Last year in the United States, opioid overdoses were responsible for some 80,000 deaths, according to the National Institutes of Health (NIH). With roots that stretch back to the 1990s, the opioid epidemic is much bigger than any one health system in any one state. However, Alabama has led the country in opioid dispensing for over a decade, so health systems in our state do have an opportunity to make a big impact.
The UAB Opioid Stewardship Program has made significant strides in addressing the oversupply of prescribed opioids in our communities by reevaluating prescribing and pain management practices for hospitalized patients. This collaborative work has taken over 1 million pills out of circulation, and it points the way toward better practices through sharing data and treating pain in multiple ways, known as multimodal treatment.
The dangers of opioid dependency are well-publicized, and even more dangerous drugs like fentanyl compound the issue of deaths from overdose. But the volume of prescriptions is alarming for another reason beyond community safety: Opioids alone are not enough to provide optimal pain relief and may not be what is needed in some cases.
The Opioid Stewardship Program focuses on inpatient and discharge pain practices and patient education by partnering with individual patient care teams. The results are promising for patients and our community.
“The goal of the UAB Opioid Stewardship Program is to provide safe and effective pain management for all of our patients,” said Juhan Paiste, M.D., MBA, CPE, chair of the program. “By using multimodal approaches that include prescribing opioids when needed for the shortest anticipated duration, UAB is helping mitigate risk and prevent harm from unnecessary opioid administrations or prescriptions.”
The big picture
The program was created in 2019 to support and advocate for safe, effective, patient-centered pain management and opioid prescribing practices. It has dedicated leadership and an interdisciplinary executive committee with representation from across UAB Medicine.
“From our patient-first perspective, the goal is to optimize pain relief using the most effective modalities – including opioids, when needed – at the lowest effective dose,” said Opioid Stewardship Manager Laura Leal, MSN, RN, CNL. “This approach should improve patients’ pain experiences while also reducing the oversupply of opioids.”
The program’s executive committee began by reviewing literature, identifying and assessing the current state of opioid prescribing, and developing best practice guidelines for acute pain using multimodal pain management, including non-medication therapies. It then created data platforms to identify opportunities and monitor changes being implemented. “We meet teams where they are, share data, and empower them to make improvements for patients in a way that works for the staff,” Leal said.
Opioid Stewardship Pharmacist Elise Dasinger, PharmD, MHA, said the committee focused on acute pain first, recognizing that it could make the biggest immediate difference with inpatient opioid use and discharge prescriptions.
“In 2019, patients who received an opioid prescription at discharge for acute pain received an average of 30 pills per prescription,” Dasinger said. “Through a series of quality improvement initiatives since that time, we have decreased the overall average to 22-23 pills per opioid prescription. With thousands of prescriptions written each month, that is a dramatic reduction of over 1 million pills – not to mention the prescriptions that have not been written due to our efforts.”
Multimodal treatment
If patients are being prescribed fewer opioids, are they still getting pain relief? Multimodal pain management fills the gap left by fewer opioids being used and results in better outcomes.
“Pain is felt in different ways, and pain relief is optimized with individualized treatment plans, so we are changing the culture and the association that pain relief only comes from opioids,” Leal said. “This effort begins with members of the care team educating patients on both non-opioid medication and non-pharmacologic treatment options.”
Leal added that the goal of the Opioid Stewardship Program is not to go from one extreme to the other but to find a balance that provides maximum pain relief to patients while minimizing the need for opioids.
Within the program’s acute pain management best practice redesign, it developed a non-pharmacologic menu to help members of the care team educate patients and make needed referrals or set up consults with UAB Medicine physical therapists, occupational therapists, spiritual counselors, music therapists, Arts in Medicine providers, and more. The program further encourages the use of nursing care items when appropriate, such as ice, heat, repositioning, and distraction (coloring, games, music).
“Non-pharmacologic options can empower patients, giving them control in determining what works for them,” Leal said.
Partnership approach
UAB Medicine stakeholders across different medical backgrounds back the mission of the Opioid Stewardship Program. Early partners included Gynecology/Oncology, kidney transplantation, and Cardiovascular Surgery.
“We took great care to build best practice guidelines as a team, and we have used these as a foundation that can be modified to meet specific patient population needs,” Dasinger said. “Once we facilitate data-sharing with different services, prescribers and staff have the ability to create their own initiatives.”
The program team regularly presents to UAB Medicine’s House Staff Council, a body that serves as the voice of residents and fellows throughout the hospital. The work to bring general awareness to the over-prescribing of opioids and make multimodal pain management part of the culture will be taken up by these doctors-in-training.
“One million pills is only the tip of the iceberg,” Dasinger said. “We are already beginning to work with our ambulatory clinics to provide resources and share data. We are laying the groundwork to help teams better manage pain.”