PHILADELPHIA – After instituting a strategy to minimize intraveneous (IV) opioid treatment for hospitalized patients with Inflammatory Bowel Disease, a study at the Perelman School of Medicine at the University of Pennsylvania showed that, in the months after the interventions, patients had decreased opioid exposure. Patients hospitalized after the implementation of the strategy also had fewer return hospitalizations within 30 days and shorter lengths of stays, with no increase in pain scores. Researchers said the results not only suggest the implemented strategies to reduce IV opioid treatment were effective but that patient health outcomes are better, study is published in The American Journal of Gastroenterology.
Inflammatory Bowl Disease (IBD) includes both Crohn’s disease and ulcerative colitis and affects roughly 3 million people in the United States, according to the most recent data from the Centers of Disease Control and Prevention. Inflammation, which characterizes the disease, can be incredibly painful and can warrant medical treatment to provide relief. In an effort to treat fewer hospitalized people with IBD with the use of opioids, specifically emphasizing reduction in opioids administered intravenously, a team of researchers put four different tactics to work over a 6-month period.
The plan involved making it easier for clinicians to prescribe IV acetaminophen to IBD patients, including computer-based notes to explain the risks of opioid use among IBD patients, posting an easily accessible pain too, when clinicians consciously try to mitigate patients’ pain without IV opioids. The management intranet plan for IBD patients, and instituting an automated text message to hospital clinicians through a platform called AGENT that was developed by the Penn Medicine Center for Health Care Innovation. Those interventions led to 31 percent of IBD patients receiving IV opioids for pain versus 44 percent of IBD patients receiving IV opioids pre-interventions. When compared to the six months before the interventions, pain scores of hospitalized patients were no higher, suggesting that other tactics like giving IV acetaminophen, were just as good at relieving pain. Additionally, fewer hospitalized IBD patients needed to be readmitted to the hospital in the following thirty days, and patients had shorter stays in the hospital—5.3 days on average compared to 7.2 days on average pre-intervention.
“Most people are of aware of addiction risks related to opioids, but there is substantial evidence that opioids can be damaging for people with IBD,” said first author Rahul Dalal, MD, a former resident in internal medicine at Penn and current fellow in Gastroenterology at Brigham and Women’s Hospital and Harvard Medical School in Boston, MA. “Opioid use in this population of patients is associated with increased risk of infection and mortality.”
“This study was performed to focus on giving our patients the safest possible approach to pain control,” said Gary Lichtenstein, MD, a professor of Medicine and the director of the Inflammatory Bowel Disease Center. “Narcotics, while effective for analgesia, have frequently been globally overused. This new approach, focusing on the patient and their safety, will hopefully be adapted in future guidelines.”
While the combination of interventions was effective in curbing opioid use, further analyses of the data after the implementation of text-message alerts suggest that the text-message tactic may have played the biggest role.
“The automated text-message alerts were received precisely when a patient with IBD was assigned to a clinician, so we think the real-time aspect of this intervention was helpful,” Dalal said.
“This intervention shows how technology and iterative workflow changes can be leveraged to improve the translation of evidence-based care pathways to practice,” said Shivan Mehta, MD, MBA, a gastroenterologist and an assistant professor of Medicine at Penn.
Opioids, especially delivered intravenously, are a popular method to treat severe pain. But it’s better to use a cautious step-up plan where clinicians and patients start with less strong treatments and increase to stronger options if pain persists.
“Clinicians in other specialties may not be as familiar with the research that points to the risks of opioid use among patients with IBD,” Dalal said. “These interventions are opportunities to educate and increase awareness.”
Dalal and the other authors plan on looking at monitoring the effectiveness and side effects of the non-opioid pain relievers that can be delivered intravenously. Nevertheless, takeaways from this study can influence medicine today and should encourage physicians who treat patients with IBD to consider the alternative treatment options available.
Penn’s Sonali Palchaudhuri, Christopher K. Snider, Yevgeny Gitelman, Mihir Brahmbhatt, Nikhil K. Mull, Christopher Klock, and James D. Lewis also authored this study.
Penn Medicine is one of the world’s leading academic medical centers, dedicated to the related missions of medical education, biomedical research, and excellence in patient care. Penn Medicine consists of the Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania (founded in 1765 as the nation’s first medical school) and the University of Pennsylvania Health System, which together form a $8.6 billion enterprise.
The Perelman School of Medicine has been ranked among the top medical schools in the United States for more than 20 years, according to U.S. News & World Report's survey of research-oriented medical schools. The School is consistently among the nation's top recipients of funding from the National Institutes of Health, with $494 million awarded in the 2019 fiscal year.
The University of Pennsylvania Health System’s patient care facilities include: the Hospital of the University of Pennsylvania and Penn Presbyterian Medical Center—which are recognized as one of the nation’s top “Honor Roll” hospitals by U.S. News & World Report—Chester County Hospital; Lancaster General Health; Penn Medicine Princeton Health; and Pennsylvania Hospital, the nation’s first hospital, founded in 1751. Additional facilities and enterprises include Good Shepherd Penn Partners, Penn Medicine at Home, Lancaster Behavioral Health Hospital, and Princeton House Behavioral Health, among others.
Penn Medicine is powered by a talented and dedicated workforce of more than 43,900 people. The organization also has alliances with top community health systems across both Southeastern Pennsylvania and Southern New Jersey, creating more options for patients no matter where they live.
Penn Medicine is committed to improving lives and health through a variety of community-based programs and activities. In fiscal year 2019, Penn Medicine provided more than $583 million to benefit our community.