Category: Professional Posters
Purpose: Pain stewardship programs serve to assure proper pain management in patients by utilizing multimodal analgesia and reduce opioid utilization in response to the growing opioid epidemic in the United States. Multimodal analgesia includes use of non-opioid analgesics and non-pharmacologic interventions has shown to reduce doses of opioids, reduce risk of opioid-related adverse events, shorten length of stay, reduce pain during rest and activity and improve patient satisfaction. The purpose of this study was to determine whether implementation of pain stewardship and palliative programs in a 130-bed suburban hospital reduced opioid utilization over a 28 month period.
Methods: In order to reduce opioid prescribing and utilization, hospital leadership initiated both a pain stewardship program and a palliative care program to meet the needs of the patient population. A multidisciplinary pain management committee was created outlines steps needed to reduce opioid use, including reviewing pain assessment techniques, developing an opioid risk tool, education of nurses, implementing various hospital-wide non-pharmacologic interventions, as well as the creation of pain-order sets in the electronic medication record to assist with analgesic prescribing and preventing therapeutic duplications. Non-pharmacologic interventions implemented included use of warm and cold packs as part of physical therapy, as well as use of aroma therapy, music therapy, pet therapy, distraction techniques, quit time and spiritual support. Patients who present with opioid dependence would be referred to receive proper assistance through the social work department. Additionally, the committee established metrics which would be used to assess outcomes, including opioid administration per 1000 patient-days, use warm and cold compresses per 1000 patient-days as well as naloxone use, opioid-related adverse events and pharmacist-driven pain interventions, including therapeutic duplications. The hospital also established a palliative care consult team, consisting of a qualified physician and nurse who assess and manage patients who have complex pain management requirements and require symptomatic care or need an evaluation for end-of-life care.
Results: Although the interventions were implemented at various times during 2018, a number of trends have been identified. Primarily, between January 2017 and April 2019, the overall change in opioid administrations was a 14.8 percent decrease. This trend was driven by a 44.4 percent decrease in hydromorphone and a 37.1 percent decrease in tramadol administrations. Morphine saw a 3.0 percent decrease, while fentanyl and oxycodone increased by 7.6 and 6.7 percent, respectively over the study period. Naloxone administrations had decreased by 41.4 percent for admitted patients, while increasing by 23.4 percent for all patients, including those in the emergency department. When evaluating non-opioid analgesics, it was found that total acetaminophen utilization increased 47.5 percent, which included a 288 percent increase in intravenous acetaminophen use. Non-steroidal anti-inflammatory drugs (NSAIDs) showed an overall increase of 38.4 percent, with increases of 25.6 and 46.3 percent in ibuprofen and ketorolac, respectively being the primary contributors. Additionally, purchasing records of warm and cold packs were evaluated as well. There was a 463 percent increase in warm packs and 33.1 percent increase in cold packs, indicating that non-pharmacological modalities play an increasing role in pain management in patients.
Conclusion: Establishment of pain stewardship and palliative care programs have been effective in reducing opioid utilization hospital-wide. A combination of multidisciplinary interventions including increased use of non-opioid analgesics, proper pain assessment and various non-pharmacologic interventions have shown to curb the use of opioids hospital-wide. Although efforts to date have shown progress, more work must be done to further reduce opioid use. Future initiatives to further curb opioid use include creation of order sets for the emergency department to better manage acute pain, increase the use of intravenous acetaminophen to manage post-operative pain and expand our palliative care program.