Clinical question: Can an opiate-prescribing standard that favors oral and subcutaneous over intravenous administration reduce exposure to intravenous opiates for hospitalized adults?
Background: IV opiates, while effective for analgesia, may have a higher addictive potential because of the rapid and intermittent rises of peak concentrations. Subcutaneous and/or oral administration is a proven method of opioid delivery with similar bioavailability and efficacy of intravenous administration with more favorable pharmacokinetics.
Study design: Intervention-based quality improvement project.
Setting: Adult general medicine inpatient unit in an urban academic center.
Synopsis: Clinical leadership of the study unit collaborated to create an opiate-prescribing standard recommending oral over parenteral opioids and subcutaneous over IV if parental administration was required. The standard was promoted and reinforced with prescriber and nurse education, and prescribers were able to order intravenous opiates per usual protocol.
After a 6-month preintervention control period of 4,500 patient-days, the 3-month intervention period included 2,459 patient-days and led to a 84% decrease in IV opiate doses (0.06 vs. 0.39; P less than .001) and a 55% decrease in parenteral doses (0.18 vs. 0.39; P less than .001). Surprisingly there was a 23% decrease in overall doses of opiates (0.73 vs. 0.95; P = .02). Pain scores were similar between the two groups during hospital days 1-3 and improved in the intervention group between days 4 and 5.
This study was limited by a narrow focus, unblinded participants, and nursing-reported pain scores. While promising, more information is needed before establishing conclusions on a broader scale.
Bottom line: Establishing and promoting an opioid prescribing standard on a single unit led to a decrease in intravenous, parenteral, and overall opiates prescribed with similar or improved pain scores.
Citation: Ackerman AL et al. Association of an opioid standard of practice intervention with intravenous opioid exposure in hospitalized patients. JAMA Intern Med. 2018 Jun 1;178(6):759-63.
Dr. Chowdury is an assistant professor in the division of hospital medicine, University of Colorado, Denver.