Opioids Often Prescribed at Hospital Discharge

An alarming 15% of patients who enter the hospital without any pain medications fill opioid prescriptions soon after discharge, new research published in JAMA Internal Medicine suggests.

Researchers from Harvard Medical School analyzed prescription claims data from a nationally representative sampling of Medicare beneficiaries in 2011 to estimate the prevalence of new opioid prescribing.

Among the more than 620,000 hospitalizations analyzed, about 92,882 (15.1%) were associated with a new opioid claim within 7 days of discharge. Among the 77,092 of the 92,882 hospitalizations with a recorded 90-day follow up, 32,731 (42.5%) were associated with a new opioid claim 90 days after discharge.

The researchers were unable to determine whether the opioid prescriptions were appropriate, but given the risks for short-term adverse events and long-term physiologic dependence, health-system pharmacists should carefully review all opioid prescriptions.

Juliana Zschoche, PharmD, a PGY2 resident in emergency medicine at Johns Hopkins Hospital, told Pharmacy Times that health-system pharmacists need to work with prescribers in order to ensure opioid prescriptions and dosages are appropriate in order to reduce the risk of overdose.

“Having an open conversation with the prescriber about what’s going on with the patient may help to identify patients at risk for opioid overdose,” she said.

Notably, many patients never receive any safety information about their opioid prescriptions.

In a separate research letter also published in JAMA Internal Medicine, researchers from the Johns Hopkins Bloomberg School of Public Health surveyed around 1000 US adults with recent opioid prescriptions about how they shared, stored, and disposed of their medications.

About 20.7% of survey respondents self-reported sharing opioid medications currently or in the past. A mere 8.6 % reported keeping the medication in a locked location most often, and an alarming 61.3% reported keeping unused opioid medication for future use despite the fact that they no longer needed them.

About half of the survey participants reported receiving information about safe opioid storage. Of those respondents, 44.1% reported receiving that information from a pharmacist.

The findings from both investigations suggest that there’s room for improvement in pharmacist communication and patient education about the dangers of sharing or keeping unused opioid prescriptions. Health-system pharmacists have unique clinical knowledge and an obligation to ensure that all possible efforts are made to equip patients and families with lifesaving resources, such as naloxone.

“More research is needed to identify effective strategies to advance safer practices related to opioid medication sharing, storage and disposal,” the researchers behind the first study wrote. “In the meantime, reducing the prescribing of large quantities of opioid medications and disseminating clear recommendations on safe storage and disposal of opioid medications widely to the public and prescribers may reduce risk.”

Suzanne Nesbit, PharmD, a clinical pharmacy specialist for pain management and palliative care at Johns Hopkins Hospital, told Pharmacy Times that the pharmacist should be at the center of those efforts.

“It starts on the inpatient side of things,” she explained. “…[Health-system pharmacists] are an integral piece of the health care team. They should start the patient education process a few days prior to discharge.”

Failing to provide comprehensive care and information to patients comes with certain risks, Dr. Nesbitt warned.

“[Health-system pharmacists] can run the risk of misuse and, in some cases, abuse if they don’t really engage the patient and adequately follow up,” she noted.

On a broader level, Dr. Nesbitt believes there’s room for improvement in communication among pharmacists, prescribers, and patients.

“In general, we need to do a better job of making sure the pharmacist is involved at discharge and making sure patients understand the medication they’re taking, and [also] understand the importance and what the goals are,” she stated.