Effectiveness of interventions on the appropriate use of opioids for noncancer pain among hospital inpatients: A systematic review

AIMS

To summarise the effectiveness of interventions on appropriate opioid use for noncancer pain among hospital inpatients.

METHODS

Two reviewers independently searched 6 databases up to March 2018 original research articles reporting on quantitative outcomes of interventions on appropriate opioid use among hospital inpatients. Appropriate opioid use was measured by changes in prescribing, such as the lowest effective opioid dose and duration, or clinical outcomes such as adequate pain control. Quality and intervention complexity assessments were performed by 2 independent reviewers. The full methodological approach was published on PROSPERO (ID: CRD42019145947).

RESULTS

Of 398 full-text articles assessed for eligibility, 37 articles were included in the review. Most articles had a moderate or high risk of bias (27 of 37 studies). Thirty-one articles primarily addressed appropriate opioid use and 6 articles targeted opioid safety as a secondary outcome. A multifaceted approach was the most common primary intervention (16 studies) and adequate pain control was the main outcome measured (14 studies). Health provider education, reinforced by hard-copy material and feedback, was associated with a 13.0 to 29.5% increase in the proportion of opioid prescriptions written in concordance with local guidelines and reduced pain scores ranging from 7.0 to 34.5%. Interventions to improve opioid safety in patient-controlled analgesia reduced medication errors by up to 89.1%.

CONCLUSION

Interventions involving academic detailing and education, especially when reinforced by feedback, show positive effects on appropriate opioid use among hospital inpatients. Future studies investigating the impact of administrative interventions on opioid use and related outcomes are warranted.

Multifaceted education initiative minimizes pethidine prescribing in the emergency department

BACKGROUND

Pain management experts have recommended a diminished role for pethidine because of lack of superiority for any indication and greater potential for adverse effects compared with morphine.

OBJECTIVES

To evaluate the impact of a multifaceted education initiative on prescribing patterns and to minimize pethidine use in the ED.

METHODS

This was a pre- and post-intervention study. The intervention was an education initiative, introduced between December 2003 and January 2004. It comprised ED pharmacist in-services for medical and nursing staff, championing by senior medical staff (ED consultants, surgical units, Drug and Therapeutics Committee) and concurrent prescriber feedback by ED pharmacists. The pre-intervention prescribing practices guided the development of in-services and the educational programme. The intervention was evaluated by a medical record review of analgesic prescribing in March-April of both 2003 (pre-intervention period) and 2004 (post-intervention period). Outcome measures were the proportions of patients who were prescribed pethidine and the proportions of pethidine ampoules supplied to the ED. Results were analysed as differences in proportions.

RESULTS

In the pre-intervention period, 60 ampoules of pethidine (7.2% of opiate doses) and 777 ampoules of morphine (92.8% of opiate doses) were administered compared with 15 ampoules of pethidine (1.7%) and 869 ampoules of morphine (98.3%) in the post-intervention period (P < 0.001). Of patients who received an opiate dose, 50 of 798 (6.3%) and 11 of 747 (1.5%) received pethidine in the pre- and post-intervention periods, respectively (P < 0.001).

CONCLUSION

Our education initiative resulted in a sustained and significant reduction in pethidine prescribing in the ED. Sustainability requires ongoing in-services for ED staff, usually as part of the orientation programme.