Background: Opiates, frequently used to provide analgesia, are associated with post-analgesia related tolerance effects such as hyperalgesia and hyperkatifeia, which lead to worsening of the pain experience. Patients can subsequently experience dissatisfaction with their care and seek further opiate use as a solution, worsening their experience further. Due to pharmacologic and healthcare-associated operational factors, the intravenous (IV) push route may be associated with increased hyperalgesia and hyperkatifeia compared to other methods of opiate administration.
Purpose: We hypothesized that minimization of IV push opiate use amongst patients hospitalized for general medical care would lead to improvements in patients’ experience of pain, memory of pain experience, and decreased length of stay (LOS).
Description: On 19 June 2017, a pharmacy level hard stop on orders for IV push opiates was implemented on a thirty bed hospital medicine ward unit at an urban, tertiary care academic hospital. Group-wide agreement to proceed with the order hard stop was obtained from hospitalists prior to implementation. One-time orders for IV push opiates for any clinical reason were allowed, as well as higher frequencies of IV push opiates for patients under hospice goals of care or with clinical conditions which required IV opiates but prevented use of a patient controlled analgesia (PCA) pump. All other orders for IV push opiates were voided by Pharmacy and not administered. Healthcare providers were otherwise allowed to exercise routine clinical discretion and administer opiates via any other route, including IV dosing via a PCA pump.
All outcomes were measured only amongst unit patients receiving opiates. Compared to a 10 month period on the unit before hard stop implementation, patients experienced a > 3 standard deviation decrease in their exposure to IV push opiates. Unit patients did not report a statistically significant change in their pain scores, as averaged from all score reports for each monthly period. Patients did report increased satisfaction with their pain experience, as evidenced by an absolute increase of 13.9% of composite pain domain “always” responses on post-hospitalization surveys. Patients experienced a trend towards decreased average LOS after implementation of the pharmacy hard stop (hard stop 7.2 days, 95% confidence interval +/- 11.1 days, versus 7.9 +/- 14.4 days, p=0.15). Qualitative feedback from clinicians, nurses, and pharmacists highlighted a subsequent change in unit culture, suggestive of increased use of other pharmacologic and non-pharmacologic pain management techniques in lieu of IV push opiate use.
Conclusions: For patients receiving opiates during their inpatient stay on a hospital medicine service, decreased IV push opiate exposure is achievable, and is associated with improvement in patient satisfaction scores as well as a trend towards decreased length of stay. If alternative opiate administration routes are available, then routine scheduled use of opiates via the IV push route for hospitalized medical patients should be abandoned.