Published in the September 2017 issue of Today’s Hospitalist
LIKE ALL PHYSICIANS, hospitalists are under the gun to reduce their opioid prescribing. To that end, several panels of experts at this year’s Society of Hospital Medicine annual meeting offered advice on everything from how to use opioids when treating the growing number of inpatients suffering from both pain and substance use disorders to more effective ways of using non-opioid analgesics and non-drug pain treatments.
“Why do we care?” asked Shoshana J. Herzig, MD, MPH, a hospitalist and director of hospital medicine research at Harvard Medical School and Beth Israel Deaconess Medical Center in Boston. “Because opioids are among the most common causes of adverse events in hospitalized patients”—and because “hospitalization contributes to opioid initiation and long-term use in millions of adults each year.”
An important article published last year in the May 2016 issue of the Journal of General Internal Medicine found that up to one-quarter of patients who were opioid-naive prior to a hospitalization filled an opioid script in the week after discharge. Another study, published in the July 2016 JAMA Internal Medicine, found that nearly half those patients were still using opioids more than 90 days later.
“We may think that this is just an outpatient problem, but we are part of the problem too.”
“If you are taking opioids 90 days after, you are taking them indefinitely,” pointed out hospitalist Theresa E. Vettese, MD, a palliative care specialist at Atlanta’s Emory University School of Medicine and Grady Memorial Hospital. “We may think that this is just an outpatient problem, but we are part of the problem too.”
How to reduce prescribing
How can hospitalists turn problematic prescribing around? Here are several key changes that panelists recommended when treating patients suffering from severe pain:
• Avoid long-acting opioids, order the lowest effective dose for the shortest time and limit opioids at discharge. As Dr. Herzig pointed out, “there are many opioid conversion apps out there” that hospitalists should use. But she recommended that doctors should go further and reduce doses by between 25% and 50%, especially for elderly patients.
“Remember, calculated equianalgesic dosages are estimates only,” she said. Moreover, patients who develop a tolerance for one opioid are unlikely to tolerate a different opioid similarly. As a result, physicians need to reduce doses when switching between opioids and when prescribing opioids in patients with comorbidities.
Dr. Vettese pointed out that she tells patients at the start of their hospital stay that she will not be prescribing them opioids at discharge. Instead, any post-discharge opioid prescription will have to come from patients’ outpatient physician, something she lets them know she will communicate to primary care providers.
And if you must discharge a patient with an opioid prescription, make sure it is for the fewest number of pills possible. When opioids are used for acute pain, said Dr. Herzig, “three days or less of therapy will often be sufficient. Longer courses lead to the higher likelihood of both chronic use and diversion.”
• Avoid intravenous opioids if possible. “The faster the rate of opioid onset, the greater the reinforcement and addiction potential,” Dr. Herzig said. That is why “the oral route is strongly preferred over injection” for almost all patients.
“We probably aren’t using NSAIDs as often as we should.”
While IV-administered opioids take effect almost immediately, oral therapies usually take between 20 and 40 minutes. “We are talking about only a 15or 30-minute difference” in the onset of pain control, and oral opioids last longer than IV agents. “You can get a bigger bang for your buck, and you don’t need as many repeated doses.”
• Always consult your state’s prescription drug monitoring program (PDMP) before prescribing. All states but Missouri have a PDMP. In some, like Massachusetts, prescribers or pharmacists are required to check these online databases before writing or filling an opioid prescription.
With a PDMP, “you can assess whether a patient has been getting refills from multiple providers or doing a bit of doctor shopping, or if they have overlapping pills or rapid consumption,” Dr. Herzig explained. “All of these can serve as red flags for possible substance use disorder and increased risk for adverse events.”
Revise your pain scale to ask about both intensity and tolerability. Clinicians should ask not just about how bad patients’ pain is (on a 1-10 scale, for instance) but also—on a similar scale—how much the pain affects their “enjoyment of life” and how much it “interferes with general activity.” That’s according to Hilary J. Mosher, MD, MFA, hospitalist and clinical associate professor at the University of Iowa Carver College of Medicine and Iowa City VA Medical Center in Iowa City.
Dr. Mosher pointed out that those three data points can help “interrupt the reflexive response that patients get an opioid when they report a high pain score, which in turn can lead to inappropriate continuation.” And hospitalists are often surprised by patients’ answers to those questions, she noted. Many patients in pain are willing to work with doctors to use non-opioid treatments to deal with discomfort in the hospital.
• Make greater use of other pharmaceutical and non-pharmaceutical treatments. Except for patients with reduced kidney function, “we probably aren’t using NSAIDs as often as we should,” said Dr. Herzig. Mounting evidence indicates that NSAIDs are “equally or more effective and have less risk for harm than opioid analgesics.” She cited several recent Cochrane reviews that compared opioid to non-opioid therapy for acute renal colic, acute post-operative pain and acute tissue injury.
Moreover, in treating most kinds of pain, doctors should pair opioids with non-opioids. That makes both work better and “reduces total opioid requirements.”
When prescribing NSAIDs for older patients, Dr. Vettese advised ordering lower doses, such as 200-400 mg of ibuprofen every six hours, for instance. Physicians should also stop patients’ ACE inhibitors and make sure they are well-hydrated.
In addition to non-opioids, Dr. Vettese recommended trying non-pharmaceutical pain-relief methods, from physical therapy and TENS units to nerve blockades administered by anesthesiologists, which show promise. (See “Four pain scenarios: What to do in the hospital.“) Some evidence also supports distraction therapy, such as music therapy.
• Have tough conversations with patients. Many patients mistakenly believe that opioids aren’t addictive, don’t have side effects or can take away all their pain. “We should be discussing risk, and—more importantly—setting realistic goals and expectations,” said Dr. Herzig. “You can save yourself a lot of headaches down the road when therapy goes awry or patients start having adverse effects.”
Deborah Gesensway is a freelance writer who covers U.S. health care from Toronto.
Scenario 1: Patients have chronic pain with no acute pain or history of opioid use. Do not start opioids in the hospital. “Even for chronic pain scores of 10, opioids should not be a first-line therapy in the absence of acute pain,” said Hilary J. Mosher, MD, MFA, hospitalist and clinical associate professor at the University of Iowa Carver College of Medicine in Iowa City. Dr. Mosher advised hospitalists to find out what patients do at home to cope and to also pay attention to disturbed sleep, anxiety, depression, boredom and immobility. All of those can be exacerbated in the hospital, and they all contribute to chronic pain.
Scenario 2: Patients have both chronic and acute pain, but no history of opioid use. Hospitalists’ first job is to focus on acute pain, and their choice of therapy will depend on proper diagnosis.
“Opioids should not be a first-line therapy in the absence of acute pain.”
If the pain is nociceptive—due to tissue injury such as inflammation, trauma or ischemia—patients typically describe it as “sharp, aching or throbbing,” said Harvard’s Shoshana J. Herzig, MD, MPH. The best choice of an analgesic is likely to be an NSAID or acetaminophen.
If the pain is neuropathic and related to a nerve injury, which patients usually describe as “burning, heavy or numbness, you are reaching for things like gabapentin, pregabalin, tricyclic antidepressants or SNRIs.”
“There is a myth out there that opioids are the most effective medications to treat severe pain,” Dr. Herzig explained. “For most pain, in fact, non-opioid analgesics are equally or more effective with less risk for harm.”
Studies have also shown that other pain reduction therapies “significantly” help reduce post-operative pain, said Emory’s Theresa E. Vettese, MD. In addition to physical therapy and TENS units, options include femoral nerve block and acupressure. According to a systematic review in the Aug. 16, 2011, Annals of Internal Medicine, the most effective pain management strategy for hip fracture patients is nerve blockade.
“It’s a low-risk procedure” that leads to less opioid use as well as decreased delirium and length of stay, Dr. Vettese said. “We should be talking to our hospital administrators and anesthesia colleagues to have nerve blockade offered as part of our pain management.”
Scenario 3: Patients have chronic pain with no acute pain, and they take opioids. Hospitalists need to determine whether the pre-hospital opioids are “causing imminent harm or contributing to the reason for the hospitalization,” Dr. Mosher said. Opioids are implicated in falls, mental status changes, respiratory distress and polypharmacy complications.
“If we don’t see those harms, it is reasonable to continue home therapy,” she noted. “If we do see harms, then consider if there is also an underlying substance abuse diagnosis.”
It is also important to “engage patients in conversation about alternatives. If they are willing to consider getting off opioids, Dr. Mosher said, “initiate a tapering protocol.”
Scenario 4: Patients have both chronic and acute pain and take opioids. If the opioids the patient takes for chronic pain aren’t “causing imminent harm and other analgesics are contraindicated or have not been effective, it is reasonable to consider increasing opioids short-term,” Dr. Mosher said.
The most difficult subset within this group is patients with an opioid use disorder. Some strategies can help, starting with up-front conversations both about the risks of opioids in hospitalized patients and expectations about their benefits.
“The message should not be that we are going to help you become pain-free,” said Dr. Herzig. “The goal is tolerability, not absence of pain. Discussing this up-front goes a long way toward forging a therapeutic alliance.”
Conversations also should cover the fact that opioids will be cut back if patients experience a lot of sedation or other side effects. “That,” Dr. Herzig pointed out, “can make discussions down the line a little easier.”