Hospital Pharmacy - February 2020 - 32

817471
research-article2018

HPXXXX10.1177/0018578718817471Hospital PharmacyFancher et al

Original Article

Evaluation of a Long-Acting Opioid
Restriction Policy: Does Restriction
Reduce the Need for Naloxone Reversal?

Hospital Pharmacy
2020, Vol. 55(1) 32-36
© The Author(s) 2018
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https://doi.org/10.1177/0018578718817471
DOI: 10.1177/0018578718817471
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Jenna L. Fancher1, Robert W. Seabury1, William Darko1,
Luke A. Probst1, and Christopher D. Miller1

Abstract
Purpose: After a sentinel event related to long-acting (LA) opioid administration at our institution and subsequent
root cause analysis, an inpatient LA opioid restriction policy was implemented to improve patient safety. The objectives
of this study were to evaluate the effect of an inpatient LA opioid restriction policy on inpatient therapy utilization
and to compare rates of naloxone reversal events among patients administered LA opioids before and after policy
implementation. Methods: To evaluate the first objective, an electronic medical record report was created to capture
all inpatient LA opioid orders prescribed to adults at our institution between March 1, 2014, and July 30, 2017. Utilization
was compared before and after policy implementation and use controlled for by patient days. To evaluate the second
objective, naloxone administrations were identified via a query of the medical record between March 1, 2014, and July
30, 2017. Naloxone reversal events were independently evaluated by 2 trained reviewers, and a third when discrepancies
existed. Rates of naloxone reversal events related to LA opioid administration were compared between the pre- and
post-policy phase. Results: The results of our first objective demonstrate that policy implementation was associated
with a statistically significant reduction in LA opioid utilization that was sustained throughout the study duration. For
our second objective, among the 144 patients deemed to have an opioid-related naloxone reversal event, a LA opioid
was administered to 12 patients (18.9%) in the pre-policy phase and 17 patients (15.9%) in the post-policy phase. This
difference was not statistically significant (odds ratio [OR] = 1.629, confidence interval [CI] = 0.711-3.732, P = .248).
Conclusion: A LA opioid restriction policy significantly reduced LA opioid utilization at our institution. Despite this, we
did not find a significant reduction in inpatient naloxone reversals related to LA opioids. Further study is warranted to
identify an optimal method to reduce LA opioid-related toxicity.
Keywords
pain management, adverse drug reactions, medication safety

Introduction
Opioid analgesics are commonly prescribed to hospitalized
patients. Despite their clinical value, available data demonstrate that these agents are among the most frequent medications associated with adverse events.1,2 To improve patient
safety, many health care institutions are increasingly obliged
to implement measures related to opioid prescribing and
administration. Special attention to long-acting (LA) opioid
products may have particular value, as these agents are
increasingly utilized and are associated with overdose and
overdose-related death.3 As such, some hospitals and international agencies are now recommending against or limiting
LA opioid use in hospitalized patients with acute, noncancer
pain.4 After a sentinel event and subsequent route cause analysis related to LA opioids at our institution, a LA opioid
restriction policy was implemented in July 2014. This policy
requires Acute Pain Service (APS) to review and approve all

LA opioids in patients not meeting criteria for opioid tolerance, defined as recent outpatient LA opioid use or daily use
of at least 60 mg morphine equivalents for at least 7 days. It
was theorized that this policy would reduce LA opioid utilization and frequency of inpatient naloxone use for reversals
of LA opioids. The objectives of this study were twofold: (1)
to evaluate the effect of an inpatient LA opioid restriction
policy on therapy utilization and (2) to compare rates of naloxone reversal events among patients administered LA opioids before and after policy implementation.
1

Upstate University Hospital, Syracuse, NY, USA

Corresponding Author:
Christopher Miller, Associate Director of Pharmacy for Clinical Services
and Research, Department of Pharmacy, Upstate University Hospital, 750
East Adams Street, Syracuse, NY 13210, USA.
Email: millechr@upstate.edu

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Hospital Pharmacy - February 2020

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