Photo Credit: LanaSweet

An analgesic stewardship program can prevent inappropriate in-hospital and discharge prescribing of opioids, optimizing outcomes and reducing over-prescribing.

“The increasing incidence of opioid-related harm associated with inappropriate opioid prescription underscores the need for effective interventions directed at enhancing analgesic prescribing practices,” Sam Maleki, BPharm, MPharmPrac, and colleagues wrote. “Analgesic stewardship (AGS) programs have emerged to facilitate appropriate analgesic use, reducing analgesic-related harm and optimizing patient outcomes.”

In the Journal of Pharmacy Practice and Research, Maleki and colleagues noted an AGS program aims to optimize patient outcomes, reduce the risks of over-prescribing, incorporate improvements as needed, and make using analgesics cost-effective while upholding optimal pain management. AGS initiatives include guideline development and adherence, supervising analgesic prescribing protocols, and providing educational materials to practitioners and patients.

However, despite well-evolved analgesic usage guidelines, a lack of adherence persists to guidance regarding the treatment of acute pain with opioids. Maleki and colleagues developed a retrospective audit of an AGS program within a metropolitan health network to study the impact of an AGS program over 2 months in a hospital setting. According to the researchers, what set this AGS program apart was its multidisciplinary approach involving nursing, medical, and pharmaceutical staff.

Guidance Adherence

The study drew data from medical records and included patients under general medical or surgical care who had been prescribed an opioid on their inpatient chart. Patients were excluded if they were prescribed oxycodone immediate-release 5 mg tablets or tramadol immediate-release 50 mg capsules. Additional exclusions were patients receiving parenteral opioids and patients who were overseen by the Acute Pain Service or a program outside of the scope of the AGS.

Of the 100 patients in the study cohort, 58 were admitted to the hospital under general medical services, and 42 were admitted to the surgical unit. Each of these patients had direct contact with the AGS team. These interactions resulted in an average of 1.7 progress notes per patient, with a mean of 2.4 recommendations.

Inappropriate Prescribing

Of the 51 patient in the cohort who arrived at the hospital opioid-naïve, 26 were prescribed modified-release or long-acting opioids for their acute pain. This is contrary to standard guideline recommendations. Upon the intervention of the AGS program, 23 of these patients ceased the inappropriately prescribed opioids and were discharged without further prescriptions of this nature.

Forty-nine of the patients in the study cohort had a documented history of consistent opioid usage prior to their hospital stay. After AGS program intervention, there was a significant reduction, equating to 19.85 mg, in the mean overall oral morphine equivalent daily dose (OMEDD) in the time spanning their hospital admission and discharge (95% CI 10.3–29.4 mg; P< 0.05).

Recommendations Made

The AGS program actively collaborated with the medical and surgical teams during the study. As a result, 240 recommendations were given, 101 of which targeted surgical patients. Thirty of these recommended ceasing inappropriate medication. As for medical patients, 139 recommendations were given, 26 of which recommended medicine cessation, 23 encouraged an alteration in dosing amounts, and 26 advocated for a weaning plan to be put into place.

The most common interventions by the AGS program were ceasing inappropriate analgesic medicines and developing a weaning plan for inpatients or upon discharge. The least common recommendations were acute pain service referrals for parenteral analgesic options and instructions on applying prophylactic treatments to ease analgesic side effects. For 82% of the patient participants, these recommendations were enacted.

“This study highlighted a clinically and statistically significant reduction in the mean OMEDD of 40.4% for non-opioid-naïve patients due to AGS intervention,” Maleki and colleagues wrote. “This finding is consistent with the expected outcome in the literature regarding the effects of multidisciplinary pain programs and has significant implications for both patient safety and hospital economics.”

Key Takeaways

• An analgesic stewardship program aims to facilitate appropriate analgesic use, optimize patient outcomes, reduce risks of over-prescribing, and incorporate improvements as needed
• The analgesic stewardship program examined in this study stopped the inappropriate prescription of opioids, and those patients were discharged without further opioid prescriptions
• The analgesic stewardship program also resulted in 240 recommendations, mainly for surgical patients; many focused on ceasing the prescription of inappropriate medication
• The most common interventions were ceasing inappropriate analgesic medicines and developing a weaning plan for inpatients or upon discharge