Published in the March 2017 issue of Today’s Hospitalist
AS A RESIDENT, Neetu Mahendraker, MD, struggled with how to appropriately dose opioids for inpatients. And working as a hospitalist since 2009, Dr. Mahendraker has continued to find pain management challenging. She believes she’s not alone, particularly when it comes to managing pain in opioid-tolerant patients.
“We physicians lack knowledge about potency differences and opioid tolerance, so we end up administering opioids inadequately,” she says. “I was always told not to give patients too much opioids because we’ll have to intubate them if they go into respiratory depression and because patients get dependent when exposed.”
As a result, she adds, “we doctors end up being very conservative. We like giving small opioid doses, and we have little data to guide appropriate dosing for adequate pain control in patients on chronic opioids.”
“We doctors end up being very conservative. We like giving small opioid doses.”
Dr. Mahendraker always knew that giving small opioid doses puts her on a collision course with the patients she treats as the lead academic hospitalist within the Indiana University Health System in Indianapolis. Her patient panels include those who are post-transplant or chronic pancreatitis, sickle cell, chronic liver disease or cancer patients who usually take “huge doses” of opioids at home.
“When we start these tiny doses and patients complain, they give us the impression that they are opioid-seeking,” she points out. “But the truth is that they’re tolerant, and we absolutely cannot treat them with minimal doses and expect them to be pain-free.”
Fortunately, Dr. Mahendraker found one potential way forward. In 2015, she attended a lunch-and-learn session held at her center by surgeons who had piloted the use of opioid tolerance levels to better manage perioperative pain among surgical patients taking chronic opiates. She and her research colleagues immediately decided to test the same tactic in a pilot on non-surgical hospitalized patients.
Setting tolerance levels
In February and March 2016, Dr. Mahendraker and her colleagues piloted the use of an opioid tolerance leveling (OTL) order set on two medical units.
In that pilot, she and her team screened patients on admission, then assigned each of them to one of three categories—OTL 1, OTL 2 or OTL 3—based on their self-reported daily morphine equivalent dosage (MED) intake during the 45 days prior to their hospital stay. OTL 1 patients were opioid naive, taking none or only intermittent daily opioids, while OTL 2s were those taking between 15 and 90 mg of a daily MED. OTL 3s were taking more than 90 mg of a daily MED.
The inpatient order set put in place spells out specific drugs, doses and dosing frequencies for mild, moderate and severe pain for each of those three OTL categories. All patients also receive at least one scheduled non-opiate, and clinicians are directed to switch from IV to PO once patients can tolerate a clear liquid diet.
Each of the three pain levels for each OTL category includes at least three separate drug options, although most categories contain four. The floor nurses were trained to try at least three of the options on the order set for a specific patient’s opioid-tolerance and pain level before paging a doctor to get involved.
One of the most immediate impacts of the trial, says Dr. Mahendraker, was how dramatically the number of pages doctors had about pain management went down.
“During a 10-hour shift,” she says, “I used to get between 30 and 40 pages about managing pain. With the order set, I’d say that decreased by 50%.”
In the trial, which included 48 patients, 44% of patients were OTL 1, 44% were OTL 2 and 12% were OTL 3. The fact that none of the patients managed with the order set needed naloxone was an indication of its safety.
Further, Dr. Mahendraker found that only 23% of patients were discharged with increased dosages of prescribed opioids. She notes, however, that those increased dosages at discharge were very short courses of around seven days. This signifies, she points out, that the addiction potential related to the order set was very low and could alleviate physicians’ fear that they were creating opioid dependence.
Due to patients’ high tolerance, she and her research team decided to refer all OTL 2 patients with psychiatric diagnosis as well as all OTL 3 patients for an outpatient addiction consult. Among the patients in the trial, 27% received such a referral.
One year later, the order set is still in effect, and the benefits of using it have been sustained. The hospitalists appreciate receiving fewer pages, plus they like having a structured approach to escalating pain management when necessary.
The nurses appreciate being able to independently address patients’ pain problems without always having to kick such problems up to doctors. In the past, Dr. Mahendraker notes, physicians would sometimes refuse to escalate dosing or frequency. Opioid-tolerant patients are now having their pain controlled, putting an end to the damaging negotiations that hospitalists used to have with patients demanding higher doses— all without need to administer naloxone.
It’s an approach that Dr. Mahendraker thinks other hospitals should put in place. One important element, she notes, is training nurses in how to use the order set. She trained the nurses on her own floor, explaining the order set during daily huddles with the nurses, but “we need more rigorous training. For the nurses, it’s definitely more responsibility.”
Another challenge: Making sure patients referred for an addiction consult can receive one. Her academic center does not have an addiction specialist, and they are few and far between even in the outpatient setting, she points out.
But having those consults available would help alleviate a challenge Dr. Mahendraker hears all the time from hospitalized patients on chronic opioids: the problems they have getting and filling outpatient prescriptions.
“An addiction specialist,” she says, “would help primary care physicians and hospitalists comanage opioid tolerant patients without over-prescribing.”
Dr. Mahendraker continues to collect data on the use of the OTL order set, following such endpoints as patients’ nausea, vomiting, constipation and respiratory depression.
She also is interested in other avenues of research related to pain. For one, she’d like to do genetic testing on opioid-tolerant patients to understand why some patients are more sensitive to opioids while others are more resistant. “Is it just dose escalation? Or is there any associated genetic component?”
She also wants to research the role of objective clinical data—such as blood pressure and heart rate—in assessing patients’ pain levels, rather than relying solely on a subjective pain scale.
“When we come in patients’ rooms to ask them where their pain is on a scale of 1 to 10, many of them seem happy and are sitting up in bed watching TV,” she says. “But then they tell us their pain is 10 out of 10. I’d like to see if we could use clinical data and integrate those into that assessment.”
Phyllis Maguire is Executive Editor of Today’s Hospitalist.