All clinicians are thinking about ways to address the opioid epidemic, but hospitalists on one unit found success by specifically targeting the IV route of administration.
Preclinical research on the pharmacokinetics of IV opioids suggests that intermittent, rapidly spiking drug levels drive the addiction process forward, said ACP Member Adam L. Ackerman, MD, an assistant clinical professor at Yale New Haven and medical director of the unit. “In the hospital, we put people on IV morphine every four hours very frequently. If you think about that in relation to that literature on animal models, it's the same exposure” that could increase addiction potential, he said.
Another reason for reducing IV opioid prescribing is the risk of adverse effects, such as nausea, hypotension, pruritus, and decreased oxygenation, Dr. Ackerman added. “All the things we worry about with opioids seem to be most exacerbated by IV use, even compared to subcutaneous use or certainly oral use,” he said.
How it works
When speaking to colleagues, however, Dr. Ackerman found a general lack of awareness of the subcutaneous route except in more experienced clinicians. “It seems like almost as a profession, we've kind of forgotten about subcutaneous opioids . . . but subcutaneous is something that, if you talk to older nurses and doctors, they'll say, ‘Oh yeah, that's the only way we ever used to give these.’”
There wasn't a need to reinvent the wheel, but there was a need for education. As part of a pilot study, Dr. Ackerman and the unit's chief nurse held a lunch conference presentation to increase awareness among prescribers and nurses about subcutaneous availability. The unit also adopted a new local standard of practice favoring oral and subcutaneous (for patients unable to take pills) over IV opioids, although clinician prescribing was not formally restricted in any way.
The unit compared the number of IV opioid doses administered per patient-day between a six-month control period of 287 patients and a three-month intervention period of 127 patients. IV opioid doses decreased by 84% from the control to the intervention period (0.39 vs. 0.06 doses per patient-day), according to results published online in May 2018 and in the June issue of JAMA Internal Medicine. During the intervention, 65% of parenteral opioid doses were administered subcutaneously, compared with fewer than 1% during the control period.
Researchers also looked at pain control “to make sure we weren't making ourselves feel better about opioids by making our patients feel worse,” said Dr. Ackerman. Patients' average reported pain scores actually got better after the intervention, with significant improvement on days four and five, but not days one through three, of admission.
Since the subcutaneous route for opioids has long been established, the group didn't have to change a single hospital policy, Dr. Ackerman said. “I was afraid that was going to be a real roadblock, but subcutaneous was already in the pharmacy policy, and everything was right there,” he said.
Changing clinicians' practice was the biggest challenge, since “Everyone is a little bit averse to change,” Dr. Ackerman said. It didn't help that the electronic health record (EHR) continued to default to IV. “It's tough to get people to go out of an order set or something that they've been using for a long time,” he said.
In addition, moonlighters and hospitalists who were working the night shift may have been unable to attend the educational presentation, Dr. Ackerman noted. “Those folks, the uptake for subcutaneous was a little slower, I think probably because our group is large and I just wasn't able to get face time with everybody,” he said. “That peer-to-peer education is so powerful.”
Dr. Ackerman said that providing peer-to-peer education and involving nursing from the start were key to the project's success. “This is something that really spread from a grassroots-type perspective. Nurses were able to see patients that were coming from the ED having maybe an IV morphine order and . . . have a little conversation with [the prescriber] and have a little teaching moment there,” he said.
The results generated interest throughout the entire Yale New Haven Health system, which is expanding the intervention to its five hospitals, Dr. Ackerman said. “We're actually in the middle of a rollout of this as a standard throughout the entire health system. . . . We're starting to see some preliminary data that's really tracking very well right along with our pilot data,” he said.
As for the EHR issue, Dr. Ackerman said that his group may work on that. “Maybe it can default to subcutaneous, which I think would be reinforcing of the education,” he said. “Education is great; it doesn't have the durability of something like an EHR change, though.”