Goal-Directed Opioid Stewardship in Acute-on-Chronic Nonmalignant Pain Management


      • Opioid abuse is a growing problem in the United States.
      • Prescription opioids are a major source of misused opioids and overdose deaths.
      • Pain management in those with chronic pain experiencing an acute exacerbation can be complex with few pain management providers available in the acute care settings.
      • Balancing pain management with opioid stewardship can be achieved through shared decision making with patients and providers.
      • Implementation of acute care pain management guidelines can support providers to decrease opioid prescriptions through risk screening, comprehensive assessments, and patient education.


      Prescription opioids were identified as being responsible for 14,000 deaths in 2019, with 9.3 million people admitting to misuse in 2020. This quality improvement project implemented the Institute for Clinical Systems Improvement (ICSI) guideline on pain management in acute care to decrease opioid prescriptions >90 morphine milliequivalents for acute-on-chronic pain. The change to current practice included completion of comprehensive functional assessments and opioid risk screening tools to guide a goal-directed shared decision-making discussion with patients. There was a statistically significant decrease in morphine milliequivalents per prescription (t43 = 2.579, P = .013).


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        • Centers for Disease Control and Prevention
        Annual Surveillance Report of Drug-Related Risks and Outcomes United States.
        • Substance Abuse and Mental Health Services Administration
        Key Substance Use and Mental Health Indicators in the United States: Results From the 2020 National Survey on Drug Use and Health. (HHS Publication No. PEP21-07-01-003, NSDUH Series H-56).
        • The Joint Commission
        Pain assessment and management standards for hospitals. R3 Report.
        (Published online August 29, 2017)
        • Institute for Clinical Systems Improvement
        Pain: Assessment, Non-Opioid Treatment Approaches and Opioid Management Care for Adults.
        Date accessed: June 14, 2021
        • Andrawis-Refila M.
        • McVane M.
        • Moulin A.
        • et al.
        Stem the Tide: Opioid Stewardship Measurement Implementation Guide. 2020. American Hospital Association.
        • Centers for Disease Control and Prevention
        Drug Overdose: Understanding the Epidemic.
        • Haegerich T.M.
        • Jones C.M.
        • Cote P.O.
        • Robinson A.
        • Ross L.
        Evidence for state, community and systems-level prevention strategies to address the opioid crisis.
        Drug Alcohol Depend. 2019; 204: 107563
        • Bonezzi C.
        • Fornasari D.
        • Cricelli C.
        • Magni A.
        • Ventriglia G.
        Pharmacological management of adults with chronic non-cancer pain in general practice.
        Pain Ther. 2020; 9: 17-28
        • Busse J.W.
        • Sadeghirad B.
        • Oparin Y.
        • et al.
        Management of acute pain from non-low back, musculoskeletal injuries : a systematic review and network meta-analysis of randomized trials.
        Ann Intern Med. 2020; 173: 730-738
        • Chou R.
        • Deyo R.
        • Friedly J.
        • et al.
        Nonpharmacologic therapies for low back pain: a systematic review for an American College of Physicians clinical practice guideline.
        Ann Intern Medi. 2017; 166: 493-505
        • Schwenk E.S.
        • Mariano E.R.
        Designing the ideal perioperative pain management plan starts with multimodal analgesia.
        Korean J Anesthesiol. 2018; 71: 345-352
        • Sheldon R.R.
        • Weiss J.B.
        • Do W.S.
        • et al.
        Stemming the tide of opioid addiction—dramatic reductions in postoperative opioid requirements through preoperative education and a standardized analgesic regimen.
        Mil Med. 2020; 185: 436-443
        • Rizk E.
        • Swan J.T.
        • Cheon O.
        • et al.
        Quality indicators to measure the effect of opioid stewardship interventions in hospital and emergency department settings.
        Am J Health Syst Pharm. 2019; 76: 225-235
        • Klimas J.
        • Gorfinkel L.
        • Fairbairn N.
        • et al.
        Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain.
        JAMA Netw Open. 2019; 2e193365
        • Butler S.F.
        • Budman S.H.
        • Fernandez K.C.
        • et al.
        Development and validation of the Current Opioid Misuse Measure.
        Pain. 2007; 130: 144-156
        • Berthelot J.M.
        • Darrieutort-Lafitte C.
        • le Goff B.
        • Maugars Y.
        Strong opioids for noncancer pain due to musculoskeletal diseases: not more effective than acetaminophen or NSAIDs.
        Joint Bone Spine. 2015; 82: 397-401
        • Herzig S.J.
        • Mosher H.J.
        • Calcaterra S.L.
        • Jena A.B.
        • Nuckols T.K.
        Improving the safety of opioid use for acute noncancer pain in hospitalized adults: a consensus statement from the society of hospital medicine.
        J Hosp Med. 2018; 13: 263-271
        • Tilli T.
        • Hunchuck J.
        • Dewhurst N.
        • Kiran T.
        Opioid stewardship: implementing a proactive, pharmacist-led intervention for patients coprescribed opioids and benzodiazepines at an urban academic primary care centre.
        BMJ Open Quality. 2020; 9e000635
        • Hah J.M.
        • Trafton J.A.
        • Narasimhan B.
        • et al.
        Efficacy of motivational-interviewing and guided opioid tapering support for patients undergoing orthopedic surgery (MI-Opioid Taper): a prospective, assessor-blind, randomized controlled pilot trial.
        EClinicalMedicine. 2020; 28: 100596
        • Montori V.M.
        • Kunnerman M.
        • Brito J.P.
        Shared decision making and improving health care.
        JAMA. 2017; 318: 617-618
        • Smalley C.M.
        • Willner M.A.
        • Muir M.R.
        • et al.
        Electronic medical record-based interventions to encourage opioid prescribing best practices in the emergency department.
        Am J Emerg Med. 2020; 38: 1647-1651
        • Manchikanti L.
        • Kaye A.
        • Knezevic N.
        • et al.
        Responsible, safe, and effective prescription of opioids for chronic non-cancer pain American Society of Interventional Pain Physicians (ASIPP) Guidelines.
        Pain Physician. 2017; 20: S3-S92
        • Burgstaller J.M.
        • Held U.
        • Signorell A.
        • Blozik E.
        • Steurer J.
        • Wertli M.M.
        Increased risk of adverse events in noncancer patients with chronic and high-dose opioid use—a health insurance claims analysis.
        PLoS One. 2020; 15e0238285
        • Herzig S.J.
        • Calcaterra S.L.
        • Mosher H.J.
        • et al.
        Safe opioid prescribing for acute noncancer pain in hospitalized adults: a systematic review of existing guidelines.
        J Hosp Med. 2018; 13: 256-262


      Ginger LeAnn Holloway, MSN, FNP-BC, AGACNP-BC, is a DNP student at the University of South Alabama College of Nursing, Mobile, AL, and can be contacted at [email protected]


      Audrey Jane Weymiller, PhD, FNP-BC, ACHPN is a nurse practitioner at Washington Regional Medical System, Fayetteville, AR.


      Angelique Allemand, DNP, FNP, AGACNP is faculty at the University of South Alabama College of Nursing, Mobile, AL.