Help Promote Safer Opioid Strategies

Your hospital will target new “opioid stewardship” strategies.

Over half of inpatients get morphine or another opioid. But giving opioids for acute pain may lead to long-term use. Anticipate changes to rein in opioid overprescribing and ensure appropriate use.

Help manage pain with fewer opioids. Expect to use multimodal pain strategies. For example, look for more non-opioids on post-op orders, such as scheduled acetaminophen plus ibuprofen or another NSAID.

Advocate for PRN opioid orders that emphasize non-opioids first. For example, instead of “for moderate pain,” ask about using “for pain not improved by acetaminophen and ibuprofen.”

Set realistic pain expectations. For example, explain that a reasonable goal might be to sit up in bed without severe pain within two days after abdominal surgery...rather than being pain-free.

Promote de-escalation strategies. Ask about switching IV opioids to PO or per tube as soon as possible. Explain to patients that oral opioids work just as well as IV.

Save IV opioid requests for patients not tolerating PO...or for a few IV doses for faster control of severe pain. Then help switch to PO.

Expect PRN opioids to “auto stop” after a few days. Ensure non-opioids are maximized before asking to renew an opioid order.

Safeguard against risky use. Verify PCA basal rates aren’t used in opioid-naive patients...and fentanyl patches aren’t used for acute pain.

Be aware of opioid overdose risks...sleep apnea, renal or hepatic impairment, old age, or use with lorazepam or another benzo. Assess breathing without talking to or touching the patient...stimuli can mask oversedation.

Ensure safe transitions. Review the MAR for recent opioid use when patients have a discharge opioid Rx. Notify the prescriber if the patient hasn’t needed a dose in the last 24 hours. They likely don’t need the Rx.

Educate patients discharged on opioids about secure storage. Encourage discarding unused opioids via “take-back” programs or community receptacles. If those aren’t options, advise flushing down the toilet.

Ask the prescriber about a naloxone Rx for patients at higher overdose risk...such as history of substance use or on high opioid doses.

See our Opioid Stewardship Checklist for more strategies.

Key References
  • J Am Coll Surg 2018;227(4):411-418
  • JAMA Surg 2018;153(10):948-954
  • Hosp Pharm Published online May 30, 2018; doi:10.1177/0018578718779005
  • JAMA Surg 2018;153(2):e174859
Nurse’s Letter. Dec 2018, No. 341217

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