An old idea made new
Hospitalists are rediscovering the benefits of ordering subcutaneous opioids.
Hospitalist Adam Ackerman, MD, FACP, had been looking for an alternative to IV opioid dosing for a long time, something he could prescribe that was “actually providing patients with adequate pain control, and at the same time, not having them on this roller-coaster of IV pain medications.”
He had talked to colleagues about the problem of rapid fluctuations in effects when opioids are delivered by IV and how these highs and lows can contribute to overuse during hospitalization and addiction after discharge. “I said, ‘I feel like the onset of this IV is just too quick. How do we slow this down? … There's got to be a device or something.’”
Eventually he discovered there was a device—and it was just a needle. “Looking in the literature, there used to be a lot of subcutaneous opioids given,” said Dr. Ackerman, assistant clinical professor of internal medicine at Yale University in New Haven, Conn.
He then confirmed with an older pharmacist and nurse that this method of pain control had been common practice within their memories. No one was sure why it stopped, although Dr. Ackerman has a theory.
“In the 1980s, even the 1970s in surgical patients, people were using subcutaneous morphine,” he said. “Then [patient-controlled analgesia] came around in the 1980s and the idea of an IV opioid became this accepted practice.”
The addiction epidemic changed the acceptability of heavy opioid doses, but no alternative practice had caught on. So, like a teenager digging a pair of wide-legged jeans from a parent's closet, Dr. Ackerman decided to try making subcutaneous (or subq) opioid delivery cool again. And now his peers are adopting the trend.
The pilot
Dr. Ackerman's test of subcutaneous opioids started small, among the clinicians (physicians, nurse practitioners, and physician assistants) and nurses on one 28-bed medical unit at Yale New Haven Hospital in 2016. It included two practice changes—making oral the preferred route for opioids if patients could take them and subcutaneous the preferred solution whenever parenteral opioids were required.
The project was conducted as a pilot study, but because it was bringing back an old practice, it didn't even require the usual experimental protocols. Dr. Ackerman had asked his pharmacist colleague what clearances would be required. “He said, ‘It's still in our policy for subq. We never took it out. The order sets even allow you to select subq. We don't have to change anything at all.’”
The initial intervention was simply education—a 30-minute formal didactic presentation for clinicians with three follow-up emails. The concept was also introduced and reinforced at nursing huddles, where nurses were encouraged to nudge prescribers to order subq dosing.
“We tried to do everything as a ground-up thing, not from a top-down perspective,” said Dr. Ackerman. “It was talking to colleagues and saying, ‘It's a time-tested thing. Have you ever tried it before? Let's talk about it. Let's do this together.’”
Once the subject was raised, many clinicians were eager to discuss it. “When you ask them, ‘What's your biggest power struggle at the bedside?’ or ‘What's your biggest difficulty with pain management?’ people say, ‘I wish we could just get rid of IV opioids,’” Dr. Ackerman said.
The project did not get rid of IV opioids, of course, but it did put a significant dent in their use on the unit. A comparison with patients treated in the six months before the pilot found an 84% reduction in IV opioid doses and a 55% decrease in parenteral opioid doses overall. Patients' mean daily overall opioid exposure decreased by 31%, according to results published by JAMA Internal Medicine in 2018.
The study also assessed patients' pain before versus during the pilot and found that it was similar on days 1 to 3 and slightly better on days 4 and 5. “We used reported pain scores as a balancing metric to make sure we weren't making people feel worse while making ourselves feel better about what we were doing. Our patients actually said that their pain control was better,” said Dr. Ackerman. “That was the thing that really surprised me, because we were assuming pain scores would remain the same with the new standard.”
He was also surprised by how demand for the change spread on its own. “People were perking up their ears on the hospitalist service saying, ‘You guys are doing this thing in one place. I rotated through and I saw what happened,’” Dr. Ackerman said. “We expanded to our entire hospitalist service, with 500 patients a day, and then to the whole health system, in pretty rapid progression.”
Once the decision was made to expand the change across the health system, the electronic health record was updated. “The parenteral orders were changed to remove any default route of administration—formerly IV was the default—and the selectable button for subcutaneous was moved in front of the intravenous button as a behavioral nudge,” explained Dr. Ackerman.
Results of the project's implementation across Yale's hospital medicine service were published by the Journal of General Internal Medicine on Sept. 2. They again showed significant decreases in use of IV opioids and pain scores that were the same or better than before the change.
The hospital has seen even more benefits since those numbers were tabulated, according to lead study author Barry J. Wu, MD, MACP, a professor of medicine. “Comparing 2017 with 2025, they've shown a 33% reduction in IV opioid use in Yale New Haven Health System, which is a big system, and a 13% reduction in opioid use, and also reduced use of opioid-related antiemetics and diphenhydramine,” he said.
Spreading the word
The subq opioid trend also made the leap to other health systems. Fredrik Amell, MD, now chairs the opioid stewardship committee for the five hospitals of the Dartmouth Health System in New Hampshire, but when he first learned about subq opioids, no such committee existed.
“There was zero use of subq before. But we struggled with certain patients—people that we worried we were harming, that kept on coming back to the hospital,” said Dr. Amell, an assistant professor of medicine at Dartmouth. “We were thinking of maybe using buccal morphine, like is common for hospice patients, but inpatient nurses were not accustomed to giving buccal morphine.”
Instead, first the Dartmouth-Hitchcock Medical Center and then the system's tertiary community hospitals began an educational campaign to move to subq. “It spread, because it was very much an intervention for the hospitalists, and they practiced across multiple units,” said Dr. Amell.
The Dartmouth project did not involve any change to standard orders—IV is still the default route for opioids—but the hospitals saw similar changes in prescribing as at Yale, according to Dr. Amell, who noted that his team's findings are in the process of publication. The project leaders did begin reporting use (and route) of opioids back to the front lines.
“It was mostly just creating the Hawthorne effect,” he said. “All we did was make training available. The most important part of the training was to make the providers know that we were following. … If you know you're being watched, behavior becomes more thoughtful.”
And once clinicians thought about it, they could see a lot of potential benefits to subq dosing, he added. “It's known that IV correlates with all kinds of harm. It's not just addictive behavior, but delirium goes up. The faster you give this, the more oxygen drops, the more pruritus and hypotension.”
Pharmacists were a key part of the team that raised awareness of the issue at Dartmouth, doing outreach to physicians who put in IV opioid orders, Dr. Amell noted.
The change holds appeal for hospital administrators as well as clinicians, he pointed out. “You may even save money because IV opioids are expensive and we're saving thousands of doses. You probably reduce overdoses, and each one of those overdoses is catastrophic,” Dr. Amell said.
Hospitalists at Hartford Hospital in Connecticut were convinced of the potential benefits of subq dosing after hearing Dr. Ackerman speak about his work.
“We invited him here to give a grand rounds presentation, and after that, we had a meeting with a small group of leaders from nursing, pharmacy, and hospitalists,” said Suparna Dutta, MD, chief of medicine. “I think we were all like, ‘It's a concept that makes total sense.’”
The Hartford team began the push to use subq instead of IV in late 2024. They are still working to analyze the effects but have already noticed changes.
“We've seen a large increase in use of oral opioids, which is interesting because it's not, strictly speaking, part of the project. But we also say that if patients need pain medicine and can take things by mouth, they should take pain meds by mouth,” said Mitchell McClure, MD, a hospitalist and leader of the project. “We've seen some increase in subcutaneous [dosing], and it's some over zero, frankly, from where we started.”
The biggest challenge in implementation was making sure nurses were ready to carry out orders for subcutaneous opioids when the hospitalists started entering them, according to Simon Castro-Montenegro, MD, ACP Member, assistant director of hospital medicine at Hartford.
“We needed to make sure they were aware, since at first they might think the order was a mistake,” he said. “We also had to ensure that the appropriate needles were readily available on the units.”
Trainees also had to be educated about the protocol, which differed from what they may have seen at other nearby hospitals where they rotate, explained Dr. McClure. “I've started meeting with all the residents at the beginning of the rotation and introducing it to them. Residents are new in practice and don't already have preformed opinions about how to do things, so it's not a tough sell,” he said.
Selling subq
There is one group of stakeholders who may not be immediately sold on the concept, advocates of subcutaneous opioid dosing noted. Patients are most likely to provide pushback on the protocol if they have gotten IV opioids during a previous admission, or even during their current stay if they came from another part of the hospital.
“Patients coming from the ED or surgery typically arrive on the medicine service with active IV opioids already in place. One of the challenges we're facing now is removing those IV orders and explaining the change to patients,” said Dr. Castro-Montenegro.
Patients should be reassured that oral and subcutaneous opioids are just as effective as an IV at controlling their pain, but with a slightly longer time to peak, Dr. Ackerman said. “The hospitalist can say, ‘I understand this is the way that you've always had opioids when you've come to the hospital. Until recently, that's what we thought was best for you. We actually have evidence now that we have a better way of doing this—better pain control with less of the bad side effects.’”
Nurses may be able to make the case most effectively, according to Dr. Ackerman. “Your nurses are actually your greatest champions for this work,” he said. “When they saw that their patients were doing better, they were the ones that were actually talking it up to patients before I came to see them.”
Dr. McClure has also developed talking points for patient interactions. “What I tell residents is when patients, and they will, try to push you around on this issue, the stance should be that our first job is to not do any harm,” he said. “The risks of narcotics, not just side effects, but also increasing risk of addiction, should come into people's minds.”
Outpatient medicine became more cautious about use of opioids long ago, noted Dr. Amell. “But for inpatient, there was never any regulation or even effective [quality improvement] until Adam [Ackerman] came along,” he said. “I've worked in hospitals across many settings—academic, community, suburban, rural, urban—and it's the same everywhere.”
Decreasing inpatient opioid use could make patients' discharge transitions to the stricter outpatient environment smoother, added Dr. Dutta. “If we're giving people fewer meds, we're not putting them in a position where they have to hunt for someone to continue them or wean them off,” she said.
Several categories of patients should be excepted from the push to avoid IV opioids, the experts noted. Those include cancer patients on chronic pain treatment, others receiving end-of-life care, and anyone who needs pain control in a hurry, for example, for an unplanned wound dressing change.
“You're not going to sit around and wait for the extra 15 minutes to get to peak effect using subq or the extra 30 minutes from oral,” said Dr. Amell.
And while the subq movement is spreading from hospital medicine—the Yale New Haven ED has adopted it, for example—one can reasonably expect other parts of the hospital to stick with IVs for now. “We don't really have evidence to work from in nonmedicine populations,” said Dr. McClure. “It'd be good to see trials.”
However, for interested hospital medicine services, the experts' advice is to go ahead and start any time. “You don't have to do this through policy,” said Dr. Amell. “You should monitor and you should encourage a standard. … We were sharing results along the way with everyone, and that made people feel like they were part of something good that made sense.”
Making sense is what the effort is all about, agreed Dr. Ackerman. “This is not experimental. This is just us remembering something we forgot,” he said.