Background: Hospitalists are at the forefront of the opioid epidemic. Over half of hospitalized patients are exposed to opioids during their admission, most of whom are opioid naïve.1 Patients discharged on opioids have a 15% chance of long-term use after one year.2 There is significant variation in provider opioid prescribing practices, even within the same hospital system.3 Recently, there has been an increase in initiatives targeting inappropriate opioid prescriptions, from guidelines created by the Society of Hospital Medicine to stewardship programs within single institutions.4,5,6 However, interventions within hospital medicine in the US are lacking.

Methods: We created an Inpatient Opioid Stewardship Program to improve opioid prescribing practices on our hospitalist-staffed general medicine service (GMS). Our intervention included forming a multidisciplinary team that created inpatient opioid prescription guidelines for opioid naïve patients, education to clinicians, nurses, pharmacists, and patients, and real-time feedback to providers when their orders were outside the guidelines. We collected data from November 2019 to July 2020 as our pre-intervention control period, and from August 2020 to February 2021 for our post-intervention period. 746 opioid naïve patients admitted to GMS with acute non-cancer pain-related diagnoses were included in our control group, and 143 patients post-intervention. For our statistical analysis, we ran multivariable negative binomial regression models for total MME (morphine milligram equivalent) per admission, MME/day, IV opioid MME per admission, and number of days of use of any opioid sparing medication per total length of stay. We used logistic regression for proportion of patients who were ordered opioid-sparing medications around the clock. We adjusted our results for language, race, gender, insurance, and age.

Results: The mean MME per admission decreased by 64%, from 49.0 pre-intervention to 17.8 post intervention (adjusted incidence rate ratio, 0.36 [ 95% CI, 0.10, 1.33], p=0.13; Figure 1).The mean MME/day decreased from 6.6 to 2.7 (adj. IRR 0.41 [95 % CI, 0.14,1.14], p=0.09). The mean IV opioid MME per admission decreased from 14.2 to 6.2 (adj. IRR, 0.44, [95% CI, 0.07, 2.64], p=0.37). The use of opioid-sparing medications around the clock increased from 0.42 to 0.52 (adj. odds ratio 1.55, [95% CI, 0.83,2.91], p=0.17; Figure 2). The use of opioid-sparing medication days per length of stay decreased slightly from 0.57 to 0.55 (adj. IRR 0.97, [95 % CI, 0.66,1.44], p=0.90).

Conclusions: Our study demonstrates that an intervention targeting opioid naïve patients admitted to the general medicine service has potential to decrease the use of opioids and intravenous opioids and optimize scheduled use of opioid-sparing medications. Although our results were not statistically significant, we did observe a trend towards reduction in opioids given. We believe our results may not be statistically significant due to reduced numbers of eligible patients post-intervention during the COVID-19 pandemic, when hospital occupancy was reduced. Barriers to implementation included competing priorities due to the pandemic. At this time, our guidelines are incorporated into an EHR safety dashboard, replacing real-time email feedback. Further efforts should focus on sustaining progress as hospital operations return to normal.

IMAGE 1: Figure 1- Pre and Post Intervention results

IMAGE 2: Figure 2- Pre and Post Intervention results