Making Healthcare Safer IV: Opioid Stewardship
Authors: Waldfogel Julie M. , Rosen Michael , Sharma Ritu , Zhang Allen , Bass Eric B. , Dy Sydney M. 
Published: December 2023

Objectives. Opioid stewardship interventions promote the appropriate use of prescribed and ordered opioids to reduce the risk of opioid adverse events. Our main objectives were to determine the effectiveness of these interventions in healthcare settings on opioid prescribing and clinical outcomes (e.g., number of opioid prescriptions, opioid dosage, overdose, emergency department visits, and hospitalizations) including unintended consequences (e.g., changes in patient-reported pain intensity), and ways these interventions can be effectively implemented. Methods. We followed rapid review processes of the Agency for Healthcare Research and Quality Evidence-based Practice Center Program. We searched PubMed and the Cochrane Library to identify eligible systematic reviews from January 2019 to April 2023 and primary studies published from January 2016 to April 2023, supplemented by targeted gray literature searches. We included systematic reviews and studies that addressed opioid stewardship interventions implemented in healthcare settings in the United States and that reported on opioid prescribing and clinical outcomes. Findings. Our search retrieved 6,431 citations, of which 34 articles were eligible (including 1 overview of systematic reviews, 13 additional systematic reviews, 13 randomized controlled trials (RCTs) [reported in 14 articles] and 6 nonrandomized studies). Systematic reviews, mostly summarizing pre-post studies, included a wide variety of opioid stewardship practices that focused on patient and family engagement, healthcare organization policy, or clinician knowledge and behavior interventions, in inpatient, perioperative, emergency department, and ambulatory settings. RCTs addressed multicomponent interventions (typically a combination of prescriber education, care management and facilitated access to resources), and patient education and engagement, mainly in ambulatory chronic pain. Opioid stewardship practices involving clinical decision support or electronic health records, or multicomponent interventions (including for chronic pain) were associated with decreases in opioid prescribing or reduced doses and no increases in pain, emergency department visits, or hospitalizations (low strength of evidence for all outcomes). Patient engagement and education interventions had mixed results for opioid prescribing outcomes (insufficient strength of evidence) and no increases in pain, emergency department visits, or hospitalizations (low strength of evidence). The evidence was insufficient on other types of interventions and on outcomes of opioid refill requests and refills, patient satisfaction, or overdose. Barriers included lack of training, workload, gaps in communication, and inadequate access to nonpharmacological resources. Facilitators included clinician and patient acceptance of intervention components. Conclusions. Selected opioid stewardship interventions may be effective for reducing opioid prescribing and dosing without adversely affecting clinical outcomes overall, although strength of evidence was low. Unintended consequences were often not measured or not measured rigorously. Interventions to reduce opioid use should monitor unintended consequences and include access to nonpharmacological pain management resources with appropriate patient education and engagement.