Novel Prevention Program May Reduce Opioid Overdose Risk

Pauline Anderson

May 02, 2018

VANCOUVER, British Columbia — Pain management experts are making headway in reducing risks for opioid overdoses.

After a targeted opioid overdose prevention program was introduced at an 18-bed inpatient rehabilitation unit, fewer patients were discharged with an opioid prescription, and more left with a naloxone kit or prescription.

"Provider and patient awareness has helped change the culture of our entire rehabilitation unit," study investigator, Stephanie P. Van, MD, resident physician, Johns Hopkins Medicine, Baltimore, Maryland, told Medscape Medical News.

Van, along with co-investigator Ada Lyn Yao, MD, presented the findings here at the American Academy of Pain Medicine (AAPM) 2018 Annual Meeting.

Big Discrepancy

The impetus for launching the program was an elderly female patient who was discharged from the unit and later turned up at the emergency department. Her husband had been accidentally giving her double doses of opioids.

That incident spurred researchers to look at prescriptions for both opioids and naloxone given to patients discharged from the unit.

"We saw a big discrepancy," Yao told meeting delegates.

On average, about half the patients were sent home with an opioid prescription, yet few received a naloxone kit or prescription.

"We felt we needed to do something about this," said Yao. "We can't just be adequately or appropriately treating pain — we need to make sure that we send patients home safely."

The researchers initiated an education program for providers and patients on the rehab unit. Patients include those with acute pain and those with chronic pain.

The medical team identifies patients who might be eligible to take part in the prevention program. Patients have to be cognitively intact and be willing to participate in naloxone administration. Caregivers also have to be on board.

Staff developed educational modules to teach patients about pain  and about risk factors for opioid overdose. They also created educational materials on naloxone administration.

Over time, the medical team became more "cautious" in prescribing opioids and "more open and transparent" in discussing pain management options with patients, said Yao.

Patients in the program felt they were "being heard" and were more open to entertaining the idea of nonopioid medications, she said.

"Because they were comfortable talking about their pain issue, they were more welcoming of other modalities."

Growing Acceptance of Naloxone

The study included 788 patients. From January to March 2016, 23% of eligible patients were transitioned to no opioids or to tramadol. This increased to 41% by the end of the following 9 months. The initial 20% of eligible patients who were discharged with naloxone increased to 54%.

"The number of patients who are eligible for naloxone and agree to it is steadily increasing," said Van.

But there are some who still don't want the medicine. "A lot of patients say, 'I'm not an addict; I'm not going to abuse this opioid'," said Van.

Programs like this could go a long way toward preventing opioid overdoses, said Van.

"We believe that anyone who goes home with an opioid is at risk for either overusing it or using it improperly, or someone else getting hold of it."

The program should curb the number of prescription opioids available in the community, which contributes to the opioid epidemic, said Van.

"People go home after elective surgery with opioids that are indicated in the acute recovery period, but some don't dispose of these drugs properly when they don't need them anymore. They just stop taking them and don't store them properly or lock them up. So that leaves access to anyone in the community."

Information on what to do with unused opioids may be incorporated into future counseling sessions, said Van. "It can be as easy as bringing them back to your pharmacy."

The researchers identified barriers they encountered in introducing the program. These included the "unavoidable" medical complexity of some patients and the "influx" of residents and nurses onto the unit, which can "hinder" the education process, said Yao.

In addition, there was initially some "pushback" from insurance companies about covering naloxone, she said.

"But with the increasing clamor to curb the opioid crisis, insurance companies actually became more of an enabler for our project rather than a big hurdle. They started allowing us to send patients home with a naloxone kit or prescription."

Lessons learned, said Yao, are that communication is key, as is an interdisciplinary approach.

The investigators intend to follow up with the patients to see if they had to use the naloxone or if they filled the prescription.

Behavior Change

This study is important because it demonstrates the effectiveness of "a simple education program," pain specialist James C. Watson, MD, associate professor, and vice chair, Department of Neurology, Mayo Clinic, Rochester, Minnesota, told Medscape Medical News when asked to comment.

The program succeeded in decreasing opioid prescriptions for patients at discharge and effectively "changed provider behavior" to offer naloxone prescriptions "for accidental overdosage," said Watson. 

However, the applicability of the data may be limited because the study involved an inpatient rehab program, where patients have some motivation to get off opioids, said Watson. As well, he added, "the provider pool is well versed in opioid risks" and is motivated to lower these risks.  

There was no funding source for this study. No relevant financial relationships have been disclosed.

American Academy of Pain Medicine (AAPM) 2018 Annual Meeting. Abstract 303. Presented April 27, 2018.

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