Opioid Stewardship Checklist

Full Update October 2020

Long-term opioid use, which is associated with the development of opioid use disorder, overdose, and other risks, often begins with opioid use for acute pain.3 Use this checklist to improve opioid use at your institution, comply with the ISMP Targeted Medication Safety Best Practices for hospitals (https://www.ismp.org/sites/default/files/attachments/2020-02/2020-2021%20TMSBP-%20FINAL_1.pdf), and meet Joint Commission standards for pain assessment and management (https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17). See our toolbox, Appropriate Opioid Use, for more information on the topics mentioned below, and patient education resources.

Goal

Suggested Approach

Set expectations. Ensure prescribers and patients are on the same page regarding opioid risks and benefits.

  • Disseminate key points about opioid risks and benefits:
    • Tolerable pain and improved function are the goals, not complete pain relief.1,3
    • Opioids are not always the more effective agents; for renal colic, post-op pain, and soft tissue injuries, non-opioids are just as effective.1 Our chart, Analgesics for Acute Pain, has additional information on non-opioid options (e.g., NSAIDs, local anesthetics, ketamine).
    • Long-term opioid use has not been proven to improve pain or function.3
  • Before surgery, educate patients about post-op pain.2
  • Use shared decision-making when prescribing opioids, incorporating expectation-setting and opioid education. Most patients will forgo an opioid prescription when given information on opioid risks.2
  •  

Employ organizational strategies that minimize unnecessary or unsafe opioid prescribing.

  • Designate a leader or team responsible for pain management, safe opioid prescribing, and performance improvement.5
  • Have policies and procedures that promote review of high-risk opioid prescriptions (e.g., high-dose, long-acting agent, fentanyl patch) by a pharmacist or pain specialist.6,10
  • Remove long-acting opioids from preoperative order sets.14
  • Do not stock long-acting opioids such as fentanyl patches in acute pain areas (e.g., emergency department).12
  • Have orders default to starting doses.12
  • Require verification that orders for long-acting opioids are only for chronic pain in opioid-tolerant patients (e.g., 60 mg oral morphine-equivalent/day for ≥7 days).3,12 Provide guidance on calculating morphine equivalents in the EHR.6 Require an indication and notation of whether the patient is opioid tolerant.12 If hard stops or questions can’t be added to the EHR, call the prescriber to confirm type of pain and opioid tolerance; don’t rely on EHR alerts to prevent error. Document findings in EHR.12
  • Take steps to eliminate order entry errors with home meds (e.g., choosing long-acting instead of immediate-release).
  • To inform safe prescribing, provide a single-screen summary within the EHR of pertinent patient information such as vitals, sedation score, analgesic doses already given, and pain assessment.14
  • Provide decision-support information in the EHR to minimize prescribing of sedating polypharmacy and trigger more frequent monitoring of sedation level when sedating meds are ordered.6
  • Have systems in place for prospectively identifying patients with risk factors for opioid-induced respiratory depression (e.g., elderly, sleep apnea, sedating meds [e.g., benzos, gabapentinoids, muscle relaxants, antidepressants], renal or hepatic insufficiency).6
  • Provide staff with educational resources to improve pain management and safe opioid use.5
    • Educate staff about the association between sedation and respiratory depression.14
  • Develop a standard sedation monitoring approach, using a validated tool that is part of the EHR.14
  • Facilitate access to applicable prescription drug monitoring program(s) (e.g., put a link on the EHR home page).5 Some EHRs can integrate PDMP data.
  • Change paper or electronic order sets so that non-opioids and opioids by non-IV routes are the default options.2,8
  • Ensure post-discharge follow-up (e.g., nurse telephone call) to alleviate prescriber concerns about untreated pain.2
  • Make non-pharmacologic pain treatment options available (e.g., physical therapy) and promote enhanced recovery after surgery protocols.5,11
  • Ensure that prescribers have access to pain specialists for complex patients (e.g., patients with opioid use disorder, patients with sleep apnea).5
  • Monitor for possible indicators of unsafe opioid use in the hospital setting (e.g., track adverse effects, naloxone use, doses prescribed, and duration of use).5

 

If an opioid is appropriate, prescribe safely.

  • Check the prescription drug monitoring program for evidence of misuse, and consider use of an opioid abuse risk stratification tool (e.g., Opioid Risk Tool).6
  • Use the oral route when possible.1 Write orders that specify use of the oral route unless the patient is NPO or vomiting.7
  • Do not prescribe long-acting opioids or fentanyl patches for acute pain.1,6
  • Use caution when converting from one opioid to another, or from parenteral to the oral route.3 See our chart, Equianalgesic Dosing of Opioids for Pain Management, for help.
  • Use a low opioid dose and combine with non-opioids.1
  • For patients admitted on a long-acting opioid, add a short-acting opioid or non-opioid for acute pain instead of increasing the dose of the long-acting agent.6,13
  • If using patient-controlled analgesia, omit the basal rate for opioid-naive patients, and use a lockout of 10 min.6 Transition to oral as-needed analgesics as soon as the patient is tolerating oral fluids and advancing diet.6

 

Promote opioid safety at transitions of care (AT ADMISSION).

  • Train nurses to examine patients for opioid patches (i.e., fentanyl, buprenorphine) on admission.6 After confirming that the patient has been using it correctly, replace it and date the new patch.6
  • Get an accurate med list, including all opioids that the patient is taking, to determine baseline opioid requirements. Sources of information include family members, the outpatient prescriber(s) and pharmacy, and prescription drug monitoring program(s). Keep in mind that the patient may be taking more or less of what has been prescribed.6
  • Identify chronic opioid users who are being tapered, and help them continue their opioid taper in the hospital.
  • Identify patients taking meds for opioid dependence; there are special considerations for acute pain treatment in these patients. Also, do not rely solely on patient report of methadone dose; confirm with patient’s opioid treatment program and notify them of the admission.9 Patients can usually continue their buprenorphine or methadone during hospitalization, even if they are receiving other opioids.9

 

Promote opioid safety at transitions of care (AT DISCHARGE).

  • Review inpatient opioid use and assess the need for a discharge opioid prescription.
  • Limit discharge opioid quantities for acute pain. Most patients will end up not taking more than a few pills, and will have leftovers.2 Twenty pills are more than plenty for post-op pain after many common surgical procedures.4
  • Advise patients of opioid side effects (e.g., respiratory depression, effects on driving, interactions with central nervous system depressants [e.g., alcohol, benzodiazepines], tolerance, physical dependence, withdrawal, constipation, nausea).3
  • Educate patients and caregivers on proper opioid use, storage, and disposal.5 Provide a timeline for tapering off opioids, or back to baseline opioid use for patients taking chronic opioids.6
  • Before discharge, identify and communicate with the provider who will be managing the patient’s pain and prescribing opioids.6 This might be the patient’s primary care provider, or a pain specialist, depending on patient needs and the comfort level of the primary care provider.6
  • Prescribe naloxone for patients at risk of overdose. See our chart, Naloxone for Opioid Overdose (FAQs) for help.
  • If needed, refer patients for opioid dependence treatment.5 Hospital leadership should keep abreast of community resources.5
  • For patients admitted on meds for opioid dependence, before discharge, contact outpatient prescriber to discuss: (1) meds received during hospitalization, (2) meds that will be prescribed at discharge, (3) any dosage change in their opioid dependence med, and (4) strategy for restarting opioid dependence med if it was held. Experts recommend that buprenorphine be restarted before discharge, when possible.9

 

Abbreviations: EHR: electronic health record; ISMP = Institute for Safe Medication Practices

Prepared by the Editors of Therapeutic Research Center (361024).

References

  1. Herzig SJ. Web exclusive. Annals for Hospitalists inpatient notes - managing acute pain in the hospital in the face of the opioid crisis. Ann Intern Med 2018;169:HO2-3.
  2. Wetzel M, Hockenberry J, Raval MV. Interventions for postsurgical opioid prescribing: a systematic review. JAMA Surg 2018;153:948-54.
  3. Dowell D, Haegerich TM, Chou R. CDC Guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep 2016;65:1-49.
  4. Overton HN, Hanna MN, Bruhn WE, et al. Opioid-prescribing guidelines for common surgical procedures: an expert panel consensus. J Am Coll Surg 2018;277:411-8.
  5. The Joint Commission. Pain assessment and management standards for hospitals. August 29, 2017. https://www.jointcommission.org/assets/1/18/R3_Report_Issue_11_Pain_Assessment_8_25_17_FINAL.pdf. (Accessed September 13, 2020).
  6. Frederickson TW, Gordon DB, DePinto M, et al. SHM’s Center for Hospital Innovation and Improvement. Reducing adverse drug events related to opioids implementation guide. 2015. http://www.chpso.org/sites/main/files/file-attachments/reducing_adverse_drug_events.pdf. (Accessed September 14, 2020).
  7. Drew DJ, Gordon DB, Morgan B, Manworren RCB. “As-needed” range orders for opioid analgesics in the management of pain: a consensus statement of the American Society of Pain Management Nurses and the American Pain Society. Pain Manag Nurs 2018;19:207-10.
  8. 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;178:759-63.
  9. Substance Abuse and Mental Health Services Administration. Medications for opioid use disorder. Treatment Improvement Protocol (TIP) series 63. Publication No. PEP20-02-01-006. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2020. https://store.samhsa.gov/product/TIP-63-Medications-for-Opioid-Use-Disorder-Full-Document/PEP20-02-01-006. (Accessed September 13, 2020).
  10. Phelps P, Achey TS, Mieure KD, et al. A survey of opioid medication stewardship practices at academic medical centers. Hospital Pharmacy 2019;54:57-62.
  11. Brandal D, Keller MS, Lee C, et al. Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: a historical-prospective study. Anesth Analg 2017;125:1784-92.
  12. ISMP. Survey shows room for improvement with two new ISMP targeted medication safety best practices. July 29, 2020. https://www.ismp.org/resources/survey-shows-room-improvement-two-new-ismp-targeted-medication-safety-best-practices. (September 14, 2020).
  13. Sorboro J. Health Services Advisory Group. March 25, 2020. https://www.hsag.com/contentassets/b296c7e560164cb9a382018d98421e87/march25opioidworkgroup_final.pdf. (Accessed September 14, 2020).
  14. Meisenberg B, Ness J, Rao S, et al. Implementation of solutions to reduce opioid-induced oversedation and respiratory depression. Am J Health Syst Pharm 2017;74:162-9.

Cite this document as follows: Clinical Resource, Opioid Stewardship Checklist. Hospital Pharmacist’s Letter/Pharmacy Technician’s Letter. October 2020.