Study: Opioids can cause harm in hospitals beyond addiction risk

Errors in opioid prescriptions and use during patients' hospital stays may be the cause of more harm than previously thought, according to a new analysis.

The study, released Tuesday by patient safety research organization ECRI Institute, found approximately 35% of adverse events involving opioids stemmed from errors in administering the highly addictive drugs during a hospital stay. Those issues included problems with providers administering the wrong medication, the wrong dosage, or inadequately assessing the patient for potential adverse effects prior to giving them an opioid.

Study co-author Josi Wergin, a risk management analyst at ECRI, said medical organizations need to train personnel how to handle opioids appropriately in an acute-care inpatient setting just as much as they focus on prescribing practices at outpatient and primary care clinics.

"The opioid epidemic has largely focused on the outpatient prescribing, but it's quite a different ball game when you look at patients who are in the hospital," Wergin said.

Improving opioid safety has gotten more attention from hospitals in recent years as providers have sought to mitigate the impact of the opioid abuse crisis. Despite the increased focus on appropriate use of opioids, many hospitals continue to see adverse events where patients are injured from unintentional overdoses, the study authors wrote.

All in all, the researchers examined more than 7,200 adverse patient events involving the use of opioids that occurred at 215 hospitals between January 2014 and November 2016.

About 80% of the adverse events identified in the analysis did not result in actual patient harm but all presented some level of risk.

Among the 20% of events that resulted in harm to the patient, the highest percentage of events were related to adverse drug reaction caused by failure to monitor the effectiveness of the drugs used or by failure to track a patient's sedation level.

Opioid-related inpatient stays have increased by 64% between 2005 and 2014 with nearly 1.3 million hospitalizations in 2014 alone, according to data from the Agency for Healthcare Research and Quality.

That uptick has created challenges for many providers as they grapple with when and how they should use opioids to treat pain.

"The question is really different in the context of epidemic opioid use where a lot of people have these medications before hospitalization," said Dr. Hilary Mosher, clinical associate professor of internal medicine at the University of Iowa and Iowa City VA Healthcare System. "It's sort of a new problem, so even old evidence isn't necessarily as appropriate or applicable to the challenges we have now."

In spite of the challenges, some organizations and providers have made an effort in recent years to provide opioid guidance.

Last December, the Society of Hospital Medicine, the leading medical society for hospitalists, launched a guide aimed at helping providers reduce adverse events related to opioid prescribing.

Called the Reducing Adverse Drug Events Related to Opioids program, or RADEO, the program offers a toolkit that hospitals can follow to help them meet 2012 recommendations issued by the Joint Commission. In their guidelines, the commission suggested providers screen patients for risk of respiratory depression and learn their history of opioid abuse to assess their tolerance level to such medications.

The analysis also recommended healthcare organizations set safety goals, educate clinicians and staff on safe opioid use and offer feedback to individual clinicians on whether they're meeting those goals.

Prescriber education on opioid safety has become more popular among healthcare providers in recent months, and it was a key recommendation in President Donald Trump's Commission on Combating Drug Addiction and the Opioid Crisis' initial findings in July.

But Mosher said many providers still find it difficult to create a standard set of clinical practices on opioid use that can be applied to a broad population of patients. Many decisions involving the use of opioids these days need to be based on individual clinical judgments, she said.

"Pain is such a complex physical and psychosocial condition," Mosher said. "Probably the best guidance is going to really prompt people to think carefully about the risks and benefits on a very patient-specific way."

Opioids are the second most frequent class of medications to cause adverse drug reactions in hospitalized patients, according to 2009 study published in the journal PLoS ONE.

Over-sedation and respiratory depression are two of the major adverse events that can occur with the use opioids, sometimes resulting in death.