Glen Brown
The devastation imposed on Canadians’ lives by the consequences of inappropriate, excessive, or unquantified opioids has been well described and well publicized in recent years. These detrimental consequences of opioids across multiple facets of society have forced all stakeholders to examine their practices in the provision of opioids to Canadians, including those individuals with an obvious need for adequate analgesia. The Canadian Society of Hospital Pharmacists (CSHP) has responded to the challenge of the opioid crisis by engaging its members in reflection and action on methods by which Canadian hospital pharmacists can contribute to minimizing the potential for inadvertent or inappropriate opioid access. A previous editorial in the Canadian Journal of Hospital Pharmacy (CJHP) highlighted the need for Canadian hospitals, and their associated pharmacy departments, to scrutinize their opioid-handling processes and resolve weaknesses that could facilitate drug diversion, and described potential mechanisms for doing so.1 CSHP has produced a 47-page guideline to assist pharmacy departments in securing the drug distribution network.2 Now, the challenge lies in optimizing opioid therapy for the treatment of pain in individual patients, both within and beyond our institutions. How can we identify the individual patients, the populations of patients, and the settings where opioid use is inappropriate, excessive, or ripe for opioid diversion?
Such a review of opioid stewardship practices within individual institutions may seem like a daunting task, but resources are becoming available to assist in identifying patients at risk. Elsewhere in this issue of CJHP, Woods and others3 describe development of a tool to identify patients within various care areas of the hospital who would be at risk of adverse outcomes from opioids. They report that practising pharmacists found the tool—which described risk factors for adverse outcomes from opioids and corresponding potential interventions to minimize risk—useful but potentially challenging to incorporate into their daily practice.3 Hopefully, these investigators will assess the impact of this tool on opioid use within their institution and share their findings in a future article. This is but one example of the tools and other resources that are now available for establishing or enhancing an opioid stewardship program.
For maximum impact from stewardship initiatives, institution-wide or health system–wide coordination of key clinicians, administrators, and quality assessment personnel is required. Two recently published articles provide thorough discussions, with examples, of the administrative structure, involved disciplines, and recommended tasks for achieving the desired change in the culture of opioid use in a health care setting.4,5 Pharmacists should not, and cannot, face the challenge of opioid stewardship alone; rather, we should utilize our expertise in pain management, drug therapy optimization, and education of clinicians and patients to assist the whole care community in the use of opioids. The authors of these 2 articles suggest that any stewardship program should, where possible, explore and adopt methods for using non-opioids as first-line analgesics, and establish processes (for drug selection, dosages, durations, routes, and discontinuation) for optimum use of any opioid therapy that is deemed essential.4,5
Strategies for using non-opioids for initial treatment of pain require agreement from all disciplines involved in the care of patients experiencing various painful conditions. Pharmacists can participate in, and potentially lead, the review of indications for and efficacy of non-opioids for the treatment of specific conditions. Through their evaluation of the published literature and their skillful provision of education, pharmacists are key contributors in achieving consensus among clinicians regarding the utility and efficacy of non-opioid treatment.
Pharmacists can also be key contributors in identifying methods to minimize the exposure of individual patients to opioids during their interactions with health care institutions. Such processes could involve utilizing the pharmacy distribution system to identify patients who are receiving more than one opioid by the same route at the same time. For inpatients, limiting the magnitude of dosage ranges, limiting initiation of parenteral administration to specific scenarios, and enhancing vigilance in administration of long-acting opioid formulations (patches or sustained-release oral dosage formulations) are examples of processes that pharmacists could undertake to reduce the risk associated with any obligatory opioid use.6 Alternatively, a pharmacist’s review of the quantity of opioid provided upon discharge may identify opportunities to reduce opioid exposure, although this approach has not been successful in all settings.7 A group of pharmacists in Minneapolis, Minnesota, have published a thorough description of the expectations for review of all opioid treatments by pharmacists within their institutions,6 which can serve as a good starting point for Canadian pharmacists wishing to establish realistic expectations of engagement.
Pharmacists can also influence opioid use through educational activities for providers and patients. Researchers from London, Ontario, demonstrated that education of clinicians and patients, in conjunction with established analgesic strategies, can reduce opioid requirements after various types of surgery.8,9 Pharmacists’ educational offerings could cover the topics of pain assessment, treatment regimens, and safe storage and disposal of narcotics.4 Education of patients about the appropriate outpatient use of naloxone and instruction in methods to identify and resolve symptoms of opioid withdrawal are additional areas that could benefit from pharmacists’ expertise.5
The need for intervention is great, and the diversity of interventions is wide. Now is the time for pharmacy departments and individual pharmacists to encourage their care communities (hospitals or heath care networks) to establish and implement effective strategies for opioid stewardship. Once launched, such initiatives are doomed to fail unless processes are established for the ongoing measurement and evaluation of the impact of these efforts on opioid use.7 Clinicians from Houston, Texas, recently published their recommendations, along with some commentary by other clinicians, for 19 quality indicators that would be useful in measuring the ongoing, sustained effects of opioid stewardship activities.10 All Canadian institutional pharmacists are encouraged to move from discussion of potential benefits to implementation of actions to optimize the use of opioids for their patients. In lay terms, it’s time for “the rubber to hit the road”. As you gain experience in this area, please measure your successes and failures, and tell others about your techniques so that we can all learn the “how” of opioid stewardship.
1 Chant C. Diversion inattention: time for action [editorial]. Can J Hosp Pharm. 2019;72(3):171–2.
2 Controlled drugs and substances in hospitals and healthcare facilities: guidelines on secure management and diversion prevention. Ottawa (ON): Canadian Society of Hospital Pharmacists; 2019 [cited 2019 Nov 26]. Available from: https://www.cshp.ca/guidelines
3 Woods B, Legal M, Shalansky S, Mihic T, Ma W. Designing a pharmacist opioid safety and intervention tool. Can J Hosp Pharm. 2020;73(1):7–12.
4 Perrone J, Weiner SG, Nelson LS. Stewarding recovery from the opioid crisis through health system initiatives. West J Emerg Med. 2019;20(2):198–202.
5 Weiner SG, Price CN, Atalay AJ, Harry EM, Pabo EA, Ratel R, et al. A health system-wide initiative to decrease opioid-related morbidity and mortality. Jt Comm J Qual Patient Saf. 2019;45(1):3–13.
6 Ghafoor VL, Phelps PK, Pastor J, Meisel S. Transformation of hospital pharmacist opioid stewardship. Hosp Pharm. 2019;54(4):266–73.
7 Villwock JA, Villwock MR, New J, Ator GA. EMR quantity autopopulation removal on hospital discharge prescribing patterns: implications for opioid stewardship. J Clin Pharm Ther. 2019. DOI: 10.1111/jcpt.13049. [Epub ahead of print.]
8 Hartford LB, Van Koughnett JAM, Murphy PB, Vogt KN, Hilsden RJ, Clarke CFM, et al. Standardization of outpatient procedure (STOP) narcotics: a prospective non-inferiority study to reduce opioid use in out-patient general surgical procedures. J Am Coll Surg. 2019;228(1):81–8.
9 Hartford LB, Van Koughnett JAM, Murphy PB, Knowles SA, Wigen RB, Allen LJ, et al. The standardization of outpatient procedure (STOP) narcotics: a prospective health systems intervention to reduce opioid use in ambulatory breast surgery. Ann Surg Oncol. 2019;26(10):3295–304.
10 Risk E, Swan JT, Cheon O, Colavecchia AC, Bui LN, Kash BA, et al. Quality indicators to measure the effect of opioid stewardship interventions in hospital and emergency department settings. Am J Health Syst Pharm. 2019; 76(4):225–35.
Competing interests: None declared. ( Return to Text )
Canadian Journal of Hospital Pharmacy, VOLUME 73, NUMBER 1, January-February 2020