PGY2 Pharmacy Resident South Texas Veterans Health Care System Getzville, New York
Abstract Title: Evaluation of Opiate Usage for Acute Non-surgical Pain
Background: The majority of patients experience acute pain at some point during hospitalizations.1Existing pain management literature, with respect to the inpatient realm, is focused on trauma, surgical, and oncological patients. In 2020, approximately 45 deaths per day involved prescription opioids.2,3 Opioid use disorder and associated overdose deaths have been linked to increased opioid prescribing.4 In the opposite vein, uncontrolled pain has been linked to worsening of patient outcomes and increased healthcare costs. A lack of evidence-based guidance makes acute pain management a challenging area for clinicians.5-7 While a multi-modal approach to pain management in the post-operative period is established as an effective approach to reduce opioid consumption, acute pain management for medical inpatients is not.8-14 Acute pain is more complex than previously realized and its effective treatment is of greater importance necessitating evaluation of acute pain management.15 Unlike other patient populations, the treatment of acute pain for medical inpatients remains without formal guidance or performance measures.
Purpose/Objectives: To identify opportunities to improve acute pain treatment through multi-modal analgesic approaches by describing opioid utilization in an inpatient setting, characterizing opioid vs. non-opioid utilization, and describing quantities of opioids provided on discharge prescriptions. The objective is to identify daily and total opioid consumption amongst groups receiving multi-modal pain treatment compared to groups which receive only opioids with the assumption that multi-modal groups will receive lesser morphine equivalents (MME). Such observations may advocate for the necessity of introducing an opioid stewardship program to improve allocation of pain medications.
Methods: A retrospective chart review of inpatient non-surgical adults admitted to a large inpatient institution with opioid orders. Collection of availability and utilization of non-opioids, MMEs received, pain score documentation, and pain prescriptions prescribed at discharge. Exclusion criteria included post-operative pain, sickle cell disease, cancer pain, and chronic pain.Study variables included demographics (age and sex), length of stay, medical history and pain diagnosis, opioid use (drug, dose, formulation), concurrent non-opioid medication use, documented pain score assessments, and discharge prescription data (opioid prescription). Ad-hoc power analysis determined 224 patients were required to meet 90% power to detect a 30% difference between cohorts. Data was randomly collected from 240 patients divided evenly into opioid only (O) and multi-modal (M) groups over a six-month period from January to June of 2023. From the acquired data, MMEs were calculated and compared to identify significant differences in daily opioid consumption. Secondary comparative analyses were performed to assess total MME consumption and subgroup analyses of daily and total MME consumption amongst male, female, elderly (≥65), and younger (< 65) cohorts. Data was analyzed using one-tailed Wilcoxon-Signed-Rank, Mann-Whitney U, and Pearson χ2 tests to detect significant differences in daily and total MMEs defined as p ≤ 0.05.
Results: The average age of the study population is 60.49 years which received a cumulative average MME of 105.65 (5-1963.5) over an average length of stay of 9.53 days equaling an average daily MME of 18.22 (0.11-585). Pain score assessments were not collected due to inconsistent and inaccurate recordings. Analysis of daily MME identified greater opioid consumption trends amongst all O cohorts, however, the dosing differences were deemed insignificant (p=0.28) with similar trends amongst all subgroups. Incidentally, the O cohort’s total MME was lesser than the M group’s (94.33 (5-1520) vs. 116.96 (5-1963.5)) identified as a significantly observed difference (p=0.02). Although the subgroups were not powered, significant differences in total MMEs were observed in the male (p=0.01) and < 65 (p=0.02) cohorts. There were no significant differences in total MMEs observed in the female and elderly cohorts. Discharge pain prescription orders were analyzed for 139 patients to identify preferences for either opioid or non-opioid pain medications. Analysis of results revealed no preference (p=0.65) for converting patients to either an opioid or non-opioid pain regimen upon discharge.
Conclusions/Implications for future research and/or clinical care: Based on the analysis, a greater daily MME was observed for the O cohorts compared to the M groups which supports the original hypothesis that multi-modal analgesic dosing would be result in fewer daily MMEs than an opioid only regimen. The results of this study provide an opportunity for the creation of an opioid stewardship program to improve utilization of opioid and multi-modal analgesics in an acute care setting to maintain low daily opioid consumption, taper opioid throughout an inpatient stay, and promote conversion to non-opioid multi-modal regimens upon discharge.
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