An Integrative Review of Opioid Stewardship: Optimizing Patient Care and Safety with a Multidisciplinary Approach

Introduction

The opioid crisis in the US continues to take the lives of tens of thousands of Americans each year.¹ According to the National Survey on Drug Use and Health, 8.9 million people aged 12 or older misused opioids in 2022. Of these, 8.5 million people misused prescription pain relievers. Among those diagnosed with a substance use disorder, less than 1% sought treatment owing to either believing that treatment was not needed or a lack of healthcare providers and treatment facilities.² Data collated by the National Vital Statistics System counted more than 105,000 drug overdose deaths in the 12-month period ending October 2023 with approximately 70% of these deaths attributable to synthetic opioids.³ A paradox of these crises is that opioids are still important medications to manage pain, especially acute pain in the inpatient hospital setting.⁴ Healthcare professionals find themselves caught between trying to prevent opioid misuse and adequately controlling the pain of patients with severe medical needs. Professionals across disciplines are now called upon to be good stewards of opioids in their management of severe pain.

Stewardship is defined as “the careful and responsible management of something entrusted to one’s care”.⁵ Healthcare professionals are frequently called to be good stewards of resources which are limited in supply and interventions whose misuse can lead to negative consequences. Antimicrobial stewardship, or the judicious use of antibiotics, has been promoted since the late 1990s due to the rise in antibiotic resistant bacteria which is directly related to the overuse of antibiotics. Antimicrobial stewardship programs within healthcare settings provide guidance, monitoring, and feedback to prescribers so that they limit their use of antibiotics to only those situations which warrant them.⁶

Similarly, there has been a call for opioid stewardship programs to reduce the use of opioids to minimize the risk of harm from the misuse of opioids past their prescribed period while still managing pain effectively. Shrestha et al⁷ proposed a universal definition based on a systematic literature review which included 19 articles that defined opioid stewardship.

Opioid stewardship programs include evidence-based guidelines, policies, person-centered practices and research to promote rational prescribing, use and deprescribing of opioids for managing pain and specified health conditions. Opioid stewardship programmes should aim to optimise treatment by maximising clinical benefits for the patients and the wider society and minimising adverse consequences, including overuse, misuse, and diversion. Effective patient-provider communications and involving patients and/or their carers in decision-making are key to implementing any opioid stewardship program by considering evidence-based outcomes that matter to patients. Stewardship programmes should also focus on safe procurement, storage, and disposal practices. (Shrestha et al, 2023, p. 391)

Their definition strives to include the patient and shared decision-making to be as important as judicious prescribing practices.

As occurs with many definitions and policy guidance, this definition contains many statements about what stewardship programs should include, with little concrete guidance on how to achieve these goals and the role of different healthcare professionals in such a program. There is a lack of consensus regarding what constitutes opioid stewardship, as well as staffing patterns that do not allow time for opioid stewardship measures. A need exists for a wide-ranging accounting of what opioid stewardship entails to allow for more consistent development and implementation.

Our findings represent a comprehensive list of best practices which can be incorporated into opioid stewardship programs across the globe. This paper aims to provide the results of an integrative review of opioid stewardship practices to inform healthcare providers and institutions and form the basis for consistent and practical development and implementation of opioid stewardship.

Purpose

As noted, current opioid stewardship programs are often institution-specific and involve internally devised metrics that have not been standardized into clear objectives that constitute “opioid stewardship”. Interventions have focused primarily on prescribers and prescribing practices and less on non-prescribing healthcare providers and multidisciplinary teams. Patient assessments and education, as well as medication regimen histories and reviews that can be performed by nurses and pharmacists are less well-studied. To fill this gap, we sought to synthesize the literature promoting concepts of opioid safety and stewardship through the lens of multidisciplinary practice and patient care as defined by the literature. We focused on opioids in general rather than on specific conditions for which opioid may be prescribed, such as cancer or chronic pain, in order to develop broad concepts of opioid stewardship rather than the specific recommendations for prescribing for acute pain, chronic pain, or cancer pain.

Methods

We chose to conduct an integrative review to address opioid stewardship because this type of review allows for the inclusion of not only qualitative and quantitative research literature but also editorials, professional organization position papers and guidelines, reports, and quality improvement projects.⁸ This allows us the broadest view of stewardship practices from a multidisciplinary perspective and the identification of the most common characteristics and themes related to stewardship.

Literature Search

We began our literature search by asking the question: How are concepts of opioid stewardship focused on patient care and safety being used by healthcare professionals in their practice-specific roles (pharmacy, nursing, medicine) and in multidisciplinary healthcare teams? Using this question, we searched the following databases: Web of Science for “opioid stewardship”, and CINAHL, Academic All Search Complete, and PubMed for “opioid stewardship AND patient care”. We limited our search to the years 2013–2023. Our search approach and terms were developed in partnership with a medical librarian within the Purdue University Library system who influenced our decisions regarding search terms and databases.

We included publications from or about healthcare settings, opioid dispensing, prescribing, and administering, patient safety or patient care, nursing, pharmacy, and physician activities. We included research publications as well as position statements and guidelines from professional organizations, reports, and editorial or opinion pieces across the globe if published in English. We excluded publications that were outside of healthcare settings including dentistry, non-professional administration of opioids, and papers published before 2013.

Our search returned 286 publications which were uploaded to Covidence for evaluation. Covidence is an online software platform that is used to manage literature reviews by research teams. There were 89 duplicate articles removed identified in multiple searched databases and an additional 76 studies were removed during screening due to the team determining they were irrelevant based on team consensus. Of the 114 full-text manuscripts reviewed, an additional 43 studies were excluded by team consensus, primarily because they reported solely on descriptive studies of opioid prescribing without any inclusion of stewardship practices or interventions. Data extraction was conducted by group consensus on 71 publications. Two reviewers independently reviewed each publication using a template described below. Not all fields applied to all publications reviewed. At each stage of the review process, two reviewers independently reviewed and made an assessment. Covidence indicated if there was a difference in assessment and a third author reviewed with the initial two who completed the review. The publication selection can be seen in the PRISMA flow diagram in Figure 1.

Figure 1 PRISMA flow diagram for review of characteristics associated with opioid stewardship.

Data Extraction

A template was created in Covidence to standardize the data extraction process. This template included the title of the paper, country in which the study was conducted, notes from the reviewer, aim of the study, study design, population description, exclusion criteria, total number of participants, population characteristics, population characteristic percentage if applicable, study findings, up to 25 opioid stewardship characteristics, up to five positive themes, and up to five negative themes. This allowed for both quantitative and qualitative data to be extracted from both research publications and other types of literature such as editorials. Themes may have been findings from qualitative studies or conclusions of opinion pieces which did not fit the description of an opioid stewardship characteristic. An example of a positive theme from an opinion piece would be having an organizational focus on opioid stewardship. Data was extracted from each paper by 2 team members independently and then consensus between the extractions was conducted by a third team member. A summary of the papers included in the data extraction is presented in Table 1.

Table 1 Description of Components of Included Publications

Data Analysis

The extracted data was exported from Covidence into Microsoft Excel spreadsheets for analysis. In total there were 708 characteristics of stewardship identified and 89 qualitative themes extracted from the 71 papers. To better manage the data, each characteristic was assigned a descriptive code with some characteristics assigned sub-topic. For example, the characteristic “assessing patient risk factors for respiratory depression” was coded as “adverse effects” with sub-topic “respiratory”. Similarly, each theme was assigned codes and sub-topics. Coding was validated by the team through consensus.

Findings

Many of the papers were about systems and research conducted in the United States, followed by Canada and Australia. Most of the papers were opinion pieces, followed by quality improvement and cross-sectional studies. There was only one randomized controlled trial and one non-randomized experimental trial. The characteristics are presented in Table 2.

Table 2 World Geographic Region and Publication Classification

There were a total of 58 characteristic codes and 70 sub-topics assigned to the characteristics. Table 3 illustrates each of the characteristics and the sub-topics within each characteristic. The top five characteristics were prescribing guidelines (103 manuscripts), patient education (71 manuscripts), refer/consult (45 manuscripts), audit of prescribing (42 manuscripts), and provider education (42 manuscripts). There were 34 characteristics that were mentioned in five or fewer manuscripts. To get another view of the data, the sub-topics were used as headings to assess their frequency. Table 4 shows the distribution of sub-topics and characteristics associated with each with frequency. The most common sub-topic was care plan and goals (32 manuscripts), followed by pain management (27 manuscripts), assessment (20 manuscripts), and prescribing (18 manuscripts). The most common characteristic associated with care plan and goals was patient education (23 manuscripts).

Table 3 Opioid Stewardship Characteristic Codes and Sub-Topics

Table 4 Opioid Stewardship Characteristic Coding and Sub-Topics

There were a total of 98 themes extracted from the literature. There was a broad variety in the themes which could only be reduced to 39 theme codes and 22 sub-topics. The top seven codes had 4 or more themes assigned to them and can be seen in Table 5 with their sub-topics. The most common theme was barriers identified that inhibited opioid stewardship (12 manuscripts), followed by team (8 manuscripts), education (5 manuscripts), accountability (4 manuscripts), patient-centered (4 manuscripts), risk and access (4 manuscripts). The most common sub-topic for barriers to opioid stewardship was a lack of staff followed by insurance.

Table 5 Most Common Themes in Opioid Stewardship

Discussion

By far, the most common characteristic of opioid stewardship was related to prescribing guidelines, with the most common sub-topic of setting limits on prescribing. Also, common was titrating opioid doses to establish the lowest dose needed for effective pain management. This intervention is primarily targeted towards physicians and other advanced practice providers who order medications and write prescriptions. The next most common feature of opioid stewardship is patient education, and the most common sub-topics are related to care planning and goal setting, general patient education, and disposal of opioids. However, we also see education as a sub-topic of both the pharmacist and nurse role and a multidisciplinary approach begins to appear. The next six most common characteristics all similarly relate to the prescriber. Not until the 7^th most common characteristic do we see a multidisciplinary approach that includes the role of the pharmacist as a significant characteristic of opioid stewardship. We found many position papers and guidelines created by professional pharmacy practice organizations. Pharmacists have a unique role in healthcare as guardians and gatekeepers of medications, so it is logical that they would lead opioid stewardship initiatives. Their advanced knowledge of medications makes them ideal to provide education to providers and patients alike. There is also mention of their interaction with nurses and patients as part of care planning. Further down the list of characteristics, non-pharmacological pain management appears as the 13^th most commonly mentioned. This is a pain management strategy that can be delivered by a wide variety of healthcare workers⁸⁰ and has long been part of nursing practice.⁸¹ As providers continue to reduce their use of opioid medications, nurses will need to augment analgesics with non-pharmacological pain management techniques.

Knowing the patient and providing appropriate patient education about expectations for treatment with opioid prescriptions has been noted to be a common feature of opioid stewardship. Recommendations for patient education included broad pain management for which opioid medications may be a part, a limited number of opioid doses per prescription, and expectations for refills. Pain contracts and care plan goals were also sub-topics in patient education. Disposal of unused opioid medications is also a part of patient education. Further sub-topics related to disposal include safe storage and the use of medication take-back programs.

Provider education about pain management treatment guidelines and the auditing of prescribing practices were common characteristics found in opioid stewardship programs. Published papers that studied the impact of provider education on opioid prescribing generally found that audits of prescribing practices led to decreases in opioid prescriptions and the number of morphine milliequivalents (MMEs) per prescription for a short duration but did not often produce longer-lasting results indicating that routine audits and continuing education are likely needed.

Patient screening for a history of or current substance misuse was a consistently recommended characteristic of opioid stewardship. Mental health assessment and treatment were strategies mentioned to provide optimal patient-centered care and pain management. Chronic pain should be addressed as a part of patient assessment and patient education. The role of pharmacists and nurses in patient and provider education, as well as patient screening, was highlighted.

Other top strategies include the need for open and consistent communication between patients and healthcare providers, committees to oversee stewardship, electronic tools to assist in decision support, patient discharge standards, the use of naloxone (Narcan), awareness of adverse effects, tapering opioids, awareness of morphine equivalents, and drug screening. There were only four mentions of teams or interprofessional collaboration presented as a characteristic of opioid stewardship. This is notable because in the assessment of qualitative themes, teams were the second most frequently mentioned concept, following barriers to successful implementation of stewardship programs in importance. Having adequate resources, including staff, appears to be the biggest barrier to successful opioid stewardship.

There is a key role for healthcare administration and clinical leadership to ensure the development of a culture of opioid stewardship amongst all members of the care team and stronger cross-discipline collaboration and teamwork in patient care. Team-based care is an important aspect as healthcare transfers into its new era of accountability through stewardship of prescribing opioids but also antibiotics and other medications.

Developing and implementing an opioid stewardship program can be challenging when faced with a myriad of possible metrics, a lack of staffing and resources, limited availability of substance use disorder treatment programs and healthcare provider bias related to substance use disorder. Funding streams for employee positions can be evaluated to allocate toward a healthcare provider who is specifically tasked with creating and leading a multidisciplinary team for opioid stewardship. In many institutions, this position is held by a nurse or pharmacist. A member of administration can champion this position and provide support and oversight. Educational objectives for healthcare providers of all disciplines should include modules on bias and stigma in addition to evidence-based opioid prescribing and monitoring practices.

Limitations

There are limitations to this review. This review may not include every publication related to opioid stewardship; however, we did see repetition in characteristics and themes suggesting data saturation. The inclusion of additional manuscripts is unlikely to alter our findings and recommendations. We chose to focus on general opioid stewardship rather than disease-specific opioid management strategies and therefore did not contrast the use of opioids for acute pain to those used for cancer or chronic pain. By design, the integrative review includes a broad variety of literature, and the quality of the literature was not assessed or used as a limitation to inclusion and it allowed us to include 22 opinion or editorial pieces, 2 guidelines, and 2 reports which appear in searches but are not peer-reviewed. We did not conduct a meta-analysis of the quantitative studies, which may have found that different characteristics of stewardship are more effective in the management and appropriate use of opioids than those that are most commonly listed. We took a quasi-qualitative approach to data analysis and although we attempted to improve rigor through consensus and independent reviews, individual bias may have affected our coding and results. Related to the content of the reviewed literature, the primary focus of current literature is on prescribers and prescribing practices with less study of the role and impact of non-prescribing healthcare professionals in opioid stewardship. Patient education about the risks of opioid misuse and expectations of opioid drug therapy, as well as screening for a history of substance misuse, is discussed but more research is needed in this area to further elevate the unique expertise of nurses and pharmacists in these areas. Exploration into the contribution of other providers, including social workers and peer recovery support specialists, is lacking and would benefit from enquiry. Research into the creation of true multidisciplinary teams that include prescribers, pharmacists, nurses, social workers, and case managers with delineation of roles and evaluation of patient outcome metrics can contribute to the evidence base. The most effective content of educational programming for prescribers and other healthcare providers is not well-studied. Findings of this review suggest that education specific to prescribing practices is helpful to apply evidence-based practices for a period of time but adherence wanes. Supplementary education that delves into personal bias, patient experiences of substance use disorder and needs in treatment, and the effectiveness of alternative forms of pain management is absent. Research into the development and delivery, as well as effectiveness of this type of education would be beneficial. This integrative review is intended to be broad in nature and discuss the current state of opioid stewardship metrics, as such, it is generalizable to wide range of institutions and healthcare providers. Editorials and opinion pieces were included in this review which may impact the applicability of the findings to specific institutions.

Conclusion

Although the concept of multidisciplinary patient care is broadly accepted, we found that the literature identifying opioid stewardship practices is heavily weighted towards the role of the prescriber. Current intervention development to improve opioid stewardship which should focus on prescribers is needed. The role of the pharmacists, nurses, and other allied health professionals must be incorporated into opioid stewardship programs as we focus on addressing opioid misuse. We believe additional research into the role of non-prescribing healthcare workers in effective pain management and opioid stewardship programs is still needed to establish true best practices. Further review of non-prescribing allied health professionals in a multi-disciplinary approach is needed as well as potential intervention design in training and practice to increase their holistic involvement in opioid stewardship.

Patient-centered care is a theme of opioid stewardship that was consistently noted throughout this review. Provider education that encompasses patient communication related to patient expectations and comfort with pain management was an important feature of opioid stewardship but outcomes of this standard as a best practice are not found in current literature. We believe this research would be an important addition to our current knowledge.