OPIOID CONSUMPTION: THE IMPACT OF REVISIONS TO AN INPATIENT OPIOID ORDER SETEisha Ludtke, Lisa Scott, MaryAnn Birch
HCA Florida West Hospital-Pensacola, FL
Background/Purpose: Investigate the impact of revisions made to an inpatient opioid order set on overall opioid consumption amongst hospitalized patients and education given to providers regarding the new order sets.
Methodology: This single-center quasi-experimental study conducted at a 515-bed academic hospital with data collection beginning September 2024 and was continued until March of 2025. Patients were excluded if admitted to the labor and delivery unit, the intensive care unit, palliative care, or to the operating room. Patients with active malignancy, opioid use disorder, opioid reversal prior to admission, opioid tolerance, scheduled opioid use, pain management consults, contraindications or allergies to study drugs, incomplete pain scale documentation by nursing, or non-numerical pain scale orders were also excluded from this study. Cohort 1 consists of patients prescribed both opioids and non-opioids (acetaminophen or ibuprofen) outside the opioid order set. Cohort 2 includes patients prescribed analgesic medications from the revised opioid order set. Cohorts were identified through facility surveillance software reports. The study evaluates the frequency of opioid administration. The primary endpoint of this study evaluated the average MME administered per 24 hours of a patient's stay, while secondary endpoints included the number of times the available MME increased, the percentage of patients with breakthrough pain orders, the number of times an opioid for breakthrough pain was given divided by the inclusion time, the percentage of patients with a scheduled acetaminophen order, and the frequency a non-opioid was given for analgesia divided by inclusion time.
Results: Baseline demographics between both cohorts, including age, sex, race, BMI, Charleston Comorbidity Index, surgical patient status, prior opioid use, presence of adjunctive pain medication, and length of stay, showed no statistical differences. For the primary endpoint, there were no statistical differences between cohort 1 and cohort 2 regarding the mean MME consumed by hospitalized patients per 24 hours of their stay, the number of times the MME increased throughout the stay, or the number of times an order for breakthrough pain was given, divided by the inclusion time (p-values: 0.9952, 0.5572, and 0.1121, respectively). The implementation of the order set increased the percentage of patients with a breakthrough pain order from 31% to 60%, demonstrating a statistically significant difference between pre- and post-intervention groups (p-value: 0.0031). An increase in the percentage of patients with a scheduled acetaminophen order from 19% to 88% post-intervention was observed (p-value: <0.0001). Lastly, there was a statistically significant increase in the frequency of either acetaminophen or NSAID administration for analgesia, divided by inclusion time, indicating more administrations of non-opioids in the post-intervention group (p-value: 0.0453).
Conclusions: Despite the addition of a breakthrough pain (BTP) order, there was no statistical difference in average morphine milligram equivalents (MME) per day, although the number of BTP orders increased significantly. This increase was anticipated due to the prechecked BTP order in the new set, which physicians could uncheck if desired. Concerns about increased opioid consumption were unfounded, as BTP orders involved lower potency opioids compared to those for moderate or severe pain. The unchanged MME, combined with significant BTP order results, indicates that standardizing the order set improved overall pain control. While there was no statistical difference in early opioid administration, offering a lower potency BTP opioid may theoretically reduce early administrations due to uncontrolled pain. Scheduling acetaminophen led to better around-the-clock pain control and increased use of opioid-sparing agents. The prechecked scheduled acetaminophen order encouraged non-opioid analgesia. Limitations include a restricted sample size due to the time required for implementation and education, and some providers' preference for custom order sets. A larger sample size and proper use of the new order set could demonstrate lower opioid use and greater utilization of opioid-sparing agents. Further data collection is needed to assess these outcomes. Potential confounders include cognitive issues and drug-seeking behavior, which could affect pain perception and reporting.
Presentation Objective: Review the impact of a revised analgesic order set on opioid consumption, non-opioid analgesic use, early opioid administrations, dose increases, and morphine equivalent increases, while also exploring how these changes influenced patient care and treatment preferences for moderate to severe pain.
Best Contact for Follow Up: Eisha Ludtke,
eisha.ludtke@hcahealthcare.com
