Implementation of opioid stewardship programs (OSPs) in hospitals: A narrative literature review
DOI:
https://doi.org/10.5055/jom.0915Keywords:
opioid stewardship programs, dissemination and implementation, science, rural health, health equity, care coordination, opioid safety, organizational cultureAbstract
Pain and addiction are persistent public health issues that can lead to serious and fatal consequences on individuals, families, and communities. With the continued development of the opioid epidemic and the subsequent rise in opioid use and misuse, it is important to recognize the need for intervention at a public health level. Opioid stewardship programs (OSPs) are promising public health interventions that aim to coordinate safe and effective pain management through evidence-based intervention strategies. This narrative literature review examined the current evidence for implementation of OSPs in emergency departments and acute care hospitals to identify best practices and gaps in evidence. We reviewed publications found through PubMed and Embase, and articles were selected for inclusion after being evaluated through the inclusion criteria. One hundred and ninety-six articles were first found via the database search, and a final 24 articles were included in the sample for full review. The results indicated that all but two studies were published within the last 4 years, and one study mentioned a rural location. Most of the studies were pre- and post-OSP implementation studies. On average, the studies implemented four of the 11 total OSP strategies of interest. Twenty-two studies included information on care coordination, with the most prevalent effect being a decrease in total morphine milligram equivalents being prescribed at discharge. Nine studies included data on patient safety measures, including adverse events such as return emergency room visits, need for naloxone administration, and increase in postoperative clinic visits. This narrative review provides us with a preliminary understanding of OSP implementation in hospital settings and provides evidence that they are feasible and accepted with a wide variety of implementation interventions and strategies. It also demonstrates a gap in the literature regarding implementation in rural settings and with some specific implementation strategies.
References
Santiago V: Painful truth: The need to re-center chronic pain the functional role of pain. J Pain Res. 2022; 15: 497-512. DOI: 10.2147/JPR.S347780.
Dowell D, Ragan K, Jones C, et al.: CDC clinical practice guideline for prescribing opioids for pain—United States, 2022. MMWR Recomm Rep. 2022; 71(RR-3): 1-95. DOI: 10.15585/mmwr.rr7103a1.
De La Rosa J, Brady B, Ibrahim M, et al.: Co-occurrence of chronic pain and anxiety/depression symptoms in US adults: Prevalence, functional impacts, and opportunities. Pain. 2023; 165(3): 666-673. DOI: 10.1097/j.pain.0000000000003056.
Zelaya C, Dahlhamer J, Lucas J, et al.: Chronic pain and high-impact chronic pain among US adults, 2019. 2022. Available at https://www.cdc.gov/nchs/products/databriefs/db390.htm. Accessed January 27, 2023.
Rafferty A, Luo H, Egan K, et al.: Rural, suburban, and urban differences in chronic pain and coping among adults in North Carolina: 2018 behavioral risk factor surveillance system. Prev Chronic Dis. 2021; 18: 200352. DOI: 10.5888/pcd18.200352external icon.
Centers for Disease Control and Prevention: Opioids. Process for the development of the 2022 clinical practice guideline for prescribing opioids for pain. 2021. Available at https://www.cdc.gov/opioids/guideline-update/index.html#:~:text=It%20contributes%20to%20substantial%20morbidity,to%20%24635%20billion%20dollars%20annually. Accessed November 24, 2023.
US Department of Health and Human Services (HHS): O of the SG. Facing addiction in America: The surgeon general’s report on alcohol, drugs, and health. 2016. Available at https://addiction.surgeongeneral.gov/. Accessed November 24, 2023.
Mattingly IIT, Pandit N, Onukwugha E: Burden of co-infection. A cost analysis of human immunodeficiency virus in a commercially insured hepatitis C virus population. Infect Dis Ther. 2019; 8(2): 219-228. DOI: 10.1007/s40121-019-0240-7.
Centers for Disease Control and Prevention: Opioid dispensing rate maps. Available at https://www.cdc.gov/drugoverdose/rxrate-maps/opioid.html. Accessed February 4, 2024.
Jenkins R: The fourth wave of the US opioid epidemic and its implications for the rural UA: A federal perspective. Prev Med. 2021; 152(Part 2): 1-4. DOI: 10.1016/j.ypmed.2021.106541.
Substance Abuse and Mental Health Services Administration: Key substance use and mental health indicators in the United States: Results from the 2021 national survey on drug use and health. 2022. Available at https://www.samhsa.gov/data/report/2021-nsduhannual-national-report. Accessed January 27, 2023.
Hedgegaard H, Spencer M: Urban-rural differences in drug overdose death rates, 1999-2019. National Center for Health Statistics. 2021: 1-7. Available at https://www.cdc.gov/nchs/products/databriefs/db403.htm. Accessed March 16, 2024.
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.
Hein Nguyen D, Baur A, Franklin L, et al.: Conceptualizing the COVID-19, opioid use, and racism syndemic and its associations with traumatic stress. Psychiatr Serv. 2022; 73: 353-356.
Stone E, Kennedy-Hendricks A, Barry C, et al.: The role of stigma in US primary care physicians’ treatment of opioid use disorder. Drug Alcohol Depend. 2021; 221: 108627. DOI: 10.1016/j.drugalcdep.2021.
Meyerson B, Russell D, Kichler M, et al.: I don’t even want to go to the doctor when I get sick now: Healthcare experiences and discrimination reported by people who use drugs, Arizona 2019. Int J Drug Policy. 2021; 93: 103112. DOI: 10.1016/j.drugpo.2021.103112.
Kelly J, Westerhoff C: Does it matter how we refer to individuals with substance-related conditions? A randomized study of two commonly used terms. Int J Drug Policy. 2010; 21(3): 202-207. DOI: 10.1016/j.drugpo.2009.10.010.
Arizona Department of Health Services: Opioid prevention. 2024. Available at https://www.azdhs.gov/opioid/. Accessed March 16, 2024.
Rooney B, Koch B, Hospodar J, et al.: Summary of Arizona critical access hospital’s community health needs assessment. 2023. Available at https://crh.arizona.edu/publications/studiesassessments. Accessed October 24, 2023.
American Hospital Association: Stem the tide: Opioid stewardship measurement implementation guide. 2020. Available at https://www.aha.org/guidesreports/2017-11-07-stem-tide-addressing-opioid-epidemic-taking-action. Accessed February 9, 2023.
Ardelijan L, Waldfogel J, Bicket M, et al.: Current state of opioid stewardship. Am J Health Syst Pharm. 2020; 77(8): 636-643. DOI: 10.1093/ajhp/zxaa027.
Santalo O: Before it is too late: Implementation strategies of an efficient opioid and pain stewardship program. Hosp Pharm. 2021; 56(8): 159-164. DOI: 10.1177/0018578719882324.
Brady B, SantaMaria B, Ortiz y Pino K, et al.: Opioid stewardship program implementation in rural and critical access hospitals in Arizona. J Opioid Manag. 2024; 20(1): 21-30. DOI: 10.5055/jom.0842.
Lane-Fall M, Curran G, Beidas R: Scoping implementation science for the beginner: Locating yourself on the “subway line” of translational science. BMC Med Res Methodol. 2019; 19: 133. DOI: 10.1186/s12874-019-0783-z.
Mehta T, Mahoney J, Leppin A, et al.: Integrating dissemination and implementation sciences with clinical and translational science award programs to advance translational research: Recommendations to national and local leaders. J Clin Transl Sci. 2021; 5(e151): 1-7. DOI: 10.1017/cts.2021.815.
Adsul P: Applying theories, models, and frameworks in implementation science. In Slide show presented at the Mountain States-Community Engaged Dissemination and Implementation Cohort 5 Training on August 5, 2023, Flagstaff, Arizona.
Ritchie M, Dollar K, Miller C, et al.: Using implementation facilitation to improve healthcare (version 3). 2020. Available at https://www.queri.research.va.gov/tools/implementation.cfm. Accessed March 16, 2024.
Pereira V, Silva S, Carvalho V, et al.: Strategies for the implementation of clinical practice guidelines in public health: An overview of systematic reviews. Health Res Policy Syst. 2022; 20: 1-21. DOI: 10.1186/s12961-022-00815-4.
Proctor E, Silmer H, Raghavan R, et al.: Outcomes for implementation research: Conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health. 2011; 38(2): 65-76. DOI: 10.1007/s10488-010-0319-7.
Sukhera J: Narrative reviews: Flexible, rigorous, and practical. J Grad Med Educ. 2022; 14(4): 414-417. DOI: 10.4300/JGME-D-22-00480.1.
Crowley AP, Sun C, Yan X, et al.: Disparities in emergency department and urgent care opioid prescribing before and after randomized clinician feedback interventions. Acad Emerg Med. 2023; 30(8): 809-818. DOI: 10.1111/acem.14717.
Fujita K, Hooper P, Masnoon N, et al.: Impact of a comprehensive intervention bundle including the drug burden index on deprescribing anticholinergic and sedative drugs in older acute inpatients: A non-randomised controlled before-and-after pilot study. Drugs Aging. 2023; 40(7): 633-642. DOI: 10.1007/s40266-023-01032-6.
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. 2022; 57(9): 130-136. DOI: 10.1016/j.jpedsurg.2021.12.008.
Villwock JA, Villwock MR, New J, et al.: EMR quantity autopopulation removal on hospital discharge prescribing patterns: Implications for opioid stewardship. J Clin Pharm Ther. 2020; 45(1): 160-168. DOI: 10.1111/jcpt.13049.
Babino JM, Thornton JD, Putney K, et al.: Evaluation of discharge opioid prescribing in coronary artery bypass patients following an opioid stewardship intervention for providers. J Pharm Pract. 2023; 36(5): 1077-1084. DOI: 10.1177/08971900221088797.
DeUgarte DA, Fleischman R, Mccollough M, et al.: Assessment of an opioid stewardship program on perioperative opioid prescribing in a safety-net health system. JAMA Surg. 2023; 158(3): 318-319. DOI: 10.1001/jamasurg.2022.4499.
Lavingia R, Mondragon E, McFarlane-Johansson N, et al.: Improving opioid stewardship in pediatric emergency medicine. Pediatrics. 2021; 148(6): e2020039743. DOI: 10.1542/peds.2020-039743.
Rennert L, Kerry H, Walker K, et al.: Evaluation of policies limiting opioid exposure on opioid prescribing and patient pain in opioid-naive patients undergoing elective surgery in a large American Health System. J Patient Saf. 2023; 19(2): 71-78. DOI: 10.1097/PTS.0000000000001088.
Reisener MJ, Hughes AP, Okano I, et al.: Effects of an opioid stewardship program on opioid consumption and related outcomes after multilevel lumbar spine fusion: A pre- and post-implementation analysis of 268 patients. J Neurosurg Spine. 2022; 36(5): 713-721. DOI: 10.3171/2021.8.SPINE21599.
Ti L, Mihic T, James H, et al.: Implementation of an opioid stewardship program to promote safer opioid prescribing. Can J Hosp Pharm. 2022; 75(2): 113-117. DOI: 10.4212/cjhp.v75i2.3115.
Beauchamp G, Deol P, Sipko J, et al.: Modifying post-operative opioid stewardship through a system of educational feedback. Am Surg. 2023; 89: 5175-5182. DOI: 10.1177/00031348221129511.
Berkley E, Takhar S, Wilson M, et al.: Effectiveness of an opioid stewardship guideline in renal transplant recipients post-discharge. J Pain Palliat Care Pharmacother. 2023; 37(1): 44-51. DOI: 10.1080/15360288.2022.2149672.
Downey J, Adams JD, Tanner S, et al.: Impact of an opioid stewardship initiative involving early conversion to oral narcotics in postoperative orthopaedic patients. J Surg Orthop Adv. 2022; 31(2): 86-89.
Linder BJ, Occhino JA, Wiest SR, et al.: Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery. Am J Obstet Gynecol. 2019; 221(5): 515.e1-515-e8. DOI: 10.1016/j.ajog.2019.06.023.
McCoy NC, Hay EL, Romeo DA, et al.: Decreased opioid consumption in bone marrow harvest patients using quadratus lumborum blocks in a standardized protocol. Front Med. 2022; 9. DOI: 10.3389/fmed.2022.862309.
Mittal S, Shukla AR, Sahadev R, et al.: Reducing post-operative opioids in children undergoing outpatient urologic surgery: A quality improvement initiative. J Pediatr Urol. 2020; 16(6): 846.e1-846-e7. DOI: 10.1016/j.jpurol.2020.09.022.
Ghafoor VL, Phelps P, Pastor J: Implementation of a pain medication stewardship program. Am J Health Syst Pharm. 2013; 70(23): 2070-2075. DOI: 10.2146/ajhp120751.
Haskel JD, Yousafzai M, Bloom DA, et al.: Opioid stewardship in orthopaedic surgery: Principles and practice. JBJS Rev. 2020; 8(8): e1900175-e1900178. DOI: 10.2106/JBJS.RVW.19.00175.
Melucci AD, Loria A, Swanson H, et al.: Are postoperative opioid stewardship protocols sustainable? Results from a 2-year quality improvement project. Surgery. 2023; 174(3): 517-523. DOI: 10.1016/j.surg.2023.05.036.
Parker DJ, Geist H, Yazdanyar A, et al.: Surgical opioid stewardship for orthopedic surgery: A quality improvement initiative. Orthopedics. 2023; 46(4): e230-e236. DOI: 10.3928/01477447-20230207-05.
Sangal RB, Rothenberg C, Hawk K, et al.: Real-world observational evaluation of common interventions to reduce emergency department prescribing of opioid medications. Jt Comm J Qual Patient Saf. 2023; 49(5): 239-246. DOI: 10.1016/j.jcjq.2023.01.013.
Barreveld AM, McCarthy RJ, Elkassabany N, et al.: Opioid stewardship program and postoperative adverse events: A difference-in-differences cohort study. Anesthesiology. 2020; 132(6): 1558-1568. DOI: 10.1097/ALN.0000000000003238.
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.
Vien A, Shyh G, Jannat-Khah D, et al.: Impact of a novel hospital-based opioid stewardship program on nonsurgical acute pain management in the hospital. J Gen Intern Med. 2021; 36(11): 3608-3610. DOI: 10.1007/s11606-020-06404-x.
Carroll S, Garba I, Figueroa-Rodríguez O, et al.: The CARE principles for indigenous data governance. Data Sci J. 2020; 19(43): 1-12. DOI: 10.5334/dsj-2020-043.
Agency for Healthcare Research and Quality: Care coordination. 2018. Available at https://www.ahrq.gov/ncepcr/care/coordination.html. Accessed March 16, 2024.
Published
How to Cite
Issue
Section
License
Copyright 2005-2025, Weston Medical Publishing, LLC and Journal of Opioid Management. All Rights Reserved.
