Opioid Stewardship Pharmacists: More Than Just the Opioid Police

Since the declaration of the opioid epidemic as a public health emergency in 2017, many hospitals and health systems have put infrastructure in place to ensure safe and appropriate use of opioids.¹ As medication experts, pharmacists often play a key role in opioid stewardship, leading taskforces and quality initiatives in addition to participating in direct patient care. Opioid prescription volumes have dropped significantly over the past several years while opioid overdoses have remained persistently high, necessitating a shifting focus of opioid stewardship.²

Opioid prescription volumes have dropped significantly over the past several years while opioid overdoses have remained persistently high, necessitating a shifting focus of opioid stewardship. Image Credit: © steheap - stock.adobe.com

Pharmacy Times reached out to several pharmacists serving in opioid stewardship roles across the country to discuss what is currently a priority for their organizations and what they see as keys to success in stewardship. This is the first interview in the series, and it is with Stephanie Abel, PharmD, BCPS, an opioid stewardship program coordinator at University of Kentucky HealthCare in Lexington.

Abel discusses her role as an opioid stewardship program coordinator and the program she leads. Abel collaborates closely with pain management pharmacists and uses quality improvement initiatives to address stigma, facilitate project management, and guide changes in organizational practices, often navigating the hospital’s governance structure to integrate opioid stewardship efforts into clinical workflows.

One of Abel’s recent projects focuses on improving access to naloxone by placing intranasal devices in public and clinical spaces within the facility, such as code carts and defibrillators, to ensure timely response to opioid overdoses. Additionally, her team educates staff and the community, integrating naloxone distribution into routine events like influenza vaccination clinics. Another major initiative involves revising pain management protocols, particularly post-surgical opioid dosing practices, to ensure safety by incorporating patient-specific factors into the decision-making process rather than relying solely on pain scores.

Abel emphasizes that a successful opioid stewardship program requires clear goals, an understanding of human psychology, emotional intelligence, and adaptability, as emotionally charged topics like pain and addiction are met with resistance to change. She also underscores the importance of clearly defined objectives and deliverables for any project to avoid "scope creep" and to improve the sustainability of quality improvement initiatives.

Pharmacy Times: What is your practice setting and role?

Stephanie Abel, PharmD, BCPS: I am fully dedicated to opioid stewardship efforts at University of Kentucky HealthCare, a 1000-bed academic medical center in Lexington, Kentucky. Our program focuses on 3 main pillars: 1) optimizing pain management, 2) appropriate and responsible use of opioids, 3) identification, treatment, destigmatization, and harm-reduction efforts for patients with opioid use disorder. I work closely with 4 pain and palliative care clinical pharmacists on quality improvement initiatives, implementing evidence-based practice, and addressing stigma and bias impacting pain management and/or patients with opioid use disorder (OUD).

I primarily meet goals and make progress via project management, collaborating and facilitating with various multidisciplinary teams, engaging in quality improvement and change management, key stakeholder management, serving as a subject matter expert, and educating multidisciplinary providers, patients, and the public. I shepherd the necessary infrastructure changes through the governance process and co-chair the opioid stewardship pharmacy and therapeutics subcommittee, electronic health record (EHR) pain and opioid practice subcommittee, and executive opioid steering committee.

Pharmacy Times: What projects have you been involved in recently?

Abel: I’ve been involved in improving access to life-saving naloxone. This is a multifaceted project addressing disparities in access from multiple angles. The first phases included adding intranasal naloxone devices to all code carts, rapid response bags, and free-standing (public-facing) automated external defibrillators to ensure that all patients, visitors, or community members within our facilities could receive timely and non-invasive administration of naloxone and avoid any delays in treatment. Of note, intravenous (IV) naloxone remains the preferred route of administration for admitted patients, but intranasal is now an option for people without IV access.

The last two facets of this project are ongoing and include decreasing the stigma and misconceptions surrounding opioid use disorder and naloxone and in-person events to get naloxone to staff, patients, and the community. For example, we have begun to integrate offering naloxone and educating employees and staff during routine influenza vaccine drives and plan to provide similar offerings in the community soon. We are also leveraging our EHR to identify and alert providers about patients who may be at higher risk of opioid-related overdose and are working toward providing automatic tailored education based on patient-specific parameters in an effort to optimize relevance and ensure consistency in our messaging.

Multidisciplinary health care provider and public education is a routine aspect of my job. Most recently the topics of focus have included the impact of opioid use disorder-related stigma and bias on patient care and outcomes and opioid safety for parents and schools.

I also work to improve the approach and associated EHR operationalization of post-surgical pain management and variable dose opioids in the acute care setting. Our post-anesthesia care unit (PACU) and postoperative order sets historically have dictated opioid doses based on pain scores. This practice is not evidence-based and is a concern for patient safety as it does not incorporate any other pertinent patient-specific factors (eg, sedation level, organ dysfunction, respiratory risk factors, age, etc). We are currently in the process of revising practice and our EHR infrastructure in the PACU with plans to adopt a similar but modified approach for the rest of the acute care setting thereafter.

Pharmacy Times: What do you see as key to success in building and maintaining an opioid stewardship program?

Abel: My current role is so very different from my prior clinical practice role as a pain management and palliative care clinical pharmacy specialist. I have had to learn a lot of things through trial and error and self-directed learning as my primary skillsets now are not things that I learned in school, residency, or my clinical roles. Leading opioid stewardship initiatives can be very rewarding but the path is often riddled with roadblocks, barriers, etc. I believe this is because pain management, opioid prescribing, and OUD are often emotionally charged topics for a lot of reasons. Combining emotionally-laden subject matter with the fact that people are inherently averse to change can make progress slow and tedious. Emotional intelligence, patience, effective communication, creativity, leadership skills, key stakeholder management, understanding what motivates people, leveraging circumstances, and knowing when to walk away or put something “in the parking lot” are all imperative for success.

Additionally, the ability to effectively define the scope and deliverables of any committee, task force, group, or project are often overlooked or are too vague. Ultimately, this leads to scope creep; getting off track; losing sight of the true goals; misunderstandings and frustration of group members, key stakeholders, and leadership; and undesirable results.

Defining the scope, deliverables, objectives, and charter can provide the destination and the roadmap. Before embarking on your quest for quality improvement, you first need to define where you are going and how to get there to avoid getting lost without a “North Star” to guide you.

Lastly, 2 out of 3 of health care projects fail. It is likely that the aforementioned points contribute to this phenomenon in the sphere or opioid stewardship. In addition to my prior musings, I have found that incorporating the principles of human psychology into the quality improvement process via change management and/or implementation science can help improve the efficacy of an initiative and ensure that changes are sustained and consistent.

REFERENCES

1. Uritsky TJ, Busch ME, Chae SG, Genord C. Opioid Stewardship: Building on Antibiotic Stewardship Principles. Journal of Pain & Palliative Care Pharmacotherapy. 2020;34(4):181-183. doi:10.1080/15360288.2020.1765066

2. Overdose epidemic report 2023. American Medical Association. 2023. Accessed October 30, 2024. https://www.ama-assn.org/system/files/ama-overdose-epidemic-report.pdf