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Why hospitals should take a good look at how opioids are being administered to patients

A new study by Yale researchers published in JAMA indicates IV dosing could be more addictive but a pill or injection curbs pain just as well.

Beth Jones Sanborn, Managing Editor

Hospitals that frequently administer opioids intravenously may want to take a second look at that method, as a new study from Yale researchers published in JAMA indicates other approaches may curb side effects and potential addiction while relieving pain just as effectively. 

The takeaway: Changing how clinicians administer such medications might mean fewer dire patients in their emergency departments down the road.  

Hospitals typically administer opioids in three forms: pills, injections and via IV. Researchers said that the intermittent, spiking manner in which an IV dose delivers the drug to the body, also known as pharmacokinetics, is similar to the pattern known to drive addiction. 

In other words, IV dosing might trigger potential opioid addiction more readily than other delivery methods. It also can create greater risk of side effects such as euphoria, nausea and hypotension, the researchers said.

[Also: Opioid epidemic: Here's one more way it's costing hospitals millions]

During a three-month period, researchers orchestrated the implementation as a 2-part quality improvement initiative with the physicians and advanced practice clinicians in an unnamed 28-bed general adult medical inpatient unit in a large academic medical center. Roughly 127 patients were involved. 

First, an opioid standard of practice was established stipulating that oral administration of included drugs was preferred for patients tolerating oral intake. For patients who could not take the drugs orally, subcutaneous administration was preferred, specifically injection over use of an IV. Notably, prescribers were not prohibited from ordering any drug or intake route as part of this investigation. Through "targeted education" prescribers were informed of the new local standard of practice and nursing staff were encouraged to actively question orders that did not align with the preferred standard.

Additionally, email reminders regarding the new standard were sent out at the two and four-week markers and part of a twice-daily nursing "huddle" that was in practice before the study, reminders and reinforcement of the standard were given by nursing leadership for two weeks before it was implemented.

Results of the study showed that intravenous opioid use dropped by 84 percent during the study period, and prescribers still ordering non-oral delivery of the drugs prescribed injections 65 percent of the time, compared to minimally during a six-month control period. The combined amount of opioid doses given via injection or IV dropped by 55 percent.

At the same time, mean pain scores were either similar or actually showed improvement during the first five days of hospitalization compared with the control period.

Researchers admitted the three-month pilot project was limited in that it was conducted with only one inpatient medical unit in one hospital.

However, the model could be applied to other settings, including specialties. 

"Creative thinking by healthcare providers and institutions, including hospitals, about how and when we use opioids may help address the crisis we see today. Our research shows a project that might be helpful to other hospitals. Healthcare is a team sport and hospitals, as part of that team, can play a key role in addressing the opioid crisis. We just need to think creatively, and we hope our paper helps move that conversation forward," said Robert Fogerty, associate professor of medicine at Yale University and co-author of the study.

With the wildfire-like ravaging of the opioid epidemic throughout the country, historical rampant prescribing methods and overexposure have come under fire as having fed the crisis. Hospitals have started examining and re-writing prescription policies for opioids in an effort to scale back the number of patients exposed to the drugs at all. 

But since opioids are an effective pain treatment, especially in the perioperative setting, if the drugs are to be administered, hospitals may do well to consider whether the manner in which they are given could also play a role in potential addiction and the prevention thereof. About 115 Americans die every day from drug overdoses according to the National Institute on Drug Abuse and prescription opioids and synthetic drugs like fentanyl killed more than 42,000 people in 2017 according to the CDC.  

Recently, New Hampshire hospitals pledged $50 million over five years to combat addiction, including opioids, in partnership with the state. Governor Chris Sununu said the $50 million pledge was the single biggest secured financial investment the state has ever achieved in funding substance use disorder programs. New Hampshire has been one of the hardest hit states in the opioid abuse epidemic.

The CDC also recently announced that it would shell out $15 million in funding for research projects that develop and pilot or thoroughly evaluate preventive interventions for opioid overdoses. 

A study published in March in the journal Pediatrics showed the impact of opioid addiction on infants, stating that in 2014 the number of babies born with neonatal abstinence syndrome spiked to 14.4 per 1000, up from 2.8. Medicaid covered 80 percent of those births, $462 million in 2014 alone, researchers said.

Twitter: @BethJSanborn
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