Best Practices for Implementing an Opioid Stewardship Program During the Opioid Crisis

While the Centers for Disease Control and Prevention marks the beginning of the opioid crisis in the late 1990s, opioid addictions and related harm have significantly skyrocketed in the past decade. Even in the face of the “war on drugs” and with measures in place to control opioid misuse, tens of thousands of Americans die due to opioid misuse each year.

The US Commission on Combating Synthetic Opioid Trafficking found that more than 100,000 people died of drug overdoses in the 12 months preceding June 2021, an increase of 30% from a year earlier. With more than $1 trillion spent on this public health crisis per year, hospital pharmacists can play an instrumental role in controlling the misuse of these substances while ensuring appropriate pain management for their patients.

Opioid addiction can start from unlawful use of these medications, but it often begins with a desire to help patients manage pain. Recognizing the role they play in combatting the opioid problem, many hospitals have considered or developed opioid stewardship programs to standardize pain management and opioid use strategies for patients; however, there are some barriers to implementation. A study conducted by the American Society of Health-System Pharmacists found that only 41% of the 811 hospitals that submitted data had an active opioid stewardship program in place.

Although it can feel like a daunting task amid myriad other organizational priorities, establishing an opioid stewardship program is imperative for hospitals to deliver the best care to their patients. Common barriers such as inadequate leadership commitment and resource allocation, lack of best practice models or easily transferable programs, and challenges around data collection and management can all hinder the formation of a successful opioid stewardship program.

In the face of these hurdles, clinical teams must acknowledge their responsibility to help patients manage pain while minimizing the risk of addiction and take action.

Secure Support from Hospital Leadership Early

Opioid stewardship programs are designed to reduce opioid overuse, misuse, and abuse, ultimately helping prevent addiction while treating pain effectively. With a well-designed stewardship program in place, providers can determine how to improve pain management outcomes based on individual patient needs while mitigating their risk for harm. This creates a dynamic partnership between patient and provider that will not only improve safety, but also patient experience.

For hospitals and health care systems implementing an opioid stewardship program, it is vital to develop a proper foundation to ensure the program will be successful. This groundwork requires the support of hospital leadership and their involvement during the planning process to promote culture development and ensure adequate resource allocation across the organization. Leadership also plays a critical role in overall organizational buy-in by prioritizing the stewardship program as a driver of quality improvement and better patient outcomes.

Embrace Evidence-Based Care and Program Accountability

In addition to identifying leaders to back the program, a successful opioid stewardship program includes policies that support the delivery of evidence-based care and best practices, and a plan for how to roll the program out across the organization. Examples of these policies may include strategies for identifying opioid use disorder (OUD) along with treatment recommendations and/or referrals for affected patients, pain management care plans and order sets that target multi-modal therapies, and guidance for how to manage drug-seeking behavior from new or existing patients.

Early planning of stewardship programs should also include tactical steps for how to educate all stakeholders on the dangers of opioid misuse and what the organization is doing to combat the problem. These resources should be available to patients and their caregivers, as well as providers and health care professionals across departments.

Finally, program organizers should be clear on goals of the stewardship program and how they intend to measure and monitor progress. Over time, these metrics will help demonstrate organizational success and can be used to support broader initiatives to fight the opioid epidemic, such as advocacy efforts for legislative action.

Provide Collaborative Team-Based Care and Training to Support Smarter Opioid Use

For physicians to give non-opioid recommendations for pain relief, they must be trained and properly educated about alternative analgesic options for their patients. Pharmacists are well-suited to provide this education within the health care system, ultimately empowering the care team to work closely with the patient to develop a multi-pronged approach to pain management.

Physicians should also be optimizing electronic health care records (EHR) capabilities and health information technology to measure opioid use and direct care in appropriate settings. This might include updating order sets to be more restrictive regarding the use of opioids and offering alternatives whenever possible. Pharmacists can help establish this guidance at an organizational level to ensure that individual providers have the education and support they need when making pain management decisions for their patients.

Use Data to Monitor Program Success

An EHR and third-party software tools can also serve as valuable pieces in monitoring program implementation and success. Sophisticated tools offer real-time tracking of morphine milligram equivalent values (MME) and opioid use data for specific agents, routes of administration, and duration of use, through which patterns will emerge to guide future action.

The MME is a critical tool in understanding opioid use. By normalizing the doses of different opioids with varying potencies, this value provides a basis for comparison and offers transparency into overall use habits. Physicians can look at a patient's daily MME value and determine whether they are at a low, medium, or high risk of an opioid-related adverse event, with high values indicating increased patient risks and reflecting an opportunity to de-escalate opioid therapy.

A recent study of patients covered by Medicaid found that abrupt discontinuation of opioids was associated with an increase in the risk of death and suicide. To avoid additional harm, physicians need to be armed with the knowledge to slowly curb opioid use if needed or to direct patients to interventional options, such as naloxone, fentanyl testing strips, or syringe service programs.

In addition to identifying a patient's opioid addition risk, MME values also reflect physicians’ prescribing patterns. This measure creates a quick and objective way to evaluate those physicians prescribing at a higher rate, allowing pharmacists to intervene. Opioid stewardship programs can help prescribers optimize pain management alternatives while simultaneously identifying patients for de-escalation of opioid use.

Create a Network of Support

Hospital executives are prioritizing funding for opioid-related issues as the urgency to address the epidemic increases. Similarly, federal funding to help combat OUD has increased, furthering research on prevention, harm reduction, treatment and recovery support services. Knowing what support is available to patients within the health care system is essential to curbing ongoing addictions.

By operationalizing pain management strategies and increasing education for both patients and providers, opioid stewardship programs allow hospitals and health care systems to support the safe use of opioids while simultaneously improving patient outcomes. Although putting an effective, robust opioid stewardship program in place is not easy, the clear benefits to patients, clinicians, and the community make the effort both necessary and worthy.

About the Author

Richard Dion, PharmD, has 15 years of experience in the practice areas of medication use safety, pharmacy informatics and clinical decision support in varied settings. His experience includes academic medical centers, community hospitals and most recently as a member of the Wolters Kluwer clinical team. Dr. Dion has a keen interest in developing workflow practices that improve both pharmacist efficiency and job satisfaction, as well as utilizing data to drive the clinical practice forward. Dr. Dion received his PharmD from the University of Rhode Island and completed both a PGY1 residency in pharmacy practice and PGY2 residency in medication use safety at the University of Massachusetts Memorial Medical Center.