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Original Investigation
June 2018

Association of an Opioid Standard of Practice Intervention With Intravenous Opioid Exposure in Hospitalized Patients

Author Affiliations
  • 1Section of General Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
  • 2Hospitalist Service, Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
  • 3Department of Medicine, Yale New Haven Hospital, New Haven, Connecticut
JAMA Intern Med. 2018;178(6):759-763. doi:10.1001/jamainternmed.2018.1044
Key Points

Question  Can adopting a new standard of inpatient opioid prescribing that prefers oral and subcutaneous over intravenous administration result in reduced intravenous opioid exposure?

Findings  In this pilot study of 127 patients and 2459 patient-days on an adult medical unit, intravenous opioid dosing was reduced by 84% after adopting an opioid standard of practice, with mean pain scores similar to those before implementation of the new standard.

Meaning  This intervention may be associated with significant reduction in inpatient intravenous opioid exposure in adult medical patients; further investigation is warranted.


Importance  Opioids are commonly used to treat pain in hospitalized patients; however, intravenous administration carries an increased risk of adverse effects compared with oral administration. The subcutaneous route is an effective method of opioid delivery with favorable pharmacokinetics.

Objective  To assess an intervention to reduce intravenous opioid use, total parenteral opioid exposure, and the rate of patients administered parenteral opioids.

Design, Setting, and Participants  A pilot study was conducted in an adult general medical unit in an urban academic medical center. Attending physicians, nurse practitioners, and physician assistants who prescribed drugs were the participants. Use of opioids was compared between a 6-month control period and 3 months following education for the prescribers on opioid routes of administration.

Interventions  Adoption of a local opioid standard of practice, preferring the oral and subcutaneous routes over intravenous administration, and education for prescribers and nursing staff on awareness of the subcutaneous route was implemented.

Main Outcomes and Measures  The primary outcome was a reduction in intravenous doses administered per patient-day. Secondary measures included total parenteral and overall opioid doses per patient-day, parenteral and overall opioid exposure per patient-day, and daily rate of patients receiving parenteral opioids. Pain scores were measured on a standard 0- to 10-point Likert scale over the first 5 days of hospitalization.

Results  The control period included 4500 patient-days, and the intervention period included 2459 patient-days. Of 127 patients in the intervention group, 59 (46.5%) were men; mean (SD) age was 57.6 (18.5) years. Intravenous opioid doses were reduced by 84% (0.06 vs 0.39 doses per patient-day, P < .001), and doses of all parenteral opioids were reduced by 55% (0.18 vs 0.39 doses per patient-day, P < .001). In addition, mean (SD) daily parenteral opioid exposure decreased by 49% (2.88 [0.72] vs 5.67 [1.14] morphine-milligram equivalents [MMEs] per patient-day). The daily rate of patients administered any parenteral opioid decreased by 57% (6% vs 14%; P < .001). Doses of opioids given by oral or parenteral route were reduced by 23% (0.73 vs 0.95 doses per patient-day, P = .02), and mean daily overall opioid exposure decreased by 31% (6.30 [4.12] vs 9.11 [7.34] MMEs per patient-day). For hospital days 1 through 3, there were no significant postintervention vs preintervention differences in mean reported pain score for patients receiving opioid therapy: day 1, –0.19 (95% CI, −0.94 to 0.56); day 2, −0.49 (95% CI, −1.01 to 0.03); and day 3, −0.54 (95% CI, −1.18 to 0.09). However, significant improvement was seen in the intervention group on days 4 (−1.07; 95% CI, −1.80 to −0.34) and 5 (−1.06; 95% CI, −1.84 to −0.27).

Conclusions and Relevance  An intervention targeting the use of intravenous opioids may be associated with reduced opioid exposure while providing effective pain control to hospitalized adults.

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    2 Comments for this article
    Randy Lamartiniere |
    As a former hospitalist and long practicing Internist I do not understand the rationale behind rationing of opiates in hospitalized patients. There is no evidence that it will make a significant impact on the incidence of addiction in the general population and will not have a significant impact on the opiate (overdose) crisis. If it is a safety issue, no one is mentioning that. Our first responsibility as physicians is to provide caring and compassionate care to patients to the best of our ability. Pain control is a vital part of this and should not be held hostage to political agendas, especially those with no scientific support and that cause increased pain and suffering for our patients. I personally had two total hip replacements and was thankful for good pain control post op and as a outpatient that were important in providing steady advancement of mobility without any negative side effects.
    Use of the subcutaneous route of administration for opioids in acute pain management
    Pam Macintyre, MBBS, FANZCA, FFPMANZCA | Acute Pain Service, Royal Adelaide Hospital and University of Adelaide
    Thank you for this paper as I think the subcutaneous route of administration has a number of advantages. This includes not only avoidance of the IV route (which we do not allow on general wards because of potential safety concerns), but placement of a small indwelling plastic cannula allows repeated but needle-less administration.

    We started using the subcutaneous route of administration for prn opioid analgesia for management of acute pain (age-based doses in opioid-naïve patients) rather than the then-popular IM route in 1989 – so nearly 30 years – in patients who could not take oral opioids as yet,
    but did not need PCA and other more advanced forms of pain relief. We have published PK absorption studies of single doses given to patients and volunteers for oxycodone, fentanyl and tramadol, and for morphine in patients. Tmax was around 15 mins for all, so uptake was not slower then IM administration. The subcutaneous route of administration for prn opioids rapidly became very popular throughout our country.

    I agree it is a technique to be encouraged as a useful route of administration.