Hospital Pharmacy - February 2020 - 35

Fancher et al
Table 2. Opioid Exposure Data.

LA opioid new start, n (%)
LA opioid + concurrent opioids, n (%)
IV short-acting agent
PO short-acting agent
IV & PO short-acting agent
Concomitant benzodiazepine, n (%)

Pre-policy (n = 37)

Post-policy (n = 107)

P value

8 (21.6)

29 (27.1)

.427

17 (45.9)
33 (89.1)
26 (70.3)
9 (24.3)

56 (52.3)
83 (77.6)
79 (73.8)
30 (28.0)

.503
.124
.674
.549

Note. LA = long-acting, IV = intravenous, PO = by mouth.

Figure 3. Comparison of naloxone reversal events due to long-acting opioids pre- and post-policy implementation.
Note. OR = odds ratio; CI = confidence interval.

One study conducted by Ray et al found that LA opioids
utilized for chronic, noncancer pain were associated with an
increased risk for all-cause mortality when compared with
anticonvulsants and cyclic antidepressants.5 Similarly, a
study conducted by Gomes et al noted an increase in both the
utilization and dose of opioids, primarily LA opioids. They
also found a strong association between opioid-related mortality and the dose of opioid prescribed.6 Last, a study conducted by Long et al found that patients receiving
intraoperative opioids had increased readmission rates, and
that this association was strongest when a LA opioid was
utilized.7
As part of the LA opioid restriction policy at our institution, providers are required to obtain APS approval to utilize
LA opioids in opioid-naïve patients. These patients are at the
highest risk of unintentional overdose, with the risk being
highest during the first 2 weeks of use.8 For this reason, institutions have similarly implemented LA opioid restriction
policies to help decrease such risks. There was a study conducted by Losby et al at Kaiser Permanente following implementation of various opioid restrictions, including a LA
restriction policy.9 Similar to our institution, they observed a
statistically significant decrease in LA opioid utilization.
However, this study did not include information concerning
unintentional overdose and the effect of a LA opioid

restriction policy on patient morbidity and mortality remains
unclear.
Our data suggest that LA opioid restriction decreases the
utilization of such products. However, this decreased utilization may not reduce the unintentional overdose as it did not
reduce naloxone reversal events due to LA opioids. This was
still the case even after adherence to the policy was assessed,
which was found to be 100%. Therefore, additional and more
robust studies would be required to determine potential strategies for reducing the morbidity and mortality related to LA
opioid utilization.

Limitations
Our study has a number of limitations to consider. The singlecenter design limits the generalizability of the study.
Furthermore, there were a small number of patients, particularly in the pre-policy implementation phase. This was largely
due to the fact that records from this phase were extracted
from paper charts, while data from the post-policy implementation phase were extracted from the electronic medical
record. It is possible that the small number of patients was not
robust enough to detect a difference between groups. In addition, utilizing paper charts for data extraction also limited the
ability to collect a similar time frame of data when compared

Hospital Pharmacy - February 2020

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