Sentinel Alert on Opioids Spotlights Provider Misuse

Unintentional respiratory depression due to incorrect use of opioids in hospitals occurs in .5% of patients after surgery, according to a new Joint Commission Sentinel Event Alert highlighting lack of providers' knowledge about potency differences and other risks.

"Of the opioid-related adverse drug events, including deaths, that occurred in hospitals and were reported to The Joint Commission's Sentinel Event database (2004-2011), 47% were wrong dose medication errors, 29% were related to improper monitoring of the patient, and 11% were related to other factors, including excessive dosing, medication interactions and adverse drug reactions," the alert said.

Asked whether the alert was issued in response to a cluster of more recent adverse reactions related to opioids, a commission spokeswoman said in an e-mail that opioid analgesics "are among the top three drugs in which medication-related adverse events are reported" to the acute care accreditation organization.

Additionally, clinicians need to be aware of alternatives, "including multi-modal therapies such as physical therapy, acupuncture, manipulation or massage; and non-narcotic analgesics such as acetaminophen and muscle relaxants," she wrote. These non-narcotics may reduce the dose of opioids.

"Healthcare workers need to be aware of the risks to patients in prescribing opioids" in inpatient settings, she wrote.

With respect to unintended respiratory depression, the alert said:
•  The risk may be greater with higher opioid doses.
•  The occurrence may actually be higher than reported.
•  There is a higher incidence observed in clinical trials.
•  Various patients are at higher risk...including patients with sleep apnea, patients who are morbidly obese, who are very young, who are elderly, who are very ill and who concurrently receive other drugs that are central nervous system and respiratory depressants (e.g., anxiolytics, sedatives).

Respiratory depression risks also increase with age by 2.8 times for patients 61-70. 5/4 times for people 71-80, and 8.7 times higher for those over age 80.

The alert pointed out the importance of assessing patients for pain thresholds. However, "notwithstanding the need for appropriate pain management," hospital providers should make staff aware of factors and activities that can help avoid accidental opioid overuse, such as assessing patients previous history of analgesic use or abuse, duration and possible side effects.

The alert advises providers to "Take extra precautions with patients who are new to opioids or who are being restarted on opioids," such as starting patients on a short-term trial at the lowest effective dose. 

Patients at higher risk include those who snore, those who undergo upper abdominal or thoracic surgery, are receiving other sedating drugs such as benzodiazepines, antihistamines, diphenhydramine, sedatives, or other central nervous system depressants.

Risks also increase for those who are morbidly obese and also have sleep apnea, who have not recently used opioids, those who are under anesthesia for longer periods of time and for those who smoke cigarettes.