Multimodal intervention reduces opioid use in hospitalized patients with IBD

SAN ANTONIO — A series of interventions promoting guidance and appropriate therapy for pain management significantly reduced opioid use among hospitalized patients with inflammatory bowel disease, according to research presented at the American College of Gastroenterology Annual Meeting.

Current data show that up to 70% of hospitalized patients with IBD receive opioids, although the drugs are associated with excess mortality and severe infectious complications among this patient population, according to Rahul S. Dalal, MD, of the department of medicine at the Perelman School of Medicine at the University of Pennsylvania and gastroenterology fellow at Brigham and Women’s Hospital.

“Previous interventions that have targeted IV opioid exposure among all patients admitted to a general medical service at an academic medical center successfully decreased these patients’ total opioid exposure without compromising their pain control,” he said during a presentation. “We therefore aimed to reduce IV opioid exposure among IBD patients admitted to the general internal medicine service at our hospital.”

Dalal and colleagues sequentially introduced four interventions at their facility from January to March 2019. The first intervention was a protocol that enabled physicians to prescribe IV acetaminophen to patients with IBD who were unable to receive oral medications. The medication was previously more restricted at the facility, Dalal said. The second intervention was the introduction of an electronic health record “smart phrase” that provided specific pain management guidance in gastrointestinal consult notes. The third intervention was an update to pain management guidelines on an existing online IBD pathway that physicians can access through the facility’s intranet website. The fourth intervention was the introduction of an automated text messaging alert system that provided clinical recommendations regarding analgesia to physicians caring for patients admitted with IBD. The automated text message highlighted the consequences of opioid use in IBD and encouraged the use of IV acetaminophen as an alternative therapy for patients without enteral access.

“We also advised stepwise management for patients who did have enteral access, which included first-line use of acetaminophen, and then consideration of celecoxib, gabapentin, cyclobenzaprine, dicyclomine and hyoscyamine, and as a last resort, tramadol and oral opioids,” Dalal said.

After launching these interventions, Dalal and colleagues compared the outcomes of 345 patients with IBD who were treated during a preintervention period (January to December 2018; n = 241) and postintervention period (January to June 2019; n = 104).

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The researchers observed significant reductions in:

IV opioid use, which decreased from 43.6% to 30.8%;
IV opioid dose exposure, which decreased from 5.5 IV morphine mg equivalents (IVMMEs) per day to 3 IVMMEs per day; and
total opioid dose exposure, which decreased from 15.6 IVMMEs per day to 8.5 IVMMEs per day.

There were also significant reductions in 30-day readmission rates, which decreased from 21.6% to 11.5%, and length of hospital stay, which decreased from 7.2 days to 5.3 days. The causes of these reductions were “not entirely clear,” but could be related to reduced IV opioid use, according to Dalal.

“A decreased length of stay can be secondary to decreased time spent weaning IV opioids, and a decreased readmission rate could be related to a decrease in the masking of symptoms of opioid use and increased treatment of underlying active disease,” he said.

IV acetaminophen use significantly increased from 0.8% to 14.4% between the preintervention and postintervention periods. There were no changes in last pain scores (2.8 preintervention vs. 2.1 postintervention) or average pain scores (3.9 preintervention vs. 3.7 postintervention).

Data from a root cause analysis that were not presented at the meeting indicated the text messaging alert system as well as the availability of IV acetaminophen had the greatest effect on reducing IV opioid use, Dalal said.

“The study is limited in that it is an observational study without randomization of patients to specific interventions, and the gradual introduction of these interventions precluded a use of more robust statistical techniques, such as an interrupted time series analysis,” he said. “However, our findings show that increasing provider awareness about the consequences of opioid prescribing and encouraging use of alternative therapies can change practice. Additional research is still needed to determine the long-term benefits of reduced inpatient opioid exposure in this patient population.” – by Stephanie Viguers

Reference:

Dalal RS, et al. Abstract 41. Presented at: American College of Gastroenterology Annual Meeting; Oct. 25-30, 2019; San Antonio.

Disclosure: Dalal reports no relevant financial disclosures.