Pharmacist-led opioid stewardship programs help bridge the gap between managing pain and minimizing risk

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      By Tamara Mihic, Kseniya Chernushkin, and Ruthdol Ywaya

      The overdose public-health emergency has brought necessary attention to the dangers of the toxic street-drug supply that, in combination with untreated addiction, has fuelled overdoses both provincially and nationally.

      That attention has also led to misunderstanding—both by the general public and among healthcare providers—about opioids and opioid use. We’ve seen in jurisdictions across North America how improper prescribing of opioids can lead to downstream harms for the patient, including addiction and overdose.

      However, opioids can and do play an important role in managing pain. Opioid-stewardship programs can help prescribers and patients manage pain safely and effectively while minimizing those downstream impacts.

      The impact of opioid prescribing in hospital and at discharge on adverse health outcomes, including addiction, was largely underrecognized until recently. Receiving an opioid on discharge from hospital was shown to increase the risk of chronic opioid use fivefold, and research has shown that receiving opioids for acute pain has been associated with development of opioid-use disorder.

      Additionally, opioid use in hospital is also associated with increased adverse events, length of stay, and hospital costs. Canada has the second-highest rate of prescription-opioid use per capita globally, second only to the United States of America. At the same time, patients who don’t have their pain managed properly may turn to other, potentially dangerous options, including the street-drug supply, so addressing how we prescribe opioids is critical.

      Within Fraser Health and Providence Health, a unique set of programs have been implemented to help reduce inappropriate opioid prescribing that could contribute to opioid dependence as well as adverse events associated with prescription opioids. These opioid-stewardship programs are led by clinical pharmacy specialists at Royal Columbian, Surrey Memorial, and St. Paul’s hospitals who work to review opioid prescriptions for patients throughout the hospital and make suggestions to prescribers around changes that could be made to improve safety and efficacy of the opioids used.

      The goal of these programs is not to remove all opioids for patients who need them for pain management or for a preexisting opioid-use disorder; rather, the goal is to make sure that they are used in the most thoughtful manner in order to maximize patient benefit and reduce potential harms.  

      Partnering with an opioid-stewardship-program pharmacist allows prescribers to address pain needs while increasing prescriber accountability through reinforcement of the potential harms of excessive use but also excessive restriction in prescribing opioids.  

      In addition to optimizing opioid use in hospitals, the opioid-stewardship programs collaborate with prescribers on optimizing pain control through nonopioid pain medications. This service has provided support for many patients, helping them to recognize that pain is an important issue and to work with a pharmacist to come up with a pain-management plan focused on patient needs.

      Having a separate team focused on opioid use, including a pharmacist with specialized knowledge of opioid medications, helps ensure that patients receive the time, attention, and expertise that is necessary to make safe, effective, and patient-centred pain-management plans.

      Along with reviewing individual patients, the opioid-stewardship programs also provide education to different healthcare providers throughout the hospital. This includes handouts and tools that can be used to improve opioid prescribing, such as the Fraser Health “patient opioid agreement” to assist with starting patients on opioids for chronic pain, and research and quality-improvement projects like the one at St. Paul’s Hospital that assesses patients' opioid use after discharge from hospital after surgery.

      Balancing the needs and risks of opioid use to manage pain effectively and safely requires cohesive efforts across the healthcare system. Opioid stewardship is an innovative way to address upstream factors and improve our overall approach to using opioids.

      Tamara Mihic (St. Paul’s Hospital), Kseniya Chernushkin (Royal Columbian Hospital), and Ruthdol Ywaya (Surrey Memorial Hospital) are all opioid-stewardship pharmacists.