Title: Systematic Use of the MORE Tool to Reduce Opioid-Related Adverse Events at a Community Teaching Hospital
Authors: Mariam Diaby, Kimm Freeman
Background: Opioids are widely used for the management of moderate to severe pain in hospitalized patients; however, their use is associated with significant risk of opioid-related adverse drug events (ORADEs), including respiratory depression, oversedation, delirium, gastrointestinal complications, and increased morbidity and mortality. ORADEs have been linked to prolonged hospital length of stay, higher healthcare costs, and poorer clinical outcomes.
In response, opioid stewardship has become a major focus of inpatient quality improvement initiatives. Numerous stewardship efforts have emphasized multimodal analgesia, dose optimization, avoidance of high-risk medication combinations, and enhanced monitoring of sedation and respiratory status. Pharmacists play a critical role in these initiatives by conducting medication reviews, identifying inappropriate opioid prescribing, mitigating high-risk regimens, and implementing safety-focused interventions. However, sustaining consistent and standardized opioid stewardship practices within routine clinical workflow remains challenging.
The Medication and Risk Factor Review, Optimize, Refer at Risk Patients, Educate and Plan (MORE) tool was developed as a structured framework to standardize opioid stewardship efforts among pharmacists. The MORE tool prompts systematic evaluation of opioid therapy, including assessment of risk factors, optimization of analgesic regimens, reassessment of safety parameters, and patient education.
Methods: This retrospective observational study evaluated implementation of the MORE tool on 3 North Telemetry and 3 South Renal units at Wellstar Cobb Medical Center from December 22, 2025, to January 16, 2026. Adult patients admitted to study units who received at least one opioid medication during hospitalization were eligible. Patients admitted for hospice or comfort measures only, those hospitalized for less than 24 hours, and those who received naloxone for indications unrelated to opioid overdose were excluded.
The primary objective was to quantify and characterize the types of medication-related interventions documented during daily MORE tool utilization. Secondary analysis evaluated potential associations between documented MORE tool interventions and the root causes of naloxone administration during the study period.
Interventions were identified through pharmacist-documented I-Vents within the electronic medical record. Data collected included patient demographics, hospital length of stay, opioid administration records, sedation and risk assessment scores, naloxone administration events, and interventions. Descriptive statistics were used to summarize intervention frequency and type. Comparative analyses were performed to explore associations between MORE tool interventions and naloxone events.
Results: A total of 108 interventions were documented across 67 patients. Of the 108 interventions, 88 were accepted and 20 were rejected. The most common intervention was the conversion of intravenous opioids to oral opioids, which accounted for 33 interventions with 27 being accepted by the provider. Other frequently implemented interventions included the addition of opioid-induced constipation (OIC) prophylaxis (32 interventions), scheduling of Tylenol (4 interventions), and the discontinuation of benzodiazepines (4 interventions).
The overall rate of accepted interventions was 81.5%, with the highest acceptance rates seen in optimizing OIC prophylaxis (100%) and converting intravenous opioids to oral opioids (81.8%). Notably, there were no NARCAN (naloxone) administration events documented during the study period.
Conclusion: The systematic use of the MORE tool in this study demonstrated a high acceptance rate of opioid stewardship interventions, with 81.5% of the documented interventions being implemented. The tool effectively prompted appropriate adjustments in opioid management, particularly in optimizing OIC prophylaxis and converting IV opioids to PO opioids. During the study period, there were no naloxone administration events, suggesting that ORADEs may have been effectively mitigated through this proactive approach. These findings highlight the potential value of utilizing structured tools like the MORE tool in reducing ORADEs and optimizing opioid therapy, thus contributing to improved patient safety and clinical outcomes. Further research with larger cohorts is needed to confirm these findings and assess the long-term impact of such interventions.
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