Focus on De-Escalation and Safe-Use Strategies for Opioids

You'll be in a prime position to expand your hospital's "opioid stewardship" strategies.

Implement protocols to reduce opioid overprescribing. And help your hospital meet pain standards from The Joint Commission, CDC, etc.

Re-evaluate surgical pain management. One-third of patients on long-acting opioids report their first opioid Rx came from a surgeon.

Use multimodal strategies, including "enhanced recovery after surgery" (ERAS) protocols. Verify that post-op order sets default to NON-opioids, such as scheduled oral or rectal acetaminophen plus an NSAID.

Suggest removing opioids from order sets when non-opioids are often enough...such as after a cardiac cath or uncomplicated vaginal birth.

Redefine PRN opioid instructions. For example, instead of saying for "moderate pain," say "pain not improved by acetaminophen and ibuprofen." And change IV opioids to "when PO isn't tolerated."

Set realistic pain expectations. For example, a goal might be to sit up in bed without severe pain within two days after abdominal surgery.

Incorporate de-escalation strategies. For instance, add auto-stop dates...such as 72 hours for opioids being used PRN.

Switch IV opioids to PO as soon as possible...and use our chart, Equianalgesic Dosing of Opioids for Pain Management, as a guide.

Verify safe and appropriate opioid use. Review daily reports. For example, ensure that PCA basal rates aren't used in opioid-naive patients...and fentanyl patches aren't used or increased for acute pain.

If able, limit opioids in those at higher risk of overdose...sleep apnea, renal or hepatic impairment, older age, or also taking a benzo.

Ensure safe transitions. Check opioid use in your prescription drug monitoring program...and ask for a link in the EHR for easier access.

Review recent opioid use before discharge. Over 40% of patients get an opioid Rx despite not needing an opioid dose in the previous 24 hrs.

Help create guidelines for discharge opioid amounts...and change EHR defaults. For example, limit to no more than 20 oxycodone 5 mg tabs after an open hysterectomy or CABG...or 10 tabs after a lap cholecystectomy.

Educate patients about opioid risks, and use shared decision making. Many patients may forego an opioid Rx or request fewer pills.

See our Opioid Stewardship Checklist for more strategies.

Key References

  • J Am Coll Surg 2018;227(4):411-418
  • JAMA Surg 2018;153(10):948-954
  • Hosp Pharm Published online May 30, 2018; doi:10.1177/0018578718779005
  • JAMA Surg 2018;153(2):e174859
Hospital Pharmacist's Letter. Dec 2018, No. 341217

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