New Haven, CT—Changing how opioids are delivered to hospital inpatients appears to reduce exposure without adversely affecting pain relief, new research reports.

A pilot study published in JAMA Internal Medicine, found that by delivering opioids with an injection under the skin or orally instead of intravenously, pain relief was maintained or improved.

The research was led by Yale School of Medicine and Yale New Haven Hospital. Background information in the article points out that hospital clinicians usually provide prescription opioid drugs in one of three forms: with an IV, orally, or with a shot subcutaneously.

Study authors note that the IV method carries greater risk of side effects because the opioids so rapidly penetrate the central nervous system. In fact, they emphasize, even one IV dose can cause changes in the brain that are associated with addiction.

The research tested a new standard of opioid prescribing giving preference to non-IV methods. The primary outcome was defined as a reduction in IV doses administered per patient-day. Also analyzed were 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 were determined after a control period that included 4,500 patient-days and an intervention period of 2,459 patient-days.

Researchers report that IV 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). At the same time, mean (SD) daily parenteral opioid exposure decreased by 49% (2.88 [0.72] versus 5.67 [1.14] morphine-milligram equivalents [MMEs] per patient-day).

The daily rate of patients administered any parenteral opioid decreased by 57% (6%. 14%; P <.001), study authors write, with doses of opioids given by oral or parenteral route 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).

Yet no significant postintervention-versus-preintervention differences in mean reported pain score were detected 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) for hospital Days 1 through 3.

Significant improvement was documented in the intervention group, however, on Days 4 (-1.07; 95% CI, -1.80 to -0.34) and 5 (-1.06; 95% CI, -1.84 to -0.27).

Lead author Adam Ackerman, MD, clinical instructor in internal medicine at Yale School of Medicine (YSM) and medical director of the pilot study inpatient unit at Yale New Haven Hospital, called for more research to validate the findings, adding that the results “have the potential to be practice changing.”

"The data shows that the non-IV use of opioids can reduce overall opioid use in adult inpatients with no change in pain control, and potentially an improvement,” added co-author Robert Fogerty, MD, associate professor of medicine at YSM.

While IV opioids have a role in medicine for relieving acute pain, Fogerty pointed out, the SC route can serve as a “bridge” to help hospital patients safely transition to pills.

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