Opioid stewardship has become a catchall phrase for the broad grouping of initiatives, legislation, regulatory oversight, and overall awareness of prescribing and usage patterns for what were once considered safe medications. Health care organizations are increasingly focusing their efforts on enforcing thoughtful and safe prescribing of opioids, but it can be difficult to pinpoint problem areas and to find technology solutions that can help improve performance. Much of the focus to date has been on outpatient and ambulatory settings, yet hospitals also have an important role to play.
Looking Beyond the EHR
While EHRs offer standard order sets, links to state Prescription Drug Monitoring Programs (PDMP) and point-of-care alerting for safety concerns like drug-to-drug interaction or drug ingredient allergy, that is not enough. Effective medication management for hospitals should also include active, real-time surveillance of patients receiving opioids to monitor for potential high-risk situations and for opportunities to de-escalate via agent selection, dose or route. Empowering pharmacists at the front line of inpatient care with active surveillance solutions may be an effective strategy for increasing the appropriate use of opioids. In addition, clinical reporting and analytics that enable a hospital to understand how opioids are being used will help to focus efforts around effective utilization as well as combat abuse.
What should be included in a suite of tools for hospitals addressing opioid stewardship?
As with antimicrobials, opioid stewardship requires effective engagement across the care team. The Joint Commission released new pain assessment and management standards effective January 1, 2018, and included the following requirements:
- Promoting safe opioid use by identifying high-risk patients
- Monitoring high-risk patients
- Conducting performance improvement activities focusing on pain assessment and management to increase safety and quality for patients
With these standards in mind, hospital pharmacists need to evaluate opioid usage across multiple dimensions and assess appropriate use in agent selection, duration of use, the reason for use and dose. Hospitals will also need to address new regulatory requirements for assessing pain scores in concert with patient needs and medication orders and reporting on specific adverse events. All of these objectives require monitoring patients receiving opioids in real-time and retrospective reporting on usage.
Some other considerations when developing opioid stewardship toolsets include:
- Ad hoc reporting functions related to several focus areas
- Setting of opioid use
- Diagnosis and condition tracking
- Timely review of PDMPs and proactive identification of opioid use disorder
- Identification of patients who may require prescriptions for reversal agents
- Provider level analysis including ordering and reordering of opioid prescriptions
- Monitoring of inpatient orders without respiratory monitoring
- Naloxone administrations for reversal of respiratory depression
Where Can Hospitals Start?
Clinical leadership should first assess their medication management clinical initiatives by looking at the teams and technology they have in place. Key elements of a successful medication management program include:
- Establishing a multidisciplinary team to study current opioid use in the hospital, review and adjust standard order sets that include opioids, review usage patterns and overall patterns of opioid usage by care area, facility, service, etc. This team must develop measurable goals for monitoring program impact(s) and develop action strategies for education and remediation of inappropriate prescribing patterns.
- Evaluating real-time surveillance technology for the inpatient setting to ensure hospitals can monitor for and prevent adverse drug events related to opioid use.
- Educating your team on regulatory requirements—current and future state—this includes looking at how to address the Joint Commission requirements for monitoring patients prescribed opioids. Retrospective reporting capabilities allow hospitals to comply with state regulatory reporting needs to demonstrate a quality improvement strategy that monitors the usage of opioids and addresses any areas of concern. These metrics are also useful for providing surveyors with information on active assessment and intervention strategies.
Regardless of strategy, organizations still have a long way to go in executing a comprehensive framework for the safe prescribing and use of these medications, and there is not a single technology solution that serves as the silver bullet. Electronic health records can deliver point-of-care decision support and standard order sets and surveillance solutions can monitor patients throughout their stay to ensure safe practices and provide robust analytics to help hospitals monitor the success of their programs. Used together these systems can identify and address issues in real-time and provide a detailed level of data analysis to identify trends and the effectiveness of efforts.
In a recently released KLAS study, How are Providers Tackling the Opioid Epidemic?, only seven providers that responded noted they felt that their efforts to foster appropriate and safe usage were ‘advanced’, with multiple technologies and strategies in place. The KLAS survey concluded “Advanced organizations report that a multifaceted approach – consisting of internal rules, technology partners, alternative treatment options, electronic prescriptions for controlled substances, and proper legislation – is necessary for effective opioid stewardship. Organizations that take such an approach have realized gains in their fight against opioid misuse.”
Health care providers are actively pursuing strategies, both novel and conventional, to reduce the impact of the vast opioid abuse epidemic in the United States. With a framework supported by surveillance strategies, inpatient facilities are key players in this effort, and a combination of technologies may be just the arsenal providers need to develop next-level interventions and assessment for pain management.