Opioid stewardship program implementation in rural and critical access hospitals in Arizona

Benjamin R. Brady; Bianca SantaMaria; Kathryn Tucker Ortiz y Pino; Bridget S. Murphy

doi:10.5055/jom.0842

Authors

Benjamin R. Brady, DrPH https://orcid.org/0000-0003-3534-1027
Bianca SantaMaria, MPH
Kathryn Tucker Ortiz y Pino, MPH
Bridget S. Murphy, DBH

DOI:

https://doi.org/10.5055/jom.0842

Keywords:

treatment, referral, opioid use disorder, pain, naloxone

Abstract

Objective: The objective of this study is to examine rural hospitals' status in implementing opioid stewardship program (OSP) elements and assess differences in implementation in emergency department (ED) and acute inpatient departments.

Design: Health administrator survey to identify the number and type of OSP elements that each hospital has implemented.

Setting: Arizona critical access hospitals (CAHs).

Participants: ED and acute inpatient department heads at 17 Arizona CAHs (total of 34 assessments).

Main outcome measures: Implementation of 11 OSP elements, by department (ED vs inpatient) and prevention orientation (primary vs tertiary).

Results: The percentage of implemented elements ranged from 35 to 94 percent in EDs and 24 to 88 percent in acute care departments. Reviewing the prescription drug monitoring program database and offering alternatives to opioids were the most frequently implemented. Assessing opioid use disorder (OUD) and prescribing naloxone were among the least. The number of implemented elements tended to be uniform across departments. We found that CAHs implemented, on average, 67 percent of elements that prevent unnecessary opioid use and 54 percent of elements that treat OUD.

Conclusions: Some OSP elements were in place in nearly every Arizona CAH, while others were present in only a quarter or a third of hospitals. To improve, more attention is needed to define and standardize OSPs. Equal priority should be given to preventing unnecessary opioid initiation and treating opioid misuse or OUD, as well as quality control strategies that provide an opportunity for continuous improvement.

Author Biographies

Benjamin R. Brady, DrPH

Assistant Professor, School of Interdisciplinary Health Programs, Western Michigan University, Kalamazoo, Michigan

Bianca SantaMaria, MPH

Health Education and Promotion Professional II, Arizona Center for Rural Health, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona

Kathryn Tucker Ortiz y Pino, MPH

Program Director, Arizona Prevention Research Center, Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona

Bridget S. Murphy, DBH

Assistant Research Professor, Arizona Center for Rural Health, Comprehensive Pain and Addiction Center, Mel and Enid Zuckerman College of Public Health, University of Arizona, on the lands of the O’odham and Yaqui peoples in Tucson, Arizona

References

Ciccarone D: The triple wave epidemic: Supply and demand drivers of the US opioid overdose crisis. Int J Drug Policy. 2019; 71: 183-188. DOI: 10.1016/j.drugpo.2019.01.010.

National Institute on Drug Abuse: Overdose death rates. National Institute on Drug Abuse. 2022. Available at https://nida.nih.gov/research-topics/trends-statistics/overdose-deathrates. Accessed July 8, 2022.

Spencer MR, Minino AM, Warner M: Drug Overdose Deaths in the United States, 2001–2021. Atlanta, GA: Centers for Disease Control and Prevention, 2022. Available at https://www.cdc.gov/nchs/data/databriefs/db457.pdf. Accessed August 22, 2023.

Alexander BK: Addiction: The urgent need for a paradigm shift. Subst Use Misuse. 2012; 47(13-14): 1475-1482. DOI: 10.3109/10826084.2012.705681.

Dasgupta N, Beletsky L, Ciccarone D: Opioid crisis: No easy fix to its social and economic determinants. Am J Public Health. 2018; 108(2): 182-186. DOI: 10.2105/AJPH.2017.304187.

Bor J, Cohen GH, Galea S: Population health in an era of rising income inequality: USA, 1980–2015. Lancet. 2017; 389(10077): 1475-1490. DOI: 10.1016/S0140-6736(17)30571-8.

Institute of Medicine: How Far Have We Come in Reducing Health Disparities? Progress Since 2000: Workshop Summary. Washington, DC: National Academies Press, 2012. Available at http://www.ncbi.nlm.nih.gov/books/NBK100492/. Accessed July 11, 2022.

van Draanen J, Tsang C, Mitra S, et al.: Socioeconomic marginalization and opioid-related overdose: A systematic review. Drug Alcohol Depend. 2020; 214: 108127. DOI: 10.1016/j.drugalcdep.2020.108127.

Rosales R, Janssen T, Yermash J, et al.: Persons from racial and ethnic minority groups receiving medication for opioid use disorder experienced increased difficulty accessing harm reduction services during COVID-19. J Subst Abuse Treat. 2022; 132: 108648. DOI: 10.1016/j.jsat.2021.108648.

Goedel WC, Shapiro A, Cerdá M, et al.: Association of racial/ethnic segregation with treatment capacity for opioid use disorder in counties in the United States. JAMA Netw Open. 2020; 3(4): e203711. DOI: 10.1001/jamanetworkopen.2020.3711.

Lapham G, Boudreau DM, Johnson EA, et al.: Prevalence and treatment of opioid use disorders among primary care patients in six health systems. Drug Alcohol Depend. 2020; 207: 107732. DOI: 10.1016/j.drugalcdep.2019.107732.

Centers for Disease Control and Prevention: Prevent opioid use disorder. 2017. Available at https://www.cdc.gov/opioids/overdoseprevention/opioid-use-disorder.html. Accessed July 11, 2022.

Carroll JJ, Green TC, Noonan RK: Evidence-Based Strategies for Preventing Opioid Overdose: What's Working in the United States. Atlanta, GA: Centers for Disease Control and Prevention, 2018. Available at https://www.samhsa.gov/resource/ebp/evidence-based-strategies-preventing-opioid-overdose-whatsworking-united-states. Accessed July 11, 2022.

American Hospital Association: Stem the tide: Opioid stewardship measurement implementation guide. 2020. Available at https://www.aha.org/guidesreports/2017-11-07-stem-tideaddressing-opioid-epidemic-taking-action. Accessed July 8, 2022.

Kapoor N, Kumar D, Thakur N: Core attributes of stewardship; foundation of sound health system. Int J Health Policy Manag. 2014; 3(1): 5-6. DOI: 10.15171/ijhpm.2014.52.

Uritsky TJ, Busch ME, Chae SG, et al.: Opioid stewardship: Building on antibiotic stewardship principles. J Pain Palliat Care Pharmacother. 2020; 34(4): 181-183. DOI: 10.1080/15360288.2020.1765066.

World Health Organization: Antimicrobial stewardship programmes in health-care facilities in low- and middle-income countries. A practical toolkit. 2019. Available at https://apps.who.int/iris/handle/10665/329404. Accessed July 11, 2022.

Centers for Disease Control and Prevention: Core elements of hospital antibiotic stewardship programs. Atlanta, GA: US Department of Health and Human Services/CDC, 2019. Available at https://www.cdc.gov/antibiotic-use/core-elements/hospital.html. Accessed July 11, 2022.

The Joint Commission: New and revised requirements addressing antibiotic stewardship for hospital. Revised Requirements Addressing Antibiotic Stewardship for hospital. Available at https://www.jointcommission.org/standards/prepublication-standards/New. Accessed July 11, 2022.

Kreitmeyr K, von Both U, Pecar A, et al.: Pediatric antibiotic stewardship: Successful interventions to reduce broad-spectrum antibiotic use on general pediatric wards. Infection. 2017; 45(4): 493-504. DOI: 10.1007/s15010-017-1009-0.

Nathwani D, Varghese D, Stephens J, et al.: Value of hospital antimicrobial stewardship programs [ASPs]: A systematic review. Antimicrob Resist Infect Control. 2019; 8(1): 35. DOI: 10.1186/s13756-019-0471-0.

Weiner SG, Price CN, Atalay AJ, et al.: A health system–wide initiative to decrease opioid-related morbidity and mortality. Jt Comm J Qual Patient Saf. 2019; 45(1): 3-13. DOI: 10.1016/j.jcjq.2018.07.003.

Gondora N, Versteeg SG, Carter C, et al.: The role of pharmacists in opioid stewardship: A scoping review. Res Soc Adm Pharm. 2022; 18(5): 2714-2747. DOI: 10.1016/j.sapharm.2021.06.018.

Ardeljan LD, Waldfogel JM, Bicket MC, et al.: Current state of opioid stewardship. Am J Health Syst Pharm. 2020; 77(8): 636-643. DOI: 10.1093/ajhp/zxaa027.

Pedersen CA, Schneider PJ, Ganio MC, et al.: ASHP national survey of pharmacy practice in hospital settings: Monitoring and patient education-2018. Am J Health Syst Pharm. 2019; 76(14): 1038-1058. DOI: 10.1093/ajhp/zxz099.

Rural Health Information Hub: Critical access hospitals (CAHs). 2021. Available at https://www.ruralhealthinfo.org/topics/critical-access-hospitals. Accessed July 28, 2022.

Harris PA, Taylor R, Thielke R, et al.: Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009; 42(2): 377-381. DOI: 10.1016/j.jbi.2008.08.010.

Shen MR, Waljee JF: Enhanced recovery after surgery protocols: Can they reduce postoperative opioid use? Ann Surg. 2019; 270(6): e72. DOI: 10.1097/SLA.0000000000003475.

Opioid Response Network: Opioid regulations: State by state guide. 2021. Available at www.acep.org/globalassets/sites/acep/media/by-medical-focus/opioids/opioid-guide-state-by-state.pdf. Accessed August 1, 2022.

Thomas CP, Stewart MT, Tschampl C, et al.: Emergency department interventions for opioid use disorder: A synthesis of emerging models. J Subst Abuse Treat. 2022; 141. DOI: 10.1016/j.jsat.2022:108837.

Sullivan RW, Szczesniak LM, Wojcik SM: Bridge clinic buprenorphine program decreases emergency department visits. J Subst Abuse Treat. 2021; 130: 108410. DOI: 10.1016/j.jsat.2021.108410.

National Quality Forum (NQF): National quality partners Playbook™: Opioid stewardship. NQF. 2018. Available at https://store.qualityforum.org/products/national-qualitypartners-playbook%e2%84%a2-opioid-stewardship. Accessed September 7, 2021.

Pattullo C, Suckling B, Donovan P, et al.: Developing a framework for implementing opioid stewardship programmes in Australian hospital settings. Intern Med J. 2022; 52(4): 530-541. DOI: 10.1111/imj.15555.

Creamer M, Trinkman H, Hamby T, et al.: Impact of an opioid stewardship program on opioid exposure for pediatric appendectomy postsurgical pain. J Pediatr Surg. 2021; 56(8): 1421-1424. DOI: 10.1016/j.jpedsurg.2020.09.067.

Ingram MCE, Tian Y, Kennedy S, et al.: Pilot implementation of opioid stewardship measures using the national surgical quality improvement program-pediatric platform. J Pediatr Surg. 2021; 57: 130-136. DOI: 10.1016/j.jpedsurg.2021.12.008.

Rizk E, Swan JT, Cheon O, et al.: Quality indicators to measure the effect of opioid stewardship interventions in hospital and emergency department settings. Am J Health Syst Pharm. 2019; 76(4): 225-235. DOI: 10.1093/ajhp/zxy042.

Pattullo C, Suckling B, Taylor S, et al.: Developing and piloting an adaptable oxycodone quality improvement strategy: Steps towards opioid stewardship. Aust Health Rev. 2021; 45(3): 353-360. DOI: 10.1071/AH20262.

Gellad WF, Good CB, Shulkin DJ: Addressing the opioid epidemic in the United States: Lessons from the Department of Veterans Affairs. JAMA Intern Med. 2017; 177(5): 611-612. DOI: 10.1001/jamainternmed.2017.0147.

Maclean JC, Mallatt J, Ruhm CJ, et al.: Economic studies on the opioid crisis: A review. 2020. Available at http://www.nber.org/papers/w28067. Accessed January 16, 2024. DOI: 10.3386/w28067.

O'Donnell B, Gupta V: Continuous Quality Improvement. Treasure Island, FL: StatPearls, 2022. Available at http://www.ncbi.nlm.nih.gov/books/NBK559239/. Accessed July 29, 2022.

Li SA, Jeffs L, Barwick M, et al.: Organizational contextual features that influence the implementation of evidence-based practices across healthcare settings: A systematic integrative review. Syst Rev. 2018; 7(1): 72. DOI: 10.1186/s13643-018-0734-5.

Jeffs L, Thampi N, Maione M, et al.: A qualitative analysis of implementation of antimicrobial stewardship at 3 academic hospitals: Understanding the key influences on success. Can J Hosp Pharm. 2015; 68(5): 395-400.

Gupta A, Lindstrom S, Shevatekar G: Reducing opioid overprescribing by educating, monitoring and collaborating with clinicians: A quality improvement study. Cureus. 2020; 12(4): e7778. DOI: 10.7759/cureus.7778.