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

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.

Successful treatment of acute mania and perineal abscess using dexmedetomidine sedation as adjunctive therapy.

Acute psychiatric illness with agitation presents the clinician with a dangerous, potentially life-threatening situation often requiring complex management. Alteration in patients' insight and judgment may result in medication non-compliance, potentially further complicating therapy directed at the primary psychiatric illness as well as any co-existing conditions. Sedation is often necessary to control dangerous behaviour during the period of antipsychotic and mood-stabilising drug titration. Dexmedetomidine is a centrally acting selective α2-adrenergic agonist with anaesthetic and sedative properties widely used in intensive care units for sedation in critically ill patients. The authors report the case of a patient managed successfully with dexmedetomidine sedation while being treated for acute mania and perineal abscess.