal sleep, easy to rouse’) was excluded due to concerns it could lead to a somnolent patient not being woken to have their level of sedation properly assessed (Table 2) 2. Sedation scores have been incorporated into order sets that standardise monitoring and responses to inadequate or excessive analgesic doses, including excessive sedation 7–9,18,19.…”