Annual Scientific Meeting
Introduction: Opioids (OPIs) are associated with increased mortality and infections in patients with IBD (AJG 2012;107(9):1409–22). Prior interventions targeting reductions in intravenous (IV) OPI exposure for all patients admitted to a general medical unit have decreased total OPI use without compromising pain control (JAMA IM 2018;178(6):759-63). We therefore performed a prospective evaluation of a multimodal intervention to reduce IV OPI exposure among IBD patients hospitalized at our institution.
Methods: This prospective study was conducted on a general medical unit at a large urban academic medical center from 1/1/19 to 5/31/19. Interventions to decrease IV OPI use were implemented in stages (Fig 1): 1. protocol for IV acetaminophen for IBD patients lacking enteral access 2. EHR “smartphrase” with analgesia guidance for use in gastroenterology consult notes 3. online IBD pain management pathway 4. automated text message alerts with analgesia guidance sent to providers. IV and total (IV+PO+TD) OPI exposures were measured in IV morphine mg equivalents (IVMME)/patient-day and compared to pre-intervention (1/1/18-12/31/18) data abstracted retrospectively from the EHR. IV acetaminophen and ketorolac use, length of stay (LOS), 30-day readmission rates (RRs), and pain scores (1-10 scale) were also assessed.
Results: Our study included 332 IBD patient encounters with similar baseline characteristics in pre-intervention (n=241) and intervention (n=91) periods (Table 1A). Between study periods, we observed a significant reduction in the proportion of patients receiving IV OPIs (43.6% vs. 30.1%, p=0.03) and non-significant reductions in mean IV and total OPI exposures/patient-day (Table 1B). The proportion with highest OPI exposure (
>39.0 IVMME/d, top quartile of non-zero total OPI exposure in 2018) was significantly reduced (13.7% vs. 5.5%, p=0.04). Run charts were performed to correlate the timing of interventions to changes in OPI exposure (Fig 2). We observed appropriately increased IV acetaminophen use (0.8% vs. 14.3%, p< 0.01), similar mean pain scores (3.9 vs. 3.8, p=0.74), non-significantly reduced IV ketorolac use (8.7% vs. 3.3%, p=0.09), and significantly reduced mean LOS (7.2 vs. 5.2 d, p=0.04) and 30-day RRs (21.6% vs. 11.0%, p=0.03).
Discussion: A multimodal intervention successfully reduced IV OPI exposure for hospitalized IBD patients. This was associated with reduced LOS and 30-day RRs. Additional research is needed to determine long-term benefits of reduced OPI exposure in this population.