A targeted intervention strategy aimed at decreasing intravenous (IV) opioid use in hospitalized adults was found to lower both IV and overall parenteral opioid prescriptions in a study published in JAMA Internal Medicine.
Although effective for immediate pain relief, IV vs oral opioids have been associated with a greater safety risk. Subcutaneous vs IV administration of opioids offers an acceptable middle ground with improved pharmacokinetics. Despite a nationwide effort to reduce opioid exposure in the face of an epidemic, little information is available regarding inpatient prescribing practices. This was the first study to examine iatrogenic harm reduction via implementation of a standard practice encouraging replacement of IV opioid administration with the safer oral or subcutaneous routes in adult inpatients.
A pilot study conducted at an urban academic hospital evaluated prescribers’ pain medication choices during a 6-month control period and during an additional 3 months after an education session on opioid administration routes and implementation of a unit-wide opioid standard of practice mandating a preference for oral or subcutaneous administration of opioids whenever possible (intervention period). Intravenous opioid dose reduction per patient-day was the primary end point; secondary end points assessed several measures of total parenteral and overall opioid exposure per patient-day. Patients reported their levels of pain during the first 5 hospital days, using a 0 to 10 Likert scale.
A total of 287 and 127 patients were evaluated in the control (mean age, 56.1; 39.4% men) and intervention (mean age, 57.6; 46.5% men) periods, respectively, representing 4500 and 2459 patient-days, respectively. During the intervention period, the number of IV doses of opioids per patient-day decreased by 84% compared with the control period (0.06 vs 0.39, respectively; P <.001), and total parenteral opioid doses per patient-day dropped by 55% (0.18 vs 0.39, respectively; P <.001).
Mean parenteral opioid exposure (in morphine-milligram equivalents [MMEs]) per patient-day decreased by 49% between the control and intervention periods (2.88 vs 5.67 MME, respectively), and daily parenteral administration rates were reduced 57% (6% vs 14%, respectively; P <.001). Doses of opioids per patient-day via any route were also reduced by 23% during the intervention period compared with the control period (0.73 vs 0.95, respectively; P =.02), and overall daily mean opioid exposure per patient-day was reduced by 31% (6.30 vs 9.11 MMEs, respectively).
Pain scores were comparable during the first 3 hospital days between control and intervention periods, but were reduced at day 4 (−1.07; 95% CI, −1.80 to −0.34) and day 5 (−1.06; 95% CI, −1.84 to −0.27) in the intervention group.
Study limitations included patients being recruited from a single unit and the possibility that the discomfort of opioids administered subcutaneously might have not been accounted for when assessing routine pain scores.
“[S]witching from intravenous to subcutaneous administration for parenteral opioids may have decreased exposure to the intermittent, spiking levels of drug and thereby decreased short-term dependence on the parenteral opioid for pain control. Switching from parenteral opioid administration to oral administration may have provided more long-acting, consistent pain control,” concluded the study authors.
Ackerman AL, O’Connor PG, Doyle DL, et al. Association of an opioid standard of practice intervention with intravenous opioid exposure in hospitalized patients. JAMA Intern Med. 2018;178(6):759-763. doi: 10.1001/jamainternmed.2018.1044