Published in the November 2016 issue of Today’s Hospitalist
AS THE OPIOID EPIDEMIC continues to rage, outpatient physicians and their prescribing practices are under growing scrutiny. New research is now testing the best ways to taper opioids in patients with chronic pain in the outpatient setting, and CDC guidelines issued this year essentially say that office-based doctors should stop prescribing opioids for chronic pain patients.
But what about prescribing opioids in the hospital? No one is suggesting that the CDC guidelines could be tailored to inpatient practice. That leaves hospitalists with no guidance to fall back on but their own individual experience—and with concerns that they may be contributing to overprescribing and abuse.
In research published online in November 2015 by the Journal of General Internal Medicine, Susan Calcaterra, MD, a hospitalist with Denver Health Medical Center, discovered that opioid-naive patients who were prescribed an opioid at hospital discharge ran a ﬁve-fold greater risk than patients not receiving an opioid script of being a chronic user one year later.
“Most physicians have had an experience with opioid prescribing that left them feeling uncomfortable.”
“That was shocking,” says Dr. Calcaterra. “I began thinking about how hospitalists may be creating chronic users by prescribing opioids at discharge.” That led her to delve further into both hospitalists’ prescribing practices and their perspectives on those practices.
“I wanted to ﬁnd out if doctors had reasons for prescribing opioids beyond the control of pain, because opioids are very complicated,” Dr. Calcaterra adds. “Prescribing opioids comes with much bigger issues than, say, prescribing blood pressure medications.”
Frustration and discomfort
Dr. Calcaterra’s latest research on opioid prescribing was published in the August 2016 Journal of Hospital Medicine. The study was based on interviews with 25 hospitalists drawn from several hospitals—two academic centers, one safety-net hospital, one VA facility and one private hospital—in either Denver or Charleston, S.C.
The interviews on hospitalists’ perspectives revealed a complicated snapshot. On the positive side, hospitalists reported feeling conﬁdent about their ability to control acute pain with opioids. But doctors admitted to much more limited success—as well as frustration and discomfort—when managing exacerbations of chronic pain. That was particularly true because they lack objective ﬁndings to explain reported pain, and they aren’t really able to achieve adequate pain control in chronic-pain patients.
Instead, hospitalists have to rely on increasing doses, even though such dosing may feed habituation, abuse or addiction. One hospitalist characterized treating patients with chronic pain as “a black hole.”
The interviews also found that just about all physicians are inﬂuenced by their past experiences. A few shared horror stories, like the patient who crushed up her oxycodone, injected it into her central line and died in her hospital bed. Another physician recalled receiving a phone call from the DEA after a patient altered a discharge script, changing an order for 18 pills to 180.
While Dr. Calcaterra says that such traumas were a small minority, “most physicians have had an experience with opioid prescribing that left them feeling uncomfortable.” Some physicians react to such experiences by becoming more rigid about prescribing.
One doctor, for example, was very strict and would treat sickle cell pain with IV medications only if patients were unable to eat. “As soon as patients could eat, he pushed them to oral pain pills,” she says. “That was the rule he’d created. It doesn’t take into account other factors, but that was what worked for him.”
The research also examined another issue: how opioid prescribing plays into hospitalists’ need to facilitate discharges and reduce readmissions. Doctors admitted that while they feel conﬂicted about the practice, they often prescribe more opioids at discharge to patients who seem at high risk of bouncing back.
Dr. Calcaterra points out that her own thinking about the use of opioids to improve discharge efficiency changed over the course of her research.
“At ﬁrst, I thought, ‘This doesn’t feel right,’ but then a colleague pointed out that if patients are readmitted because of uncontrolled pain, that’s an admission we could have prevented by giving them enough pain meds,” she says. “It’s really the pragmatic thing to do, and we’re doing patients a service by keeping them out of the hospital and at home.”
As for her own opioid prescribing, Dr. Calcaterra says she very much takes a case-by-case approach, talking to patients and trying to get as good of an understanding as possible about what’s going on with their chronic pain. She also notes that, “I’m lucky in that we have a closed system, so I can communicate very easily with primary care providers.” Most of the time, outpatient physicians sign off on her inpatient treatment and discharge plans in terms of pain control.
“But sometimes, they’ll get back to me and say, ‘We have an opioid contract, and that would exceed their monthly limit,’ ” she points out. “The more communication you can have with the provider who knows the patient best, the better it is in every scenario.”
As for learning how to discuss opioid prescribing with patients, Dr. Calcaterra says that residents may have more opportunities now than in the past.
“There are more palliative care services in hospitals, so residents are getting a little more training,” she explains. But generally, whatever training residents receive “is going to be based upon whichever attendings they work with and those attendings’ interest in educating them about opioids. There’s generally not curriculum-speciﬁc training for this.”
Instead, doctors fashion their own approach. It’s her sense that, instead of actively broaching the subject of opioids at discharge with chronic pain patients, “doctors try to avoid that conversation by reviewing patients’ home medications and asking, ‘What do you need reﬁlls on?’ If patients say they need an oxycodone reﬁll, doctors will address the issue then by saying either ‘yes’ or ‘no,’ or ‘that is (or is not) my practice.’ ”
That brings Dr. Calcaterra back to the lack of inpatient guidelines for opioid prescribing, something she would like to see developed.
“Part of the reason to have guidelines is to take the burden off individual physicians,” she notes. Instead of arguing with patients about discharge prescriptions, doctors would be able to point to guidelines and say, “This is how we practice at this hospital.”
An even more frequent—and uncomfortable— confrontation, she says, occurs when she’s not the ﬁrst physician to treat a patient during a hospitalization. “I’ve had patients say to me, ‘Well, Dr. X said he’d prescribe me this when I was discharged.’ That makes me the doctor who has to say, ‘I’m not going to do that.’ ”
If inpatient guidelines were developed and in place, “I could fall back on those and say, ‘It’s not up to me or your previous physician. This is how we practice at this hospital,’ ” she points out. “But until then, it’s going to be up to each individual doc.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.