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. 2022 Jan-Dec:3:26334895221096290.
doi: 10.1177/26334895221096290. Epub 2022 Apr 27.

Implementation of a clinical pathway to screen and treat medical inpatients for opioid withdrawal

Kimberly D Williams  1 , Beverly L Wilson  2 , Claudine T Jurkovitz  1 , Jo A Melson  3 , Jeffrey A Reitz  4 , Carmen K Pal  5 , Sherry P Hausman  6 , Erin Booker  2 , Linda J Lang  2 , Terry L Horton  2
Affiliations

Implementation of a clinical pathway to screen and treat medical inpatients for opioid withdrawal

Kimberly D Williams et al. Implement Res Pract. 2022 Jan-Dec.

Abstract

Background: Opioid-related inpatient hospital stays are increasing at alarming rates. Unidentified and poorly treated opioid withdrawal may be associated with inpatients leaving against medical advice and increased health care utilization. To address these concerns, we developed and implemented a clinical pathway to screen and treat medical service inpatients for opioid withdrawal.

Methods: The pathway process included a two-item universal screening instrument to identify opioid withdrawal risk (Opioid Withdrawal Risk Assessment [OWRA]), use of the validated Clinical Opiate Withdrawal Scale (COWS) to monitor opioid withdrawal symptoms and severity, and a 72-h buprenorphine/naloxone-based treatment protocol. Implementation outcomes including adoption, fidelity, and sustainability of this new pathway model were measured. To assess if there were changes in nursing staff acceptability, appropriateness, and adoption of the new pathway process, a cross-sectional survey was administered to pilot four hospital medical units before and after pathway implementation.

Results: Between 2016 and 2018, 72.4% (77,483/107,071) of admitted patients received the OWRA screening tool. Of those, 3.0% (2,347/77,483) were identified at risk for opioid withdrawal. Of those 2,347 patients, 2,178 (92.8%) were assessed with the COWS and 29.6% (645/2,178) were found to be in active withdrawal. A total of 49.5% (319/645) patients were treated with buprenorphine/naloxone. Fifty-seven percent (83/145) of nurses completed both the pre- and post-pathway implementation surveys. Analysis of the pre/post survey data revealed that nurse respondents were more confident in their ability to determine which patients were at risk for withdrawal (p = .01) and identify patients currently experiencing withdrawal (p < .01). However, they cited difficulty working with the patient population and coordinating care with physicians.

Conclusions: Our study demonstrates a process for successfully implementing and sustaining a clinical pathway to screen and treat medical service inpatients for opioid withdrawal. Standardizing care delivery for patients in opioid withdrawal can also improve nursing confidence when working with this complex population.

Keywords: Clinical Opiate Withdrawal Scale; addiction medicine; clinical pathway; inpatient medicine; opioid use disorder; opioid withdrawal.

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Conflict of interest statement

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This work was partially supported by an Institutional Development Award (IDeA) from the NIH National Institutes of General Medical Sciences (grant no. U54-GM104941).

Figures

Figure 1.
Figure 1.
Care process model of the opioid withdrawal clinical pathway. Note. OWRA = Opioid Withdrawal Risk Assessment; COWS = Clinical Opiate Withdrawal Scale; UDS = Urine Drug Screen.
See this image and copyright information in PMC

References

    1. Agency for Healthcare Research and Quality. (2021). Rate of Opioid-Related Inpatient Stays and ED Visits per 100,000 Population. HCUP Fast Stats – Opioid Hospital Use Map. https://www.hcup-us.ahrq.gov/faststats/OpioidUseMap. - PubMed
    1. American Society of Addiction Medicine. (2005). Public Policy Statement on Rapid and Ultra Rapid Opioid Detoxification. https://www.asam.org/docs/default-source/public-policy-statements/1rod-u....
    1. American Society of Addiction Medicine. (2015). National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use. https://www.asam.org/docs/default-source/practice-support/guidelines-and....
    1. Centers for Disease Control and Prevention National Center for Health Statistics. (2021). Drug Overdose Deaths in the U.S. Top 100,000 Annually. CDC, National Center for Health Statistics, Office of Communication. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm.
    1. Dearing J. W., Cox J. G. (2018). Diffusion of innovations theory, principles, and practice. Health Affairs, 37(2), 183–190. 10.1377/hlthaff.2017.1104 - DOI - PubMed

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