Canada is in the midst of an opiate crisis. Hospitalizations due to
opiate poisoning have been increasing in Canada.
is in part driven by legal prescriptions,
of opioid prescribing more important than ever. As part of
the effort to mitigate opioid-related morbidity and mortality,
recommend cautious opioid prescribing
and optimizing adjuvant pain control prior to starting opioids.
Multiple studies address opioid prescribing on surgical
units, but few studies have evaluated opioid use among medical
Internal medicine (IM) units care for patients with
a variety of presenting illnesses, many of which involve acute
or chronic pain. Nonopioid analgesics are recommended by
multiple guidelines prior to and along with opioids,
practice is not well studied within the IM inpatient population.
Our study investigated the rationale, timing, and use of adjunct
therapies associated with opioid prescriptions on IM inpatients
in an academic hospital in Saskatoon, Canada.
A retrospective chart review with a cross-sectional design was
conducted investigating events surrounding the initiation or
escalation of opioid-prescribing practices for IM inpatients.
Population and Data Sources
We identified inpatients admitted to an IM clinical teaching unit
(CTU) at Royal University Hospital (RUH) between July 1, 2017
and June 30, 2018 who were given at least one in-hospital opioid
prescription. RUH is a tertiary academic center in Saskatoon,
Canada. Patients who underwent neuraxial or general anesthesia
within 30 days of admission or were prescribed methadone or
suboxone in the community were excluded. Opioids given for
major procedures (e.g., cardiac catheterization) were excluded.
Patients were identified using the RUH inpatient pharmacy
database, BDM Pharmacy. BDM Pharmacy tracks all inpatient
medication orders as well as the inpatient unit that patients are
discharged from. A list of inpatients discharged from an IM CTU-
specific ward with opioid prescriptions was generated by BDM
Pharmacy, and 60 unique IM patients were chosen by simple
random sample for chart review. If patients had multiple CTU
admissions within the study period, the first one was selected.
Chart review and Variables Collected
Details of opioid initiation or first escalation including the opioid
dose, route, frequency, service, who wrote the order, clinical
rationale for opioid use, and whether opioids were ordered during
daytime or on-call coverage hours were gathered from chart
review. Regular hours were defined as daytime (07:30–16:59) or
on-call hours (17:00–07:29). Medication reconciliation of home
medications, including opioids, was routinely performed for all
inpatients at the time of admission. Patients were considered
opioid naive if they did not have any active opioid prescriptions
at the time of admission. Opioid prescriptions given at the time
of discharge were also recorded.
Opioid escalation was defined as either: (i) an increase in
opioid dose or frequency, (ii) administration of intravenous
(IV) opioid, (iii) new breakthrough opioid dose prescribed
(different from a patient’s home opioid regimen), or (iv) a change
in opioid type with a greater maximum dosage when converted
to morphine equivalents.
Patient details were gathered, including age, sex, date of
admission and discharge, past history of any substance abuse,
and past or current liver disease. Prescriptions of adjunct
analgesics prior to opioid initiation or escalation, including
acetaminophen, nonsteroidal anti-inflammatory medications
(NSAIDs), pregabalin, or gabapentin, were recorded.
Descriptive results were reported in medians with interquartile
ranges (IQR) or percentages. Characteristics were compared
Des 57patients, 34 (60%) n’avaient jamais pris d’opioïdes avant leur hospitalisation et 48 (84%)
ont reçu leur première dose d’opioïdes ou une augmentation de dose. De ces 48patients, 27
(56%) ont reçu leur dose durant les heures de garde. La justification de l’augmentation de dose
est documentée dans 31cas (65%), les raisons étant les soins de fin de vie (17%), la douleur
musculosquelettique (15%) et les infections de la peau et des tissus mous (13%).
Souvent, la justification de l’utilisation des opioïdes n’est pas documentée. Le moment où la
décision initiale de modifier la dose d’opioïde est prise est réparti de façon égale entre le jour et
durant les heures de garde.
C a n a d i a n J o u r n a l o f G e n e r a l I n t e r n a l M e d i c i n e V o l u m e 1 6 , I s s u e 2 , 2 0 2 1 15
Quan S et al.
CJGIM_2_2021_177932.indd 15CJGIM_2_2021_177932.indd 15 07/06/21 3:48 PM07/06/21 3:48 PM