TY - JOUR
AU1 - Raymo, Laura, L.
AU2 - Camejo,, Madeline
AU3 - Fudin,, Jeffrey
AB - Health care organizations around the nation have been working to reduce the use of meperidine as a first-line agent for pain management. Despite the wealth of documentation in the primary literature outlining the dangers of meperidine, it continues to be prescribed as a first-line agent, particularly by surgeons.1 We outline two different approaches to meeting this challenge, both of which were implemented at the Memorial Healthcare System, a 1300-bed, four-hospital system in Fort Lauderdale, Florida. Open in new tabDownload slide Open in new tabDownload slide Meperidine has been used as a first-line agent in pain management for decades, lending to practitioners having a high comfort level in prescribing the drug. Meperidine’s efficacy is equivalent to other opiate analgesics, but meperidine causes less hypotension and gastrointestinal (GI) adverse effects than morphine. When meperidine was first introduced, this was an advantage over morphine. It was later discovered that meperidine’s metabolites (most notably normeperidine, also known as desmethyl-meperidine) are associated with a neurotoxic syndrome.2,–7 Reasons for the late discovery of this syndrome included the expectation of insomnia, restlessness, and confusion associated with pain. A thorough review of the literature elucidates the differences among opioid analgesics. It is indisputably clear today that, in most cases, the risks of using meperidine outweigh the benefits. In summer 2002, Memorial Regional Hospital’s Pain Total Quality Management Team met to outline a plan encouraging safer pain management options, devoid of meperidine. This plan included nursing and pharmacy education, the development of a pain consultation service, and intensive monitoring of meperidine use. This approach was labor-intensive for nursing and pharmacy and led to a 20% drop in meperidine use over one year. The 20% reduction remained fairly constant, with only a slight decline over the following year. In June 2004, the team met again to review meperidine use. A four-phase plan was devised to decrease the use of meperidine. Phase 1 included pharmacist review of all inpatients receiving meperidine, including indication, dosing and frequency, patient’s renal function, number of doses administered in 24 hours, effectiveness, and identification of potential alternatives. Review of indication differentiated patients into three categories: pain management, sedation for procedure, and rigors associated with anesthesia or drug therapy (typically chemotherapy or amphotericin B). Interventions were made for all patients receiving meperidine for pain management. Almost all prescribers were willing to alter therapy in the interest of patient safety. None of the reasons given by prescribers who were resistant to altering therapy were literature based. The majority of patients were successfully switched to a safer alternative, with success being measured by review of outcomes including efficacy, rates of adverse drug reactions (ADRs), and tolerability. Phase 2 focused on providing support for continued change in pain management. Physicians’ order forms were revised, and meperidine was removed from all forms. The form for patient-controlled analgesia (PCA) was updated to offer an alternative for morphine-allergic patients. Nursing education was provided by pharmacists and focused on the rationale for and administration of safer narcotic alternatives. Inservice education prepared pharmacists for discussions with physicians about opioid analgesics. Phase 3 centered on an automatic interchange from meperidine to an equianalgesic dose of morphine for pain management. Since education initiatives in phases 1 and 2 were so effective in reducing the number of patients with meperidine orders, the automatic substitution was manageable. Phase 4 involved continued safety monitoring in the absence of meperidine. Since the frequency of reported ADRs with meperidine at our institution was low, no difference in ADR rates was expected. Surprisingly, the total number of narcotic-related ADRs decreased. This decrease validates the original conviction that meperidine is dangerous and should not be used. When comparing the initial with the later four-stage strategy, it is clear that intense multidisciplinary education, followed by therapeutic interchange, can be an effective tool to manage prescribing. The importance of educational content cannot be overlooked, as education without support is often ineffective. The first attempt lacked a tailored approach to audience specificity. For example, when presenting to nursing, focusing on the administration of alternatives and monitoring is most useful. Rather than limiting inservice education to the dangers of meperidine, in our later efforts we focused on how to administer alternatives and what to monitor. This helped to decrease ADRs with newer agents as well. When interacting with physicians, the academic textbook approach was less useful and was met with direct verbal challenges, resistance, and apathy. Many physicians believed that the opioid analgesics were generally similar. It is important to explain why the change was initiated, focusing on safety as the rationale rather than cost in order to dispel any assumptions that the pharmacy-driven formulary change is financially motivated. Presenting the legal ramifications was most useful for physicians, considering multiple lawsuits favoring the plaintiff when safer analgesics were available. Physicians were most interested in opioid comparisons, equianalgesic doses, and how to use alternatives (e.g., dosing, population concerns). When presented effectively, attendees left with an appreciation that safer, more effective agents were available for their patients. This also helped develop a respectful relationship between physicians and pharmacists. When educating pharmacists, it is important to focus on the dangers of meperidine and the specific rationale behind choosing an alternative. The most common myths about meperidine need to be dispelled, and pharmacists should be armed with specific literature to support their recommendations. For example, when presented with a patient allergic to all other narcotics but meperidine, the patient should be given fentanyl. The structure of meperidine is so similar to fentanyl that if the patient can tolerate meperidine, he or she should be able to tolerate fentanyl.8,9 This is particularly important in patients with sickle cell anemia, since high doses of narcotics are often needed, rendering meperidine even more dangerous. Fentanyl PCA is an excellent alternative in this population, and we have observed tremendous success with this in the Sickle Cell Day Hospital at Memorial Regional Hospital. There is also a misconception that meperidine has an advantage in biliary colic and certain GI procedures. This myth has been dispelled in the recent literature.10,–12 It is important to note that the decision to target only pain management was not due to meperidine having advantages in its other indications. The project was managed this way because the patients at greatest risk were those receiving multiple doses, and the sheer volume of patients made this a more practical objective. Meperidine was available only for procedures and rigors. Since the use of meperidine for rigors is nominal, we could actually see the meperidine use fluctuate with the number of procedures each month. Educating physicians, pharmacists, and nurses about meperidine is important but not wholly effective in changing prescribing habits. Each discipline needs appropriate support to effectively implement change. A knowledgeable person must be assigned to champion change, especially in the face of habitual prescribing without appropriate rationale. The overwhelming body of literature over the past two decades has demonstrated that meperidine is not an appropriate first-line narcotic for managing pain. Pharmacists need to be cognizant of this literature and share it with prescribers in the interest of patient safety. References 1 Kornitzer BS, Manace LC, Fischberg DJ et al. Prevalence of meperidine use in older surgical patients. Arch Surg . 2006 ; 141 : 76 –81. Crossref Search ADS PubMed 2 Eisendrath SJ, Goldman B, Douglas J et al. Meperidine-induced delirium. Am J Psychiatry . 1987 ; 144 : 1062 –5. Crossref Search ADS PubMed 3 Stone PA, Macintyre PE, Jarvis DA. Norpethidine toxicity and patient controlled analgesia. Br J Anaesth . 1993 ; 71 : 738 –40. Crossref Search ADS PubMed 4 Danziger LH, Martin SJ, Blum RA. Central nervous system toxicity associated with meperidine use in hepatic disease. Pharmacotherapy . 1994 ; 14 : 235 –8. PubMed 5 Clark RF, Wei EM, Anderson PO. Meperidine: therapeutic use and toxicity. J Emerg Med . 1995 ; 13 : 797 –802. Crossref Search ADS PubMed 6 McDermot P. Recognizing normeperidine toxicity. Nursing . 2003 ; 33 : 24 . 7 Seifert CF, Kennedy S. Meperidine is alive and well in the new millennium: evaluation of meperidine usage patterns and frequency of adverse drug reactions. Pharmacotherapy . 2004 ; 24 : 776 –83. Crossref Search ADS PubMed 8 Fudin J. Chemical classes of opioids. www.paindr.com/Opioid%20Chemistry%2004-2006.rtf (accessed 2006 Dec 21). 9 Baumann TJ. Analgesic selection when the patient is allergic to codeine. Clin Pharm . 1991 ; 10 : 658 . PubMed 10 Hubbard GP, Wolfe KR. Meperidine misuse in a patient with sphincter of Oddi dysfunction. Ann Pharmacother . 2003 ; 37 : 534 –7. Crossref Search ADS PubMed 11 Palacioz K. Inappropriate meperidine use. Pharm Lett. 2001 ; 17 :document 171117 –8. 12 Latta KS, Ginsberg B, Barkin RL. Meperidine: a critical review. Am J Ther . 2002 ; 9 : 53 –68. Crossref Search ADS PubMed Author notes The Management Consultation column gives readers an opportunity to obtain advice on common management problems from pharmacists practicing in health systems. AJHP readers are invited to submit questions for this column. Selected questions will be forwarded to one or two experts in the field, who will prepare brief responses for publication. Questions should be narrow in scope, such that they can be answered in approximately 500 words. Responses will be sent to the inquirer before publication. Readers are also invited to comment on the answers of consultants; such comments will be considered for the Letters column. Suggestions for topics should be submitted to AJHP, 7272 Wisconsin Avenue, Bethesda, MD 20814 (301-664-8601 or ajhp@ashp.org). Copyright © 2007, American Society of Health-System Pharmacists, Inc. All rights reserved.
TI - Eradicating analgesic use of meperidine in a hospital
JF - American Journal of Health-System Pharmacy
DO - 10.2146/ajhp060672
DA - 2007-06-01
UR - https://www.deepdyve.com/lp/oxford-university-press/eradicating-analgesic-use-of-meperidine-in-a-hospital-CTHMHRkfP4
SP - 1148
VL - 64
IS - 11
DP - DeepDyve
ER -