S t . P a u l ’ s H o s p i t a l
Providence Health Care
Opioid Stewardship Program
Year Four Program Report | January–December 2023
Published: June 2024
2 Opioid Stewardship Program |
Table of Contents
Executive Summary 1
Opioid Stewardship Program 3
Background 4
Opioid Stewardship at St. Paul’s Hospital 5
OSP Team Members 6
Clinical Team 6
Operational Team 6
Research Team 7
Opioid Stewardship Advisory Committee (OSAC) 8
Program Activities 9
Overview 9
Audit and Feedback Program 9
Review of Audit and Feedback Statistics 13
Patient Baseline Demographics 13
Review of Opioid Orders 15
Identified Risk Factors 17
Patient Screening and OSP inclusion 18
Recommended Interventions and Acceptance Rate 19
Education and Presentations 22
Quality Improvement and Research 24
Post-Operative Pain Management PowerPlan Review – Department of Cardiac Surgery 24
Post-Operative Pain Management PowerPlan Review – Department of Orthopedic Surgery 24
Inappropriate Administration of Subcutaneous Opioids 25
Opioid Post-Operative Discharge Prescriptions from
Orthopedic Surgery 25
Opioid Stewardship Program Beyond Year 4 26
Acknowledgements 27
References 28
1 Opioid Stewardship Program | Executive Summary
Executive Summary
In the midst of the overdose crisis within
British Columbia (BC) and in response to the
longstanding prescription opioid crisis, the
St. Paul’s Hospital (SPH) Opioid Stewardship
Program (OSP) was established in January
2020. The goal of the OSP is to improve opioid
prescribing at SPH to reduce adverse events,
long-term dependence and avoid future opioid
misuse, while maintaining or improving pain
management for individuals receiving opioids
during their acute admission. This is the first
OSP within the Providence Health Care (PHC)
and the Vancouver Coastal Health (VCH)
authority geographical areas, and the third
within BC. Following its inaugural year, the
program secured sustained funding from PHC
beginning in 2021.
In the fourth year of the program (2023),
the OSP has continued to provide audit
and feedback and consultation services
to numerous clinical programs at SPH.
Other initiatives at SPH have included
a number of educational presentations,
clinical trainee rotations, review of inpatient
prescribing protocols and PowerPlans, and
continued convening of the established Opioid
Stewardship Advisory Committee (OSAC).
Through our audit and feedback approach, the
OSP provided a total of 2,207 recommendations
for improving opioid prescribing among 898
unique patient encounters in 2023. Examples of
the most common recommendations provided
include: stopping as needed (PRN) opioids
(34%), adjusting opioid dosage (16%), and
adding or increasing non-opioid analgesic
medications (14%). The OSP has demonstrated
continued success in its fourth year, with 95%
of recommendations offered being accepted
and integrated into clinical practice.
In addition to the program’s clinical activities,
a number of educational initiatives have been
undertaken to improve opioid prescribing.
During the fourth year of the program, the OSP
team has successfully delivered presentations at
11 educational events to increase awareness of
the program and disseminate results regarding
its effectiveness. The range of educational
events is substantial and spans across a
number of clinical groups within the hospital
(e.g., general and cardiac surgery nursing
rounds, pharmacist education sessions, general
surgery monthly resident and fellow teaching,
and both teaching of pharmacy students and
residents) as well as internationally (including
at conferences such as the Quality Forum,
the Association of Multidisciplinary Education
and Research in Substance Use and Addiction
[AMERSA] conference, the BC Centre on
Substance Use [BCCSU] conference, and
the Canadian Society of Addiction Medicine
[CSAM] conference). The OSP has also
provided clinical rotations/observerships to two
pharmacist trainees in its fourth year
of operations.
Furthermore, the OSP team has been
actively participating in research and quality
improvement initiatives including ongoing
knowledge translation for projects such as
discharge opioid prescribing from both general
and orthopedic surgery patients. Funded by
the Vancouver Foundation, our overarching
research project evaluating the impact of the
OSP on high-risk opioid prescribing continues,
with results expected by the end of 2024.
2 Opioid Stewardship Program | Executive Summary
Finally, the SPH OSAC, a group of
interdisciplinary health care providers at SPH,
continues to convene quarterly to review
system level changes that may be required
to optimize opioid prescribing in the hospital
setting. Activities have included: submitting
requests for the review of new and modification
of existing Cerner opioid-related PowerPlans,
as well as collaboration to improve medical
staff education and confidence in providing
appropriate opioid discharge prescriptions
where a BC Controlled Prescription is required.
To date, the OSP has demonstrated tremendous
success at improving patient care and safety
with regards to opioid prescribing in the
hospital setting. Such success could not have
occurred without the incredible support of
all of the staff at SPH and their commitment
to improving patient care. The OSP team are
committed to ensuring that the changes we
make today have an equally substantial, positive
impact moving forward.
This report describes key indicators for the
fourth year (e.g., January – December 2023)
of the St. Paul’s Hospital Opioid Stewardship
Program.
3 Opioid Stewardship Program
St. Paul’s Hospital
Opioid Stewardship Program
January 2023 – December 2023
Objective
To improve opioid prescribing
practices to reduce adverse
events and long-term
dependence and avoid future
misuse, while maintaining or
improving pain management
for individuals receiving opioids
during their acute admission.
Program Activities
Clinical Activities
• Consultations
• Audit & Feedback
Education
• Presentations
• Guideline Development
Quality Improvement, Research
& Evaluation
• Research Projects
• Quality Improvement Initiatives
In the fourth year...
14,411
patient encounters identified to
be potentially prescribed opioid
inappropriately
4,083
identified patient encounters
that were screened
2,269
screened patient encounters
that were reviewed
898
reviewed patient encounters that
were offered an intervention
2,207
recommendations were
provided by the OSP
95%
recommendations accepted
5
most common recommendations
34% stop as-needed opioids
16% adjust opioid dosage
14% add or increase non- opioid
pain medication
10% patient education
3% communication to GP
or community team
opioid naïve > 60 years
S t . P a u l ’ s H o s p i t a l
Providence Health Care
n=5,982 n=5,982
4 Opioid Stewardship Program | Background
Background
Prescription opioid misuse and illicit use has become an increasing
problem globally and is linked to an array of negative consequences
including addiction, overdose and mortality.1–3 Canada, the second
highest opioid consumer in the world after the United States,
demonstrated rates of prescription opioid use tripling over the past
decade alone.1,4,5 As rates of opioid prescribing increase, so too has the
development of opioid misuse, addiction and prescription opioid related
overdose deaths, as well as other related morbidities.6–9
Hospitals are a major contributor to the prescription opioid epidemic and related harms.
Hospitals that use opioids most frequently have been shown to have increased rates of adverse drug
events (ADEs) which can also have a negative impact on length of stay and related costs.10-12
Past research has also documented inappropriate opioid prescribing practices in hospitals that can
lead to various harms in the community, such as the development of opioid dependence and opioid
use disorder, overdose, or opioid-induced hyperalgesia.9, 13-15
Despite this evidence, there have been relatively few initiatives put in place to target opioid
prescribing within hospitals. Prescribing stewardship programs in the past have broadly focused on
other medications, notably antimicrobial prescribing which has resulted in reduced antimicrobial use,
reduced C. difficile infections, and significant cost savings.16,17 From the small number of hospital-
based opioid stewardship programs in North America, preliminary results show cost-savings, a
reduction in opioid-associated rapid response calls and code blues, and successful interventions and
consultations related to pain medication reconciliation.18,19
5 Opioid Stewardship Program | Background
Opioid Stewardship at St. Paul’s Hospital
The SPH OSP was implemented in January 2020. The clinical team
consists of a clinical pharmacy specialist and an addiction medicine
physician. The SPH OSP is the third OSP within acute care in the Lower
Mainland and in Canada. Other programs within Canada are focused on
community prescribing. Furthermore, the SPH OSP is the only acute
care program that includes both a physician and a pharmacist along
with a significant research program running concurrently with the
clinical program.
SPH is an optimal location for an inpatient opioid stewardship program as it is an acute care,
teaching, and research hospital servicing the heart of downtown Vancouver. Every day, hundreds
of patients are admitted for care at SPH and at least half of these patients are prescribed an opioid
medication. SPH has a number of world class surgical programs (e.g. cardiac, colorectal, vascular,
and orthopedic surgery) which often involve the prescribing of opioid medications. It is also a centre
for internal medicine, urban health, and mental health services for downtown Vancouver which
provides care for structurally vulnerable patients who may be more likely to have opioid addiction.
With Vancouver being at the epicentre of North America’s overdose crisis, SPH has an important
opportunity to lead clinical practice locally and beyond by demonstrating a commitment to improve
opioid prescribing to reduce adverse events and long-term dependence.20
In the fourth year of the program, the primary goal of the OSP remains to improve opioid
prescribing, utilization, and monitoring at SPH in order to prevent or reduce adverse events, risk of
inappropriate long-term use and dependence, and to improve or maintain adequate pain control for
SPH patients.
This is accomplished through:
1. Clinical activities including implementation of a prospective audit and feedback intervention
as well as clinical consults
2. Quality improvement and research initiatives including evaluation of the program and
outcomes as well as collaborative projects around opioid use in various departments; and
3. Education including development of clinical tools, presentations to various departments and
health disciplines.
6 Opioid Stewardship Program | Background
OSP Team Members
Clinical Team
The clinical team consists of the Opioid Stewardship Clinical Pharmacy Specialist
(Dr. Arielle Beauchesne) and the Opioid Stewardship Physician Lead (Dr. Seonaid Nolan).
Together, they work on the front line providing audit and feedback and clinical consultations, as
well as education to SPH staff, review/development of clinical guidelines and protocols, and
dissemination of program data. Dr. Nolan also collaborates with Dr. Lianping Ti as part of the
Research Team (see below).
Operational Team
The operational team consists of Dr. Michael Legal (Pharmacy Director PHC Acute and Long Term
Care) and Dr. Steven Shalansky (SPH Pharmacy Clinical Coordinator). They support the program by
providing overall direction, logistics, and pharmacy management.
Arielle Beauchene
PharmD
Seonaid Nolan
MD
Michael Legal
PharmD
Steven Shalansky
PharmD
7 Opioid Stewardship Program | Background
Research Team
The research component of the OSP is led by Drs. Lianping Ti (Research Scientist at the BCCSU) and
Seonaid Nolan (Clinician Scientist at the BCCSU and holder of UBC’s Steven Diamond Professorship
in Addiction Care Innovation). They work to conduct research and evaluation initiatives related to
review of the OSP, as well as research related to opioid prescribing in hospital settings.
Lianping Ti
PhD
Seonaid Nolan
MD
“The Opioid
Stewardship team
provides very
useful information
and teaching to
the patient.”
- Provider
8 Opioid Stewardship Program | Background
Opioid Stewardship Advisory Committee (OSAC)
The OSAC was developed by the OSP in order to bring together representatives from major
stakeholder groups to provide advisory support, as well as to disseminate information from the OSP
to their respective practice areas. Current OSAC members include:
• Dr. Rupinder Brar (Regional Addiction Program)
• Elizabeth Dogherty (Addictions Medicine, Nursing)
• Dr. Joan Ng (Addiction Medicine, Pharmacy)
• Dr. Renee Janssen (Addiction Medicine, Internal Medicine)
• Dr. Andrew Kestler (Emergency Department)
• Dr. Isabelle Miles (Emergency Department)
• Linda Jang (Medication Safety, Pharmacy)
• Isabel Diogo (Medication Safety, Nursing)
• Derreck Lee (Medication Safety, Nursing)
• Courtney Symes (Medication Safety, Nursing)
• PJ Matras (Acute Pain Service)
• Dr. Ainsley Sutherland (Acute Pain Service)
• Dr. Michael Legal (Pharmacy)
• Dr. Steve Shalansky (Pharmacy)
• Dr. Felicia Yang (Road to Recovery, Pharmacy)
• Dr. Arielle Beauchesne (Opioid Stewardship, Pharmacy)
• Dr. Seonaid Nolan (Opioid Stewardship)
• Dr. Lianping Ti (BC Centre on Substance Use)
9 Opioid Stewardship Program | Program Activities
Program Activities
Overview
The program activities of the OSP can be divided into three sections: 1) clinical activities,
2) education, and 3) research and quality improvement. Below, activities and preliminary findings
from each of the sections are described in detail.
Clinical Activities
Audit and Feedback
Consultations
Education
Presentations
Development and
review of guidelines
Quality
Improvement,
Research and
Evaluation
Quality Improvement
Initiatives
Research Projects
Audit and Feedback Program
Audit and feedback is an evidence-based strategy to improve professional practice. It involves the
review of specific professional performance (in this case opioid prescribing) then provision of
feedback to the healthcare provider on opportunities to improve prescribing based on available
guidelines and literature. The SPH OSP utilizes a screening list of patients on opioids (as described
below) to identify those who would most benefit from re-assessment and intervention. Audit and
feedback in opioid stewardship is often more time-intensive compared to other audit and feedback
strategies (e.g. antimicrobial stewardship) as pain is multi-factorial and subjective, thus requiring a
more in depth assessment with the patient to determine the most optimal areas for adjustment and
improvement.
As an initial screening, the OSP clinical team extracts daily reports from pharmacy of patients who
have been admitted to SPH (excluding emergency department, critical care areas, and palliative care
unit) and have an active opioid order. Patients are then further assessed if they are not followed by
another consulting service specializing in opioid prescribing (e.g. acute pain service [APS], addiction
medicine consult team [AMCT], palliative care team). Full details regarding the screening process
are included below.
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10 Opioid Stewardship Program | Program Activities
Screening Process
* Abbreviations: NSAID – non-steroidal anti-inflammatory drug, SPH – St. Paul’s Hospital, PCA –
patient-controlled analgesia, APS – acute pain service, AMCT – addictions medicine consult team
STEP 1: Computer generated report
Pharmacy generates a daily report of patients receiving opioids, acetaminophen, NSAIDs,
antiepileptics, and antidepressants at SPH
STEP 2: Computer algorithm
Patients are removed if: (1) they are without an opioid order; (2) they have a PCA/epidural
(followed by APS); (3) have an opioid order from an AMCT attending physician; or (4) they
are admitted by the palliative care service
High risk opioid orders are flagged.
STEP 3: Manual Screening: Patients screened
OSP team then manually remove any remaining patients followed by AMCT, APS, and
Palliative Care and identifies a final list of patients eligible for inclusion in the OSP.
STEP 4: Manual Assessment: Patients included
OSP pharmacist triages the final list according to the number of high-risk opioid orders (e.g.,
a patient with 4 high-risk opioid orders would be seen preferentially over a patient with 1)
STEP 5: Manual Assessment: Patients receiving recommendations
OSP team reviews full patient electronic health record and may speak to patient and care
team, if felt appropriate, and provides recommendations on improving opioid prescribing
11 Opioid Stewardship Program | Program Activities
Screening Steps
STEP 1: Computer Generated Report
An initial screening list is compiled by the OSP Clinical Pharmacy Specialist using the Cerner
electronic health record and includes all patients that are prescribed opioids or other target
medications (e.g. antidepressants, anticonvulsants, benzodiazepines, zopiclone, acetaminophen,
NSAIDs) who reside on an inpatient ward at SPH (excluding critical care and palliative care units).
STEP 2: Computer Algorithm
A separate screening algorithm then removes any patients without an opioid order, those with
patient-controlled analgesia (PCA) or epidural orders (as a marker of APS involvement), and orders
written by an attending physician from the addiction medicine consult team (AMCT).
Following this, the screening algorithm then identifies the number and type of high-risk opioid orders
for each patient. The 13 criteria used to identify a high-risk opioid order were developed based on a
comprehensive literature review and consultation with physicians with expertise in chronic pain and
addiction management. These include
Patient-related Risk Factors:
1. Use of opioid medication in a patient who is opioid naïve
2. Use of opioid medication in a patient with personal history of depressive disorder, anxiety
disorder, and/or post-traumatic stress disorder
3. Use of opioid medication in a patient greater than 60 years old
Prescription-related Risk Factors:
4. Use of parenteral opioids when orders suggest the patient is receiving a normal diet and
taking nutrition orally
5. High frequency opioid prescribing (<4 hours)
6. Multiple different opioids prescribed concomitantly for regular and as needed (PRN) use
7. Regular dosing of an opioid prescribed for PRN use
8. Long-acting opioid prescriptions within the first 5 days of a patient’s hospital stay
9. High daily dose of an opioid, defined as a prescribed daily dose of 90 morphine milligram
equivalent (MME) or greater
10. Long duration of opioid prescribing, defined as a patient on opioids on or beyond day 5 of
hospitalization
11. Concurrent opioid and sedative (e.g. benzodiazepine) prescription
12. No adjunctive order for non-opioid analgesics including acetaminophen, NSAIDs, and/or
medication for neuropathic pain (where appropriate)
13. Use of an opioid medication where naloxone administration was required in the last 24 hours
12 Opioid Stewardship Program | Program Activities
Of note, there are other evidence-based criteria that increase the risk of opioid-related adverse
events (e.g. renal and hepatic impairment, history of or active substance use disorder) that we were
unable to include due to limitations with our screening list. However, these are assessed during STEP
4 by the Opioid Stewardship Clinical Team.
STEP 3: Manual Screening: Patients Screened
The OSP Team manually screens through the list and patient charts to remove additional patients
followed by AMCT, APS, and palliative care.
STEP 4: Manual Assessment: Patients Included
The OSP pharmacist triages the final list of patients according to the number of high risk opioid
orders (i.e. a patient with 4 high-risk opioid orders would be seen preferentially over a patient
with 1).
Based on a preliminary review of the electronic health record, patients are identified who may
benefit from an intervention to optimize opioid prescribing.
STEP 5: Manual Assessment: Patients Receiving Recommendations
Patients identified in STEP 4 then receive a full clinical assessment from the opioid stewardship
pharmacist (including full review of electronic health record and often times discussion with the
patient and clinical team) to determine how analgesic therapy can be optimized to improve or
maintain pain management while improving opioid safety.
For patients who would benefit from an intervention, recommendations are delivered in any
combination of the following four ways: (1) documenting a note in the patient’s electronic medical
record; (2) speaking to the patient; (3) speaking to the attending physician; and/or (4) speaking
to the ward pharmacist. Multiple actions may be done for the same assessment (i.e. speaking to
physician and documenting in note).
13 Opioid Stewardship Program | Program Activities
Review of Audit and Feedback Statistics
This section summarizes the baseline demographics, risk factors, and opioids ordered for patients
exposed to opioids at SPH from January 01, 2023 to December 31, 2023. The patients included in this
analysis are from “STEP 2: Computer Algorithm” of the screening process listed on page 10.
Furthermore, this section will also provide details regarding all patients screened for and assessed
by the OSP as well as the number and type of recommendations and acceptance rate of these
recommendations between January and December 2023.
Patient Baseline Demographics
Below, we have described patient characteristics, patient’s admitting clinical service, and patient’s
history of opioid use prior to hospital admission among a total of 5,982 patient encounters across
5,652 unique patients (as some patients were admitted multiple times) who were exposed to opioids
between January and December 2023. These patients were identified by pharmacy’s daily generated
report (and prior to manual screening by the OSP team). Many patients appeared on multiple daily
reports during their hospital stay, but only the data from the first day is included in this review of
patient baseline demographics.
Age and Sex
Of the 5,652 unique patients exposed to opioids from January to December 2023: 44% were female
and 56% were male. The mean age was 57 years for females, and 61 years for males.
Admitting Clinical Service
Of the total patient encounters (n = 5,982), patients were admitted under the care of a variety
of clinical services at SPH. The largest proportion of patients were admitted to General Internal
Medicine (30%), Cardiac Surgery (11%), and General Surgery (11%). It is important to note that
some of these patients may be prescribed opioid agonist therapy for opioid use disorder and would
have been excluded from further assessment by the OSP during the next step of the screening
process. Also, the distribution of patients prescribed opioids by various services does not necessarily
reflect suboptimal prescribing practices on these services, rather it may relate to the volume of
patients admitted under these services.
14 Opioid Stewardship Program | Program Activities
Opioid Use Prior to Admission
History of opioid prescription within 30 days prior to hospital
admission was collected as a marker of whether the patient
was opioid naïve or not (n = 5,982). The majority of patients
(69%) were opioid naïve at the time of unique hospital
admission.
Patients prescribed opioids who are previously opioid naïve
are at higher risk of adverse events from opioids due to a
lack of tolerance. This provides an opportunity for the OSP
to provide recommendations to encourage safer use of
opioids. Patients who do have a history of opioid use often
times have a complex pain history, escalated doses of opioids
in community, and may be at higher risk for poorly managed
acute pain in hospital. There is an opportunity for the OSP to
intervene and provide recommendations to improve acute
pain management (including liaising with our pain teams)
and reduce inappropriate, long-term use of opioids for both
patient populations.
General Internal Medicine
0% 5% 10% 15% 20% 25% 30% 35%
General Surgery
Cardiac Surgery
Orthopedic Surgery
Cardiology
Infectious Diseases
Obstetrics
Urology
Psychiatry
Gastroenterology
Vascular Surgery
Gynecology
Geriatric Medicine
Transplant
Respirology
Other
Figure 1: Admitting Clinical Service of Patients Prescribed Opioids at SPH
(n=5,982)
* Other includes: Hematology, Nephrology, Emergency Medicine, Plastic Surgery, Neurology, Critical Care, Neurosurgery, Ophthalmology,
Otolaryngology, and Pain Medicine.
Figure 2: 30-day Opioid
Use of Patients Receiving
Opioids at SPH (n=5,982)
31%
History of opioid use
No history of opioid use
69%
15 Opioid Stewardship Program | Program Activities
Review of Opioid Orders
Below, we have reported on active opioid orders during unique patient encounters among patients
exposed to opioids from January to December 2023 that were included in the OSP screening list.
Key indicators included: type of opioid(s) prescribed, whether opioids were prescribed regularly or
as needed, and route(s) of administration.
Type of Opioid Prescribing
Numerous formulations of opioids were prescribed for patients at SPH. Hydromorphone was the
most common opioid prescription and the majority of patients received hydromorphone during their
hospital stay (89%) with morphine as the second most common (14%). Patients could have multiple
opioids prescribed; thus, the sum of the percentages is greater than 100%.
Hydromorphone
Morphine
Methadone
Fentanyl
Acetaminophen / Caffeine / Codeine
Sufentanil
Oxycodone
Codeine
Other
89% 14% 9%
*Other category includes: Meperidine, Oxycodone-Acetaminophen, Tramadol, Tramadol-Acetaminophen, Diacetylmorphine.
Figure 3: Type of Opioid Prescribed (n=5,982)
0% 20% 40% 60% 80% 100% 120% 140%
89% 14% 9%
16 Opioid Stewardship Program | Program Activities
Frequency of Opioid Prescribing
The majority of patients (70%) were exclusively prescribed as needed (PRN) opioids, 30% received
a mixture of both PRN opioids and regularly prescribed opioids, while none were prescribed only
regularly scheduled opioids.
As the majority of opioids are prescribed as needed, this presents an opportunity to reduce or
discontinue opioids that are no longer required (to avoid inappropriate long-term use or exposure)
or to optimize pain control by recommending a change to a regularly scheduled regimen for patients
that require it.
Route(s) of Administration for Opioid Prescribing
For patients exposed to opioids, the majority of patients were prescribed at least one opioid with an
oral administration route (93%). About a third of patients (30%) were prescribed an intravenous
opioid and 17% had a subcutaneous opioid order. Patients could have multiple treatment routes;
thus, the sum is greater than 100%.
Although the most common route of opioid prescribing is oral, several patients were still receiving
parenteral opioids. This may represent an example of inappropriate use if patients were able to take
an oral formulation. Accordingly, an opportunity arises for the OSP to intervene and reduce the
unnecessary use of parenteral opioids which have been associated with increased risk of adverse
events and medication errors.
Oral
Intravenous
Subcutaneous
Sublingual
Topical
Other
* Other category includes: Buccal, G-tube, GJ-tube, Intramuscular, Intradermal, NG-tube, OG-tube, and PEG-tube
Figure 4: Opioid Routes of Administration (n=5,982)
0% 20% 40% 60% 80% 100% 120% 140% 160%
93% 30% 17%
17 Opioid Stewardship Program | Program Activities
Identified Risk Factors
The screening algorithm identified risk factors for 14,411 total encounters captured by the OSP
among 5,982 unique patient encounters for 5,652 unique patients exposed to opioids between
January to December 2023. The most common risk factors identified included: long duration of
opioid prescribing (80%; risk factor #10 above), patient is opioid naïve (73%; risk factor #1 above),
and high frequency opioid prescribing (69%; risk factor #5 above).
A number of the most common risk factors are modifiable and can be intervened on to reduce the
risk of adverse events. Additional risk factors such as patient being opioid naïve or age >60 years
further increase risk of adverse events and allow for opportunities for the OSP to provide targeted
interventions to those who would benefit most. The most common risk factor (i.e., long duration of
opioid prescribing) is also associated with increased risk of long-term dependence and provides a
major opportunity for intervention that could have a long-term impact beyond acute care.
Long duration of opioid prescribing (>5 days)
0% 10% 20% 30% 40% 50% 60% 70% 80%
Patient is opioid naïve
High frequency opioid prescribing
Patient is >60 years
Concurrent opioid and sedative ordered
Use of parenteral opioids
Patient with a history of depression, anxiety or PTSD
Multiple different concomitant opioids ordered
Long-acting opioid prescriptions within the first 5 days
High daily dose of morphine (>90 MME)
Not ordered non-opioid analgesic
Regular dosing of an opioid prescribed for PRN use
Naloxone administration
Figure 5: Identified Risk Factors for Patients Receiving Opioids at SPH (n=14,411)
18 Opioid Stewardship Program | Program Activities
Patient Screening and OSP inclusion
In the fourth year of the program, the OSP clinical team screened 4,083 patient encounters from
1,994 unique patients who were exposed to opioids (STEP 3: Manual Screening: Patients Screened).
The number of “patient encounters” reflects that some patients were assessed multiple times during
the course of their admission or over repeat admissions. Of these, 2,269 patient encounters from
1,331 unique patients met the criteria for inclusion (i.e. admitted to a non-critical care unit and
not followed by addiction medicine, acute pain, or palliative care services) and received further
assessment to determine if intervention to improve opioid prescribing was required (STEP 4: Manual
Assessment: Patients Included). A subset of 898 patient encounters for 691 unique patients resulted
in recommendations for interventions being offered (STEP 5: Manual Assessment: Patients Receiving
Recommendations).
“Very thorough evaluation
of the patient’s pain
management and needs.
Communication was very
clear to both the team
and patient.”
– Provider
Screened
0
500
1000
1500
2000
2500
3000
3500
Included Intervened
Figure 6: Patient Encounters Screened, Included, and Interventions Offered by OSP
(n=1,994 unique patients)
4,083
2,269
898
4000
4500
19 Opioid Stewardship Program | Program Activities
Recommended Interventions and Acceptance Rate
Below, we have reported on the different intervention recommendations, acceptance rate of these
recommendations, and number of consultations received.
Type of Recommended Intervention
Of the 898 patient encounters from 691 unique patients that the OSP clinical team assessed, a total
of 2,207 interventions were recommended. The three most common were: stopping as needed PRN
opioids (34%), adjusting the opioid dose (16%), and add or increase non-opioid analgesic (14%).
The most common recommendations are indicative of the general overall approach to improving
opioid prescribing through optimizing non-opioid analgesia, educating patients on the use of
opioid medications and associated adverse effects, and reducing or discontinuing opioids where
appropriate. The recommendations correspond to the most common risk factors described above
(i.e. long-duration of opioid prescribing may lead to discontinuation of PRN opioid, use of opioid in
opioid naïve patient or patient > 60 years of age may lead to adjustment in dose).
Stop as needed (PRN) opioid
0% 5% 10% 15% 20% 25% 30% 35%
Adjust opioid dosage
Add or increase non-opioid analgesic
Patient education
Communication to GP or community team
Tapering plan for opioids
Discharge prescription opioid - change quantity
Change/add oral (PO) route
Switch to different opioid
Decrease dose or stop non-opioid analgesic
Stop regular short-acting opioid
Stop or taper bzds
Recommended non-drug measure
Stop regular long-acting opioid
Discharge prescription opioid - change drug
Discharge prescription opioid - discontinue
Naloxone kit dispensed or inpatient orders added
Figure 7: Types of Interventions Provided by the OSP (n=2,207)
* Other category includes: Add bowel medications, Naloxone kit assessed – not given because patient already has a kit, Refer to APS,
Refer to Palliative Care, Stop or taper zopiclone, and organizing drug coverage
Change opioid (including change formulation)
Refer to AMCT
Other
20 Opioid Stewardship Program | Program Activities
Acceptance Rate of Recommended Interventions
In the third year of the OSP, we offered a total of 2,207 recommended interventions. The overall
acceptance rate of OSP recommendations for this period was 95%. Of the 5% of recommended
interventions that were not accepted (n = 105), 13% were not accepted by the patient, and 56%
were not accepted by the prescribing physician (or their team). Reasons for not accepting were not
provided for the remaining 31%. Instances of patient non-acceptance were often due to concern for
worsened control or escalation of pain. Similarly, prescribers may also have been hesitant to make
adjustments to opioid regimen due to perceived severity of pain and fear of destabilizing patients.
These cases often required further education and collaborative care between the patient, prescriber
and the OSP.
“Practical recommendations about
optimizing opioid routes, dosing
regimens, adding or optimizing
adjunctive pain or anxiety
medications, liaising directly
with prescribers about opioid
tapering regimens, answering drug
information questions related to
opioid dose conversions, helping
to select most appropriate opioid
based on patient factors.”
– Provider
Accepted
Not Accepted
95%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Figure 8: Overall Acceptance Rate of Recommended Interventions (n=2,207)
5%
21 Opioid Stewardship Program | Program Activities
Consultations
The total number of consultations the OSP received over year four of the program was 149.
This figure continues to increase across the fourth year of the program and demonstrates that
the program continues to sustain uptake. The number of consultations per month spanned a wide
range with 3 in August 2023 to a high of 21 in January 2023, averaging at about 12 consultations
per month. This not only indicates increased awareness about the OSP, but also increased appetite
among clinicians to involve the program in patient management. These consultations are generally
more complex and help the OSP identify patients at higher need of an assessment in a timelier
manner than through general screening. It is our hope to further increase awareness of the program,
increase consultations, and increase impact of the OSP on providing recommendations for patients
who would most benefit from it. As the OSP is one of a number of consult services available at SPH
in regards to opioid prescribing (in addition to the Acute Pain Service, Addiction Medicine Consult
Team, and Palliative Care Service) we also anticipate that we may continue to act as a bridge to
facilitate appropriate consultations to other services for more comprehensive, targeted interventions
and longitudinal follow-up.
Jan Feb Mar Apr May June
Number of OSP consultations
July Aug Sept Oct Nov Dec
6
4
2
0
8
10
12
14
16
18
20
Figure 9: Number of Consultations the OSP Received (n=149)
22
22 Opioid Stewardship Program | Program Activities
Education and Presentations
The OSP has been involved in a number of educational activities to improve the prescribing and use
of opioids at SPH in a number of clinical areas including:
Date Area Presentation Approximate
number of
attendees
January 12, 2023 PHC Acute Nursing
Practice Council
Meeting
Opioid Stewardship Program 30
February – March 2023 SPH Inpatient
Surgery
Nursing inservice on
the utility of oral vs.
subcutaneous opioids
35
April 3 - 28, 2023 Pharmacy Clinical rotation for Lower
Mainland Pharmacy Services
Year 1 Resident
1
June 12 - 13, 2023 Pharmacy Clinical observership for
BCCSU Pharmacy Fellowship
1
September 4 - 15, 2023 SPH Inpatient
Cardiac Surgery
Nursing rounds for nurses and
nursing students on 5B
35
September 19, 2023 SPH CSICU Care
Team Meeting
Post-operative opioid orders
and opioid stewardship
paired with appropriate post-
operative analgesia
15
July – December 2023 General Surgery
Resident & Fellow
Teaching
Post-operative analgesia and
opioid discharge prescribing
25
September – December
2023
Pharmacy Education session for UBC
Entry-to-Practice PharmD
students
12
23 Opioid Stewardship Program | Program Activities
The OSP has also presented at conferences to educate others on the importance of opioid
stewardship and share lessons learned from the SPH OSP:
Date Area Presentation Approximate
number of
attendees
April 28, 2023 Pacific Pain Forum An Exploratory Analysis of
Post-Surgical Discharge Opioid
Prescribing and Consumption
Patterns in a Canadian Setting
170
April 20 - 22, 2023 BC Centre on
Substance Use
Conference
A 3-year review of a hospital-
based Opioid Stewardship
Program
579
June 8, 2023 Quality Forum An Exploratory Analysis of
Post-Surgical Discharge Opioid
Prescribing and Consumption
Patterns in a Canadian Setting
50
Oct 19 - 21, 2023 CSAM-SMCA
2023 Scientific
Conference and
Annual Meeting
A 3-year review of a hospital-
based Opioid Stewardship
Program
100
November 2 - 4, 2023 AMERSA 2023
Conference
A 3-year review of a hospital-
based Opioid Stewardship
Program
2,000
24 Opioid Stewardship Program | Program Activities
Quality Improvement and Research
The OSP has also been involved in quality improvement projects and
initiatives around opioid prescribing at SPH.
Post-Operative Pain Management PowerPlan Review – Department
of Cardiac Surgery
Through audit and feedback, the OSP identified orders within the Cardiac Surgery Post-Operative
Pain and Symptom Management PowerPlan to require review. The opioid ranges identified contained
doses that were above what is recommended (e.g. Hydromorphone 1-4mg orally every two hours
as needed) for opioid naïve patients, placing them at higher risk for opioid-related adverse events.
These orders are not only utilized in the cardiac surgery intensive care unit, but on the cardiac
surgery ward as well.
In collaboration with the SPH Acute Pain Service and with endorsement from various stakeholders
in the cardiac surgery working group across all Cerner sites, the OSP was successful in submitting
and implementing a request for the opioid orders within this PowerPlan to be redesigned with a
more judicious opioid dosing range (e.g. Hydromorphone 1-2mg orally every two hours as needed).
System changes went active in Cerner during July 2023.
To address the changes, education was provided to both frontline nursing staff as well as clinical
nurse educators and other members of the cardiac surgery care team.
Post-Operative Pain Management PowerPlan Review – Department
of Orthopedic Surgery
In 2022, several medication orders were identified within the orthopedic post operative pain and
symptoms management PowerPlan to need review. More specifically, the use of high dose opioids for
opioid naïve patients and inappropriate use of long-acting opioids for acute pain, placing patients at
increased risk of opioid-related adverse events.
A request for this PowerPlan to be redesigned was submitted in 2022 in collaboration with the
SPH Acute Pain Service and with endorsement from the Department of Orthopedic Surgery.
Throughout the fourth year of the OSP program, 2023, some additional education was
provided to other Cerner sites in order to gain further endorsement for the requested changes.
After endorsement from the orthopedic groups at all Cerner sites, the changes went live May 2023.
Since implementation, there has been anectodal reduction in inappropriate use of high-dose opioids
for opioid naïve patients, use of subcutaneous opioids for patients who are otherwise able to take
medications orally, and use of long-acting opioids for acute post-operative pain.
25 Opioid Stewardship Program | Program Activities
Inappropriate Administration of Subcutaneous Opioids
Subcutaneous opioids are routinely ordered either ad-hoc or as part of PowerPlans for use as
an alternative to oral opioids in patients who are unable to tolerate oral intake. Prior to Cerner
implementation, subcutaneous opioid orders included clear comments that they are not to be given
in addition to oral opioids. However, these order comments have been removed with implementation
of Cerner and are no longer attached to any ad-hoc or PowerPlan subcutaneous opioid orders.
Since this change, several Patient Safety and Learning System (PSLS) incidents relating to patients
inappropriately receiving opioids concurrently via both oral and subcutaneous routes have been
recorded. These incidents have demonstrated increased risk of adverse effects and negative
outcomes related to inappropriate subcutaneous opioid use.
In collaboration with the Medication Safety team and Professional Practice, the OSAC has
successfully requested system changes to include appropriate order comments to all subcutaneous
opioid orders available on Cerner (ad-hoc and within PowerPlans). This request requires further
education in addition to discussion with affected working groups and sites, thus the changes have yet
to be implemented but are expected to be completed in 2024/2025.
Opioid Post-Operative Discharge Prescriptions from
Orthopedic Surgery
It has been previously documented that a large proportion of patients who are discharged from
surgical services receive a larger supply of opioid on their discharge prescription than required.
These opioids are generally not stored in a locked location and not appropriately disposed of.
The SPH Department of Anesthesiology, in collaboration with the OSP, undertook an exploratory
analysis of discharge opioid prescribing and consumption within the SPH Department of Orthopedic
Surgery to further characterize local prescribing practices.
Overall, a median of 400MME was prescribed upon discharge after orthopedic surgery.
Significant discordance was observed between the amount prescribed on discharge compared
to consumed post-discharge (412.5MME [IQR 400] vs. 142.2MME [IQR 240.9], p= 4.68e-7).
Reassuringly, 93% of participants were either satisfied or very satisfied with their pain management.
Zero participants reported storing their opioids in a locked location or disposing of excess pills at the
time of the survey. The discordance between the amount prescribed versus consumed, paired with
the lack of appropriate storage and disposal of opioids, contributes to the excess opioid reservoir
available in community and represents a risk for diversion.
The results highlight the need for interventions to improve opioid discharge prescribing, including
individual prescriber education, ongoing OSP intervention where possible, and ideally a more
standardized opioid prescribing pathway utilizing individual patient characteristics and inpatient
consumption patterns to inform more appropriate post-surgical discharge opioid prescribing.
26 Opioid Stewardship Program | Program Activities
Opioid Stewardship Program Beyond Year 4
The fourth year of the OSP held continued success and uptake for the program while maintaining
a strong focus on education, teaching, and knowledge translation. Importantly, the OSP received
guaranteed funding for continued operations from PHC in the Fall of 2021.
In the fifth operational year of the program, the OSP will continue with a strong clinical focus,
providing audit and feedback services as well as consultations. In addition, the OSP will continue to
advocate for system-level change and creation of other OSP or OSP-like programs to improve opioid
prescribing across all Cerner sites, alongside ongoing educational and quality improvement initiatives
at a site-specific level.
27 Opioid Stewardship Program | Acknowledgements
Acknowledgements
The OSP would like to offer thanks to the participants of its program.
Providence Health Care and St. Paul’s Hospital
Additionally, we would like to acknowledge and thank
senior leadership at SPH for its support of the OSP as
well as the amazing staff and healthcare teams at SPH
and their continued willingness to work with the OSP
team. We would also like express our gratitude to
Providence Health Care who assumed permanent
financing for the OSP in the Fall of 2021.
BC Centre on Substance Use
We would like to thank the BCCSU for their continued
financial and resource contributions including research
expertise, administrative and analytical support.
SPH Pharmacy
We would like to thank the SPH Pharmacy Department
for management and resource contributions including
administration support.
Opioid Stewardship Advisory Committee
We would like to express our gratitude to all the members
of the OSAC for generously donating their time to tackle
issues related to opioid prescribing.
Clinical Systems Transformation group
We would also like to thank the CST group for their
support of the OSP and working with us to develop a
screening report to increase efficiency of our audit
and feedback program.
Vancouver Foundation
The OSP was originally made possible by a grant from
the Vancouver Foundation.
Fraser Health Opioid Stewardship Programs
We would like to thank the OSPs at Royal Columbian
Hospital and Surrey Memorial Hospital for sharing their
experience and expertise, and for the work that they do
to improve opioid prescribing in the Fraser Region.
SPH Antimicrobial Stewardship Program
We would like to thank the Antimicrobial Stewardship
Program (AMS) for sharing their support and guidance
as we worked to establish the OSP modelled around the
success of AMS.
Providence Health Care Communications
We would like to thank PHC Communications for their
support in preparing this forth year report.
Suggested citation: Beauchesne A, Crepeault H, Legal
M, Shalansky S, Ti L, Nolan S. (2024). St. Paul’s Hospital
Opioid Stewardship Program: Fourth Annual Program
Report January – December 2023. British Columbia
Centre on Substance Use and Providence Health Care,
Vancouver, Canada.
28 Opioid Stewardship Program | References
References
1. Fischer B, Argento E. Prescription opioid related
misuse, harms, diversion and interventions
in Canada: a review. Pain Physician.
2012;15(3 Suppl):ES191-203.
2. Miller M, Barber CW, Leatherman S, et al.
Prescription Opioid Duration of Action and the Risk
of Unintentional Overdose Among Patients Receiving
Opioid Therapy. JAMA Intern Med. 2015;175(4):608-
615. doi:10.1001/jamainternmed.2014.8071
3. Fischer B, Jones W, Urbanoski K, Skinner R, Rehm J.
Correlations between prescription opioid analgesic
dispensing levels and related mortality and morbidity
in Ontario, Canada, 2005-2011. Drug Alcohol Rev.
2014;33(1):19-26. doi:10.1111/dar.12089
4. Shield KD, Jones W, Rehm J, Fischer B. Use and
nonmedical use of prescription opioid analgesics in
the general population of Canada and correlations
with dispensing levels in 2009. Pain Res Manag J Can
Pain Soc. 2013;18(2):69-74.
5. Pain & Policy Studies Group. Opioid Consumption
Data. Published 2016. http://www.painpolicy.wisc.
edu/opioid-consumption-data
6. BC Coroners Service. Illicit Drug Overdose Deaths in
BC: January 1, 2007-August 31, 2016. Office of the
Chief Coroner, Minstry of Justice
7. Correa D, Farney RJ, Chung F, Prasad A, Lam
D, Wong J. Chronic opioid use and central
sleep apnea: a review of the prevalence,
mechanisms, and perioperative considerations.
Anesth Analg. 2015;120(6):1273-1285. doi:10.1213/
ANE.0000000000000672
8. Carullo VP, Fitz-James IA, Delphin ES. Opioid-induced
hyperalgesia: A diagnostic dilemma. J Pain Palliat
Care Pharmacother. 2015;29(4):378-384. doi:10.310
9/15360288.2015.1082006
9. Bannister K. Opioid-induced hyperalgesia:
where are we now? Curr Opin Support Palliat
Care. 2015;9(2):116-121. doi:10.1097/
SPC.0000000000000137
10. Oderda GM, Gan TJ, Johnson BH, Robinson SB.
Effect of opioid-related adverse events on outcomes
in selected surgical patients. J Pain Palliat Care
Pharmacother. 2013;27(1):62-70. doi:10.3109/15360
288.2012.751956
11. Herzig SJ, Rothberg MB, Cheung M, Ngo LH,
Marcantonio ER. Opioid utilization and opioid-
related adverse events in nonsurgical patients in US
hospitals. J Hosp Med. 2014;9(2):73-81. doi:10.1002/
jhm.2102
12. Oderda GM, Said Q, Evans RS, et al. Opioid-
related adverse drug events in surgical
hospitalizations: impact on costs and length of
stay. Ann Pharmacother. 2007;41(3):400-406.
doi:10.1345/aph.1H386
13. Brat GA, Agniel D, Beam A, Yorkgitis B, Bicket M,
Homer M, et al. Postsurgical prescriptions for opioid
naive patients and association with overdose and
misuse: retrospective cohort study. BMJ. 2018 Jan
17;360:j5790.
14. Jenkins BG, Tuffin PHR, Choo CL, Schug SA.
Opioid prescribing: an assessment using quality
statements. J Clin Pharm Ther. 2005;30(6):597-602.
doi:10.1111/j.1365-2710.2005.00690.x
15. Zacny J, Bigelow G, Compton P, Foley K, Iguchi
M, Sannerud C. College on Problems of Drug
Dependence taskforce on prescription opioid
non-medical use and abuse: position statement.
Drug Alcohol Depend. 2003;69(3):215-232.
doi:10.1016/s0376-8716(03)00003-6
29 Opioid Stewardship Program | References
16. Nowak MA, Nelson RE, Breidenbach JL, Thompson
PA, Carson PJ. Clinical and economic outcomes of
a prospective antimicrobial stewardship program.
Am J Health-Syst Pharm AJHP Off J Am Soc Health-
Syst Pharm. 2012;69(17):1500-1508. doi:10.2146/
ajhp110603
17. Malani AN, Richards PG, Kapila S, Otto MH,
Czerwinski J, Singal B. Clinical and economic
outcomes from a community hospital’s antimicrobial
stewardship program. Am J Infect Control.
2013;41(2):145-148. doi:10.1016/j.ajic.2012.02.021
18. Ghafoor VL, Phelps P, Pastor J. Implementation
of a pain medication stewardship program. Am J
Health-Syst Pharm AJHP Off J Am Soc Health-Syst
Pharm. 2013;70(23):2070, 2074-2075. doi:10.2146/
ajhp120751
19. Erickson A. Knocking out pain: Hospital pharmacists
launch new approach to pain management.
Published 2016. Accessed July 30, 2020. https://
www.pharmacist.com/article/knocking-out-pain-
hospital-pharmacists-launch-new-approach-pain-
management
20. British Columbia Coroners Service. Illicit Drug
Toxicity Deaths in BC January 1, 2010 - August 31,
2020 [internet]. Vancouver: Ministry of Public Safety
& Solicitor General. 23 Sept 2020 [cited 1 Oct 2020].
Available from: https://www2.gov.bc.ca/assets/gov/
birth-adoption-death-marriage-and-divorce/deaths/
coroners-service/statistical/illicit-drug.pdf
21. Han B, Compton WM, Blanco C, Crane E, Lee J,
Jones CM. Prescription opioid use, misuse, and use
disorders in U.S. adults: 2015 national survey on drug
use and health. Ann Intern Med. 2017;167(5):293-
301. doi: 10.7326/M17-0865
22. Feinberg AE, Chesney TR, Srikandarajah S, Acuna
SA, McLeod RS, Best Practice in Surgery Group.
Opioid use after discharge in postoperative patients:
A systematic review. Ann Surg. 2018;267(6):1056-
1062. doi: 10.1097/SLA.0000000000002591
23. Bicket MC, Long JJ, Pronovost PJ, Alexander GC,
Wu CL. Prescription opioid analgesics commonly
unused after surgery: A systematic review.
JAMA Surg. 2017;152(11):1066-1071. doi: 10.1001/
jamasurg.2017.0831
