Published in the July 2015 issue of Today’s Hospitalist
NO ONE WOULD EVER CONSIDER prescribing a course of treatment for patients experiencing a blood clot without first considering their recent history of serious bleeding. But that is exactly what happens all the time when hospitalists prescribe opioids to patients in pain who also have a history or indications of addiction or mental illness.
That’s according to Charles P. Reznikoff, MD, a hospitalist and addiction medicine specialist at Hennepin County Medical Center in Minneapolis and an assistant professor of medicine at the University of Minnesota. All too often, Dr. Reznikoff told hospitalists at this spring’s Society of Hospital Medicine annual meeting, doctors “don’t consider the opioid addiction as a contraindication” to the “very treatment that is indicated.”
Instead, they just prescribe the narcotics to an addict in pain, telling themselves that, ” ‘If they take the medications as prescribed, no problem; if they don’t take them as prescribed, it’s their problem,’ ” Dr. Reznikoff pointed out. “But we never prescribe penicillin and, if someone is allergic, say, ‘Hey, that’s your problem, not mine.’ ” Like penicillin, he added, opioids create an important adverse reaction in a fraction of patients who receive them, and doctors must begin taking responsibility for managing that adverse reaction.
Unfortunately, most settings do not manage addictive behaviors well. That can result in both bad care for patients and in unnecessarily difficult working conditions for hospitalists, nurses and ED physicians, who struggle with demanding, drug-seeking patients.
The good news is that in some places, the situation is starting to improve, Dr. Reznikoff said. Experts are now rethinking several beliefs about pain, addiction and narcotics that have become standard practice. And some medical centers and physicians are taking it upon themselves to change their narcotic-ordering practices and break the cycle. Changes include improved documentation and instituting “high-risk care plans” for specific patients built around narcotic restriction protocols.
How we got here
The belief that hospitalized patients in pain can be managed with opioids without triggering addictive behaviors can be traced back to a letter to the editor published in the Jan. 10, 1980, New England Journal of Medicine. That letter purported to show “incorrectly, it has turned out “that addiction was rare in hospitalized patients being treated with narcotics for pain. As a result, most clinicians trained since 1980 believe that treating physical pain somehow trumps addiction.
“This has been canonized as when you are in pain, you can’t be addicted,” explained Dr. Reznikoff. “It’s not science, it’s dogma.”
In the decades since, there has also been a radical rethinking of “pain” as a diagnosis in and of itself that can be measured on a linear scale of 1-10. Some pharmaceutical companies have also done some very aggressive marketing to encourage clinicians to treat “chronic pain.”
Throw in a lack of medical evidence about both opioid effectiveness and the side effects of long-term use, said Dr. Reznikoff, and you end up where we are today: with a population that feels it has “an entitlement to opioids.”
A lack of evidence
According to an article in the Nov. 18, 2010, New England Journal of Medicine, one unintended consequence of this increased aggressiveness in treating pain has been a dramatic increase nationwide in fatal drug overdoses. That article noted that “more than 40% of opioid prescriptions are written by general or family practitioners, osteopaths, or internists,” and that “more than 3% of U.S. adults currently receive long-term opioid therapy for chronic noncancer pain.”
“We have all had the experience where we feel badgered to prescribe an opioid that our clinical judgment tells us is not a good idea,” Dr. Reznikoff said. “To make matters worse, the system often does not support us in following our better clinical judgment.”
And hospitalists have little evidence to guide them. “With pain and opioids,” he noted, “we are not in the randomized, controlled trial zone, but in the editorial zone.”
In addition, most hospitals “particularly smaller facilities or those in rural areas “have no addiction or pain treatment infrastructure, with few specialists available to consult with on these difficult patients. And in many hospitals, Dr. Reznikoff pointed out, the specialists commonly consulted on pain questions are experts in palliative care who have little to no training in handling addicted or mentally ill patients.
“It’s a different kind of patient and a separate training,” he said. Sometimes, psychiatrists are the best people to call for assistance, but that’s not universally true. Some psychiatrists look at these patients and say that a “pain consult” is what’s needed.
Pain: a symptom of disease
What can help, said Dr. Reznikoff, is for hospitalists to more precisely define what they mean by “pain” when seeking a consult, just like they would for any other medical question.
“You would never get a ‘dyspnea consult,’ ” he said. Instead, you would find out what’s causing the dyspnea to guide your choice of consult and the questions you ask. “You need to think about ‘pain’ like ‘rash’ or ‘dyspnea’: not a disease in and of itself, but a symptom of disease.”
Pain, he said, can be addiction manifesting as pain complaints, mental illness manifesting as pain complaints or physical pain manifesting as pain complaints. To make things even harder, pain is not always one problem.
As an example, he presented the case of a 24-yearold veteran who, after coming home from Afghanistan, underwent dozens of surgeries for an orthopedic injury sustained in combat. His history included alcohol misuse, marijuana use and a failed suicide attempt. The patient was also taking high doses of opioids for pain that he still complained of.
In this case, physicians might conclude that the patient’s demands for ever-more narcotics were related to addiction or to orthopedic pain, but this wasn’t so.
“He wasn’t manifesting addictive behavior but mental illness,” specifically PTSD, Dr. Reznikoff said. That was his conclusion because the patient participated in physical therapy comfortably and adhered to his opioid use contract, yet had never addressed his PTSD symptoms. “It’s confusing, and even an experienced person is going to have a hard time on the first visit sorting out what is what.”
Because hospitalists are likely to be the clinician who comes in cold to treat such patients, Dr. Reznikoff said, it’s their job to at least not make things worse.
“That means go slowly,” he advised. Take your time to diagnose what is causing the “pain” and then document your thought process “so the primary care doctor and the next hospitalist have a leg up and are not starting all over” the next time the patient shows up.
Opioids and addiction
As for the claim that people in pain “are immune to the addictive properties of opioids,” Dr. Reznikoff said there is little to no science to back that up. It is true that people in severe acute pain “from a pelvic fracture, for instance, or extensive burns “can safely be treated with opioids in the acute care setting with very little risk of developing opioid addiction.
“But we are not talking about people with pelvic fractures,” he said. “We are talking about people who come in with backaches without evidence of a serious cause. They are given so many opioids that after the backache goes away, they still have a bottle of opioids “and if they have an addictive vulnerability, they are likely to take those in an addictive pattern.”
Another case Dr. Reznikoff presented illustrates a common patient that hospitalists treat: one with a known heroin addiction who also has a pain-causing problem, in this case MSSA diskitis and an epidural abscess. The hospitalist service’s plan for the patient was to place a PICC line for four weeks of IV nafcillin and pain-controlling opioids.
“While that’s a sufficient plan for the average patient,” he said, “in this case something is missing. Her addiction should be factored into the plan, and it wasn’t.”
Many doctors, he added, “have the misperception that as soon as the pain generator happens, they don’t have to worry about the fact that a patient is actively addicted. They think pain or addiction. But for me, it’s treat both or neither.” That means that if and when you order morphine, you have to “talk more extensively with the patient, set limits and watch them more closely.”
And when you discharge that patient, he added, don’t send her home with excess pills. Other rules of thumb, he said, include “never giving an intravenous medicine when an oral will do,” not escalating doses, avoiding IV boluses, and documenting and communicating with both patients and outpatient providers. If there are specialists available, ask for help.
Methadone or Suboxone
There are also medications that can be used as alternatives, like methadone or Suboxone. As Dr. Reznikoff explained, inpatient physicians can prescribe methadone to patients seeking addiction treatment.
“You don’t need to personally walk them into the treatment center,” he said. “If they verbalize that they intend to seek addiction care, you can give them up to three days of methadone as an inpatient, never as an outpatient.” For addicts, methadone is highly regulated, and doctors need to understand the regulations and document carefully. It is always wrong, he noted, to give a patient oxycodone or morphine solely for the purpose of treating an addict’s withdrawal.
If patients are opioid addicted and withdrawal is exacerbating a myocardial infarction or if their withdrawal is making a psychotic episode worse, “you can stabilize them on methadone “or continue it if they are already enrolled in a clinic,” Dr. Reznikoff said. “A 30-mg daily dose is often enough for the worst opioid addicts with the highest tolerance to take the withdrawal away and stabilize them.”
Plus, “giving opioid addicts methadone as an inpatient can improve the patient’s satisfaction and take stress off the care team, so nurses aren’t tied up caring for patients in bad withdrawal,” he pointed out. “But it does not save lives; outpatient addiction treatment saves lives.” He urged hospitalists to recommend addiction treatment to patients who qualify.
As for treating “both or neither” the addiction and pain in this particular case, he said, that meant telling the patient that he would give her opioids only if she would agree to addiction treatment. When she refused, “we discontinued the opioids, and surprisingly she did really well.”
Breaking the cycle
The case illustrates the fact that some patients may not need the opioids they are often given. ” ‘Painkiller’ is a misnomer,” Dr. Reznikoff said. “Many clinicians and patients overvalue the benefit of opioids.” The best data show that opioids relieve between 30% and 50% of pain. “We overestimate how powerful they are, how necessary they are and how many we need to give,” Dr. Reznikoff said.
In addition, this patient demonstrates the problem with “intermittent rewards” that simultaneously drive addicts crazy and ensure that hospital staff remain stuck in a frustrating cycle of asking and denying. Patients are often characterized as “difficult” when they are only reacting to the unpredictable and inconsistent care they receive.
“When opioid addicts come to the hospital, they will ask and ask and ask,” Dr. Reznikoff pointed out. “If they ask five times and they are told ‘no’ four times and ‘yes’ once, they are going to ask six or 10 times the next time.”
In this particular case, the patient was actually happier with the certainty that she would not be receiving opioids. “She could relax now and take care of her health,” Dr. Reznikoff explained. “What she really wanted was consistency and communication.”
When you are in over your head, “don’t pretend there’s no addiction and then create instability in the patient with excessive or unpredictable morphine dosing,” he said. “Mentally ill and addicted patients are challenging. They need consistent care and communication, and they demand more of their hospitalist than other patients. But they can be managed safely and compassionately.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.