Background: Therapeutic duplication is the practice of prescribing multiple medications within the same class without a clear indication to use one over the other. Also referred to as “drug stacking”, this prescribing behavior is a violation of Joint Commission standards and leads to adverse opioid events such as increase risk of falls, respiratory failure, and death. Even when ordered appropriately, opioids are considered “high risk” analgesics and are one of the most common causes of adverse drug events during a hospital stay
Purpose: The goal is to help providers minimize therapeutic duplication of opioids in the hospital setting and decrease related adverse drug events.
Description: The research team reviewed all inpatient cases at Regions Hospital (a level 1 trauma center with ~450 beds in St. Paul, MN) where a patient received intravenous narcan during stays from 2011-2013. In 397 charts, therapeutic duplication of opioids was demonstrated in 39% of those reviewed; transfer to a higher level of care was seen in 15%. Nine falls were observed during this period, and five deaths were primarily attributed to excessive narcotic use.
An interdisciplinary team of physicians, nurses, and pharmacists proposed interventions to affect prescribing practices. An emphasis was placed on differentiating acute pain from chronic pain or a chronic pain flare. This distinction allowed for a pain management module to be developed and integrated into the EMR listing pain medications used by class, i.e. PO vs. IV, short-acting vs. long-acting, mild vs. moderate vs. severe pain indications. This integration allowed a phasing out of therapeutic duplication by limiting prescribers’ ability to select more than one medication per class. Education regarding the order set changes was implemented for ordering providers, pharmacists, and nurses.
Conclusions: Data is being collected since the changes to the EMR narcotic orders. We plan to compare the number of adverse events, including number of naloxone administrations, to those before the intervention. Although numbers for recent adverse drug events are not currently available, the preliminary data is showing decreased naloxone use.