Time to rein in opiates in the hospital?

Time to rein in opiates in the hospital?

Unsafe prescribing may not be just an outpatient problem

May 2014

Published in the May 2014 issue of Today’s Hospitalist

ARE YOU TOO QUICK to give patients opioids to treat their pain?

Twenty years ago, pain management experts chided physicians for being too stingy with pain medications. But the use of such therapies, including opioids, has skyrocketed over the last 15 years. New data indicate that the booming use of opioids is not limited to the outpatient setting “and that hospitalists may be part of the problem.

According to a study in the February Journal of Hospital Medicine, more than half of nonsurgery inpatients were prescribed at least one opioid during their hospitalization, and nearly one-quarter were exposed to multiple opioids. About one-quarter of the patients studied were taking opioids on the day of discharge.

The high number of inpatients receiving opioids wasn’t the only problem. The study found that many patients were prescribed very high doses, with the average dose coming in at about 68 milligrams of oral morphine equivalents per day. Even more concerning, about one-quarter of patients received a dose of 100 milligrams or more on at least one day of their hospitalization.

Shoshana J. Herzig, MD, the study’s lead author, says both the frequent use of opioids in the hospital and the high doses being given are a problem because at least some of these patients will go on to develop addiction problems once they return home. Data from the CDC show that the rate of fatal overdoses from opioids nearly quadrupled in the last decade, taking more than 14,000 lives each year.

Dr. Herzig, a hospitalist and researcher at Beth Israel Deaconess Medical Center in Boston, talked to Today’s Hospitalist about the scope of the problem, and how hospitalists can make sure they’re prescribing opiates wisely.

Why did you want to examine the inpatient use of opioids?
In my practice as a hospitalist, I see that any time a patient complains about pain, our reflex is to give an opiate, often without even thinking about whether the patient tried acetaminophen or an NSAID like ibuprofen. We give out opiates like water on the inpatient side. Unfortunately, it’s likely that a portion of people who go on to chronically use opioids and have addiction problems were exposed to these drugs in the hospital.

Were you surprised at how many inpatients were being prescribed opioids?
I knew the number would be high, but this was probably a little higher than I had expected. By comparison, something like 95%-plus of surgery patients receive opiates during the course of their hospitalization, which seems appropriate.

Why are high doses such a problem?
Studies in the outpatient setting have shown that about 100 milligrams of oral morphine a day is the threshold at which patients have a high risk for adverse events. We found that inpatients were receiving the equivalent of 68 milligrams per day, which is getting close to that threshold, and that one-quarter received more than the equivalent of 100 milligrams for at least one day. That’s well in the range of significant risk.

The study also noted regional prescribing variations, with a 37% difference between the highest and lowest prescribing regions. There was also a big variation between the lowest prescribing hospitals (where 5% of patients were exposed to opiates) and the highest prescribing hospitals (72% received opiates).

Why are those differences significant?
We found a jump in the rate of adverse events related to opioids at hospitals that are heavy prescribers. The data were similar to what has been found in the outpatient setting, which is that rates of opioid-related adverse events go up with the overall use of opioids. Patients in hospitals with higher rates of opioid use have disproportionately higher rates of adverse events, many of them severe. Hospitals that use opioids more frequently are not necessarily using them more safely.

What role do you think hospitalists play in the problem of increased prescribing of opioids?
I see two scenarios. In one, hospitalists may be contributing to the problem because we often don’t have access to outpatient records, so we don’t know what medications the patient is getting in the outpatient setting. That discontinuity can contribute to us prescribing opioids that the primary care physician may not have wanted the patient to get, perhaps because of previous problems with opioid use.

On the other hand, I think it’s sometimes easier for hospitalists to try to talk some sense into patients and explain that opioids really aren’t what they need. A doctor who has a long-term relationship with a patient can have a harder time talking about the dangers of addiction.

So I can see both sides. But I suspect there’s probably more of a possibility that we are contributing to the problem by virtue of not knowing the patient well and not having access to outpatient data. The problem is that pain management is purely subjective. We are unable to definitely say that a patient is or isn’t having severe pain.

What can hospitalists do when managing pain to avoid unnecessarily providing opioids?
I’ve changed my practice since doing this research by taking a few simple steps. I encourage hospitalists to consider using Tylenol and Advil before jumping to an opiate. That’s an easy change that could dramatically reduce the use of opiates in the hospital.

I would also encourage hospitalists to talk about the side effects of these drugs. I think some patients expect their pain to be completely eliminated, and they don’t think of these drugs as dangerous. I ask patients if they really think their pain is severe enough to warrant opioids or if they want to try safer alternatives like NSAIDs. We find a lot of patients who say, “I didn’t know these drugs were risky. I’m fine with an alternative.”

Finally, I think we need to change the message we deliver about pain. The message can’t be, “You deserve to be 100% pain-free.” That’s really become the message in the inpatient setting, and that’s not good for anyone. If you sprain your ankle or get sick, you should expect to have some pain. Pain is the body’s way to tell people to be careful. Changing expectations surrounding pain control is critical.

Edward Doyle is Editor of Today’s Hospitalist