Last month, the research round-up provided you with an overview of articles on prescribing of proton pump inhibitors. This month we will be reviewing articles on opioid stewardship. The first article looks at the barriers and promotors of implementing an opioid stewardship programme. The second reviews the clinician's perspective of an opioid stewardship programme in the areas of acute pain management. Finally, we will examine an appraisal of the implementation of an opioid stewardship programme in the primary care setting.
Perioperative opioid stewardship program: barriers and promotors of implementation and sustainability
This article, published in Global Implementation Research and Applications, sought to uncover the perceived barriers and promoters of implementing a perioperative opioid stewardship programme in three health services in Melbourne, Australia. The three sites were chosen as they shared electronic medical records and had introduced a perioperative opioid stewardship programme at the same time.
‘The introduction of an opioid stewardship programme was an essential mechanism for harnessing the benefits of adequate analgesia and mitigating harm in the perioperative period’
Recruitment was delayed due to the COVID-19 pandemic and the stewardship programmes had been running for 18 months at the time of recruitment. This study used a semi-structured approach and recruited 20 participants between October 2021 and May 2022. Interviews were a mean of 30 minutes in length and covered areas including participants' roles and health service, awareness of opioid stewardship programme, introduction of the programme and its components, their perceptions of change and implementation, and any recruitment suggestions. The participants included specialist pain medicine physicians, anaesthetist managers, pain nurses, pharmacists and junior doctors.
After analysis and coding, themes elucidated included patient needs and resources, discharge communication, leadership and culture, knowledge and beliefs, patient and provider education and hospital–community prescriber communication. These themes were then mapped to the four pillars of the opioid stewardship programme and finally classified as barriers or promotors.
The study goes on to describe the main findings around the four pillars, these being discharge prescription guidelines, patient education, provider education, and discharge communication. They additionally looked at themes of programme implementation and, sustainability and optimisation.
The study found that participants were generally aware of perioperative opioid stewardship principles, but that senior clinicians had greater specific knowledge. Adherence to the discharge opioid prescription guideline was promoted by hospital leadership and workflow integration. A universal barrier to programme adherence was found to be lack of resourcing. Additionally, role clarity inconsistencies were seen as a barrier to patient discharge opioid education. Discharge communication was variable but often limited to discharge summaries rather than a comprehensive, personalised approach.
The researchers conclude that the introduction of an opioid stewardship programme was an essential mechanism for harnessing the benefits of adequate analgesia and mitigating harm in the perioperative period. They also suggest that their findings increase the understanding of promotors and barriers and could influence the continuation of existing stewardship programmes or inform the roll-out of new programmes to achieve good opioid stewardship while minimising risk.
Clinicians' perspective of the opioid analgesic stewardship in acute pain clinical care standard
This article, published in Health Policy and Technology, aimed to investigate clinicians' perspectives of an opioid stewardship programme in an acute pain setting. This Australian study employed qualitative one-to-one interviews with doctors, pharmacists, nurses and patient safety officers responsible for medication safety and opioid use using a convenience and purposive approach.
Online semi-structured interviews lasted between 30 minutes and 1 hour and used an interview guide informed by the Consolidated Framework of Implementation Research. Interviews covered areas leading to main themes of organisational priorities, organisational capacity for implementations, changing prescribing practices, and the opioid stewardship standard.
On analysis, each of these revealed subthemes that emerged during the interview process. In total, 32 clinicians from 26 sites across Australia were interviewed, with 18 of those by convenience sampling and 14 by passive snowballing. Of these, 10 were doctors, 10 pharmacists and 12 were nurses. Demographic data revealed that 78% were female and the geographical split was 59% from New South Wales, 19% from Victoria, 9% from Western Australia and 6% from Queensland.
Results were discussed in themes with reference to subthemes, and participant quotes were included for many points. With regard to organisational priority, it was found that clinicians felt the stewardship standard was an important factor for programme implementation and buy-in to allow for allocation of resources. In the organisational capacity theme, clinicians perceived that their organisation's capacity was a major factor in programme success and that areas with COVID fatigue and overloaded services were barriers to successful integration.
Under the umbrella theme of changing prescribing practices, several factors were identified, including prescriber attitudes and time pressures. Clinicians did, however, say this was mitigated by the availability of the opioid stewardship standard. Another subtheme was around resources and education of prescribers around pain management. An important consideration in this theme was patient expectation around their pain management and this can put pressure on the prescriber.
The final theme around the opioid standard itself revealed considerable clinician support and it being regarded as a benchmark in acute care. Clinicians were concerned about the evidence base supporting it and that the lack of robust data may prevent effective implementation. It was also commented that the scope of the standard was not sufficient to cover the extent of the opioid prescribing issues.
The authors conclude the results of this study demonstrate that clinicians supported the opioid stewardship standard but were unsure if there were issues in their local organisation or how to implement them. They felt that local data was important to facilitate implementation by assisting with organisational readiness and capacity. They suggest that education is an important aspect, and that future studies should evaluate the impact of such strategies on implementation.
Influence of implementing an opioid stewardship team in the primary care setting
This article, published in Hospital Pharmacy, set out to assess reduction in morphine milligram equivalents (MME) from baseline to 6 months of inpatient opioid doses after an educational intervention to the medical team by opioid stewardship clinicians and to assess any changes in naloxone prescriptions.
This American multi-site primary care-based study, where an interprofessional opioid stewardship team was created to target high-risk opioid prescribing and improve practice, was conducted over 30 primary care sites in one health system across West Michigan between April 2021 and May 2022. The opioid stewardship team included two physicians, three pharmacists, a project operations manager, and IT support. Interventions included creation of a dashboard, provider education, dissemination of policy, and chart audits.
Using the electronic health record dashboard, patients on chronic opioid doses ≥90 MME daily or missing an active naloxone prescription were identified. Primary care providers were provided with an individual list of patients for whom to consider intervention. Support was provided for prescribers, but the team did not interact with patients directly. A total of 290 patients to be followed up were identified.
Results showed that there was a significant reduction in MME from baseline to 6 months in the overall study population. At 6 months, 181 patients had been given a prescription for naloxone vs 108 who had one at baseline; this was also a significant change.
The authors report that the process of providing education and resources resulted in a significant change in MME dosages prescribed to the study population over the 6 months of study. This is a scalable approach that could be integrated into existing healthcare models using available medical and pharmaceutical expertise and technology.
The authors acknowledge that the study was limited by involving only a single system and focusing on primary care, limiting generalisability to other patient populations, practice settings and medical specialties.
They conclude that future research studies could assess the range of opioids used, patient-specific information including pain scores, and patient and provider perceptions.
Conclusion
The concept of opioid stewardship is fairly new, but one that is growing in importance and pace. The so-called ‘opioid crisis’, referring to the rapid increase in the overuse (and misuse) of opioids and the relationship to deaths involving these drugs, has focused the healthcare arena on this issue and looked at ways to manage and mitigate the crisis, both in the UK and globally.
This public health crisis has had a significant impact on many areas including health, crime and society, and is known to be an economic burden. Government statistics from April 2023–March 2024 show that of the 310 863 adults in England in contact with drug and alcohol treatment services, 44% (137 965) of these did so because of opioid use (Office for Health Improvement and Disparities, 2024), making this the largest single group in the review. This highlights the need for prescribers to be aware of this issue and of strategies, such as opioid stewardship, to help reduce these numbers.