Stephen Bekanich, MD

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

©iStock/thinkstockphotos.com

Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

©iStock/thinkstockphotos.com

Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Our team has been involved with a patient whose hospital stay is measured not in days, weeks, or months but in years. The scope of the problems surrounding not only the medical issues but also the family dynamic, out-of-hospital support system, and social situation can easily make the most seasoned providers feel paralyzed. It is fair to use words such as helpless, hopeless, overwhelmed, angry, confused, and conflicted for how the dozens of team members caring for this patient feel on a regular basis.

While the details of this case would eat up multiple columns, it might better for the reader to recall when a patient whose case you’ve been involved in has brought out strong, and often times, negative emotions from the faculty and staff that resulted in conflict. Finding a path to resolve conflict can be one of the most rewarding aspects of working within a system that relies on teamwork for desired, successful outcomes.

©iStock/thinkstockphotos.com

Toxic feelings build up easily in cases in which it seems like there is no end, no chance for our good intentions and hard work to salvage a patient’s spiraling course. Conflict with those we work with is almost inevitable. Hospitalists disagree with the surgeons, nursing staff and the pain team aren’t on the same page, hospital administration might seem to have the C-suite agenda. It is in times like this that conflict resolution smarts can preserve the peace. While maintaining a collegial attitude might not ultimately transform the patient’s outcome, the presence of on-going conflict amongst health care professionals is well studied and studded with unwanted outcomes.

There are conflict resolution books, courses, and even graduate degrees. For the hospitalist on the run, what principles can be applied immediately?

• Don’t react. Think it through. Emotions are strong and feelings differ. This is the crucible for doing something we might later regret. If you hear or read something that makes you upset, then first assume that your colleague has attempted to craft the absolute best plan for the patient. Before making statements or casting judgment, ask many questions. Never send a text or e-mail, make a phone call, or approach someone when you’re having trouble suppressing strong emotions.

• Practice active listening. This takes concentration, so rid yourself of distractions while engaging in listening. Use body language such as smiling or nodding to acknowledge the other person’s message. Pay attention to their gesticulations and nonverbal cues to their position. Avoid interruptions and defer judgment until they have finished. Summarize what you’ve heard from them to demonstrate that their message has been received. Even when you heartily disagree, show respect. We have the ability to find ways of being both candid and kind in our responses.

• Always go after the problem. It is too easy to attack a person rather than the underlying issue. Everyone involved in the care of a patient has the potential to contribute to the solution. By staying focused on the problem and not the people, you are building trust with your colleagues.

• Continue to show up. We all tire and become jaded with these marathon cases. Throwing your hands up in surrender and failing to remain a participating member of the team will send a message that you are not accepting responsibility. Showing up shouts that you’re committed.

• Be mindful of the words used in communication. Focus on "I" statements rather than "You" statements.As in "I need feedback on the plan of care I’ve proposed," rather than "You haven’t provided me with feedback on my plan." ... "I need more information before deciding on whether this procedure would be beneficial," rather than, "You haven’t told me why the procedure needs to be done now."

• Find common goals. Don’t spend time picking apart a nurse’s point of view or your consultant’s idea to work-up diagnoses that seem farfetched. Instead agree upon a goal or two and ask how we can get there together.

• Look toward tomorrow. Focusing on what has happened in the past leads only to war, litigation, or stagnation. Talking about how you can go forward from here can help reset the dynamic.

Like negotiation tools we’ve previously written about conflict resolution skills have broad applicability outside the work place and can make life better in a variety of situations.

As always if you’d like suggested readings or resources please contact us.

Dr. Bekanich and Dr. Leigh A. Fredholm are codirectors of Seton Palliative Care, part of the University of Texas Southwestern residency programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Steven Q. Simpson, FCCP commented: Dr. Fredholm and Dr. Beckanich adeptly discuss how to weigh possible life-sustaining measures in terms of whether they are providing comfort for patients and how to ensure that such treatments are discussed with patients in that context.

Additionally, they provide a very nice example of how to proceed when patients cannot communicate for themselves and have no family or other surrogates to speak for them.

Join us in the Critical Care NetWork’s eCommunity.

If you’re interested in more about these topics, you can join a discussion on this topic within the Critical Care e-Community. Simply log in to ecommunity.chestnet.org and find the Critical Care group If you’re not part of the Critical Care NetWork, log in to chestnet.org and add the Critical Care NetWork to your profile.

Questions? Contact communityadmin@chestnet.org.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

"Palliatively Speaking," appears monthly at ehospitalistnews.com.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Steven Q. Simpson, FCCP commented: Dr. Fredholm and Dr. Beckanich adeptly discuss how to weigh possible life-sustaining measures in terms of whether they are providing comfort for patients and how to ensure that such treatments are discussed with patients in that context.

Additionally, they provide a very nice example of how to proceed when patients cannot communicate for themselves and have no family or other surrogates to speak for them.

Join us in the Critical Care NetWork’s eCommunity.

If you’re interested in more about these topics, you can join a discussion on this topic within the Critical Care e-Community. Simply log in to ecommunity.chestnet.org and find the Critical Care group If you’re not part of the Critical Care NetWork, log in to chestnet.org and add the Critical Care NetWork to your profile.

Questions? Contact communityadmin@chestnet.org.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

"Palliatively Speaking," appears monthly at ehospitalistnews.com.

Recently, members of our palliative care team participated in the care of a man approaching the end of his life. The patient had suffered an in-hospital cardiac arrest 4 weeks earlier, and though he had survived the immediate event, it resulted in anoxic encephalopathy, which rendered him incapable of making decisions.

When it became clear that the patient was declining despite full support, the hospital’s ethics committee was convened to determine goals of care and next steps, as the patient had no family or surrogate decision maker. After determination that the hospital staff had exercised due diligence in attempting to locate a surrogate, the physicians involved reviewed the patient’s case and recommended a change in goals to comfort care. More than one member of the committee expressed confusion as to what interventions are and are not included in comfort care, including medically administered nutrition and hydration (MANH).

Comfort care has traditionally included medications for distressing symptoms (pain, dyspnea, nausea), personal care for hygiene, and choice of place of death (home, hospital, nursing facility), usually with the assistance of a hospice agency.

As the number and complexity of interventions used near the end of life expand, clinicians and hospital staff report confusion about whether these interventions, generally considered to be life-sustaining treatments, can also be considered comfort care. We generally find that when interventions are considered in the context of the patient’s goals of care, the dilemma is clarified. Often the situation is made more complicated by considering the interventions before settling on goals. Broadly speaking, goals of care are derived from a careful consideration (by patient, physician, and family) of the natural history of the illness, expected course and prognosis, and patient preferences.

In the case of the above-referenced patient, we were unable to ascertain his goals because of neurological impairment. We did know, however, that the patient had steadfastly avoided hospitals and medical care of any kind. The attending hospitalist, pulmonologist, and palliative care physician agreed that the patient’s clinical status was declining despite all available interventions, and that his constellation of medical problems constituted a terminal condition. The physicians agreed that future ICU admission, resuscitation, and other new interventions would only prolong his dying process, but not permit him to live outside the hospital. At that time, the patient was receiving nutrition and hydration via a Dobhoff tube, and was tolerating enteral nutrition without excessive residuals or pulmonary secretions.

As with other interventions, whether or not to consider MANH a part of comfort care is individualized. In this patient’s case, in the absence of evidence that he would not want MANH, it was continued. Other patients have expressed the wish that they would under no circumstances accept MANH while receiving comfort care. Both are correct as long as they reflect that patient’s wishes.

With respect to other interventions – including but not limited to BiPAP, inotrope infusion, chemotherapy, radiation therapy, and transfusions – whether or not they provide comfort is a decision to be made jointly by the patient and physician(s). As advances in medicine allow patients to live longer with serious illness, the definition of comfort care must also expand.

Dr. Steven Q. Simpson, FCCP commented: Dr. Fredholm and Dr. Beckanich adeptly discuss how to weigh possible life-sustaining measures in terms of whether they are providing comfort for patients and how to ensure that such treatments are discussed with patients in that context.

Additionally, they provide a very nice example of how to proceed when patients cannot communicate for themselves and have no family or other surrogates to speak for them.

Join us in the Critical Care NetWork’s eCommunity.

If you’re interested in more about these topics, you can join a discussion on this topic within the Critical Care e-Community. Simply log in to ecommunity.chestnet.org and find the Critical Care group If you’re not part of the Critical Care NetWork, log in to chestnet.org and add the Critical Care NetWork to your profile.

Questions? Contact communityadmin@chestnet.org.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

"Palliatively Speaking," appears monthly at ehospitalistnews.com.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. 

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. 

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. 

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

It is difficult to know precisely how this change will affect hospitalists.

In our community, a significant portion of hospitalists have chosen not to obtain the necessary prescription blanks for Schedule II drugs and prescribe exclusively hydrocodone products upon discharge. We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. Though we cannot know the exact timing of the expected change, hospitalist groups should begin developing their approach immediately.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

It is difficult to know precisely how this change will affect hospitalists.

In our community, a significant portion of hospitalists have chosen not to obtain the necessary prescription blanks for Schedule II drugs and prescribe exclusively hydrocodone products upon discharge. We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. Though we cannot know the exact timing of the expected change, hospitalist groups should begin developing their approach immediately.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, the Food and Drug Administration announced that it will submit a formal recommendation to the Department of Health and Human Services to reclassify hydrocodone combination products as Schedule II.Efforts to reschedule hydrocodone date back several years and originate from the increase in overdose deaths attributed to hydrocodone as well as the drug’s relative overrepresentation in opioid abuse.

Hydrocodone has been the most prescribed drug in the United States for more than 5 years – more than medications for hypertension, diabetes, and infections, just to name a few. Studies of opioid abuse have found the majority of diverted opioids are obtained from a friend or relative who received the drug from a treating physician (as opposed to buying on the street or from a "pill mill"). Paradoxically, the FDA simultaneously approved Zohydro ER, a long-acting hydrocodone product, despite an 11-2 vote against approval in the FDA’s own advisory committee.

Our colleagues are understandably confused by these developments. Physicians and patients alike perceive that hydrocodone is weaker than other opioids, largely because it is not currently classified as Schedule II. In states with Prescription Monitoring Programs, this misperception is increased by the fact that hydrocodone prescriptions do not require a special prescription pad. Prescribers often are very surprised to discover that hydrocodone and morphine are 1:1 in opioid equianalgesic tables (Clin. J. Pain 19:286-97). While a change in the schedule classification for a drug has no bearing on its pharmacokinetics or safety profile, it will have the intended effect of decreasing the number of prescriptions written. It remains to be seen whether this change will limit access to opioids for patients with legitimate need for opioids, as is feared by many chronic pain patients and their advocates. On the other hand, there will be no perverse incentive to use a combination opioid, with consequent increased risk of hepatotoxicity from acetaminophen.

It is difficult to know precisely how this change will affect hospitalists.

In our community, a significant portion of hospitalists have chosen not to obtain the necessary prescription blanks for Schedule II drugs and prescribe exclusively hydrocodone products upon discharge. We suspect that hospitals will need to devote significant resources to early transition from parenteral to oral opioids, with subsequent transition away from opioids altogether as part of the discharge planning process. Additional time will need to be allotted for counseling patients and their families about the rationale and timing of these transitions. Furthermore, reclassifying hydrocodone will limit the number of refills permitted without a physician visit, which may lead to increased ED visits and duplicative testing, as well as patients who are dissatisfied with hospital care.

Chronic pain is a difficult and complex clinical problem. The evidence for long-term opioid therapy in chronic nonmalignant pain is weak, but for many patients opioid therapy is the only choice fully covered by insurance, or the only affordable choice for the uninsured/underinsured. Other modalities to be considered include but are not limited to adjuvant drugs (selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants), physical therapy, exercise, lifestyle modifications, massage, acupuncture, biofeedback, and counseling. Hospital systems will bear the consequences of this change, and may be well served by developing additional service lines for pain management. Though we cannot know the exact timing of the expected change, hospitalist groups should begin developing their approach immediately.

Dr. Fredholm and Dr. Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Earlier today our team was consulted to see an 85-year-old gentleman. A request was made that we conduct a family meeting to elicit the goals of care.

The patient had several underlying illnesses including diastolic heart failure, chronic renal insufficiency, and COPD. He was admitted after experiencing a complication from an outpatient procedure aimed at alleviating his chronic low back pain. After paging through his chart, it was clear that he suffered multiple setbacks throughout his admission, and that over the last 12 hours he was rapidly decompensating from hospital-acquired pneumonia and subsequent sepsis.

Though I was quite certain that his family had been approached about treatment goals, there was no documentation of this in the chart or reflection of these goals in the care plan. This was hospital day No. 32.

Two decades are behind us after being confronted with the impressive discord between what patients with advanced illnesses desire for themselves, what we think they want, and the actual care we deliver to them(JAMA 1995;274(20):1591-98). Where are we today when it comes to having dialogue with patients and families about advance care planning (ACP) or code status and our documentation of these critical decisions?

Recently, a study from 12 hospitals spanning Canada set out to see how often seriously ill elderly patients in the hospital were engaged in ACP (JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]). The mean age of the patients was 80 years, and they all had advanced illnesses that were not expected to be curable. Over 75% of the almost 300 patients enrolled reflected on end-of-life preferences prior to hospitalization, and only 12% were interested in life-prolonging care versus care that focused on quality of life. While in the prehospital period patients are completing advance directives (AD) and identifying a surrogate (48% and 73% respectively), the disconnect comes when looking at whether the documentation in the medical record is in agreement with patient preferences. It is not. The medical record accurately reflects the patient choice only 30% of the time. This led the invited commentary to declare that this disregard be classified as a medical error(JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]).

Are we the barriers to seeing ACP take place and properly chart the results?

Clearly that is part of the problem (the patient side of this equation will be explored in a future piece). In 2010, a group of hospitalists were audio-recorded during their initial encounter with a newly admitted patient (J. Gen. Intern. Med. 2011 26(4):359-66). During a total of 80 encounters, ACP was brought up less than 20% of the time. When it was addressed, the median length of a code status discussion was 1 minute. Prognosis was mentioned in only one encounter. No physician made a quantitative estimate of prognosis, nor did anyone make recommendations on whether or not CPR was medically appropriate.

Here is a sample from the recording with a hospitalist discussing code status with a patient diagnosed with cholangiocarcinoma:

Physician: "... If for some reason you got so sick that your heart stopped beating or your lungs got so sick that they couldn’t breathe on their own, would you want us to attempt to bring you back to life with electricity shocks and other things?"

Patient: "Yes."

Physician: "Yes. Okay. Okay. I think that’s all my questions."

How does the lack of ACP and documentation impact the hospitalist in 2013? Two big-ticket items come to mind: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and 30-day readmissions. Both of these will be explored in the next column, along with what we can do to make both immediate and long-term positive impacts on ACP.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Earlier today our team was consulted to see an 85-year-old gentleman. A request was made that we conduct a family meeting to elicit the goals of care.

The patient had several underlying illnesses including diastolic heart failure, chronic renal insufficiency, and COPD. He was admitted after experiencing a complication from an outpatient procedure aimed at alleviating his chronic low back pain. After paging through his chart, it was clear that he suffered multiple setbacks throughout his admission, and that over the last 12 hours he was rapidly decompensating from hospital-acquired pneumonia and subsequent sepsis.

Though I was quite certain that his family had been approached about treatment goals, there was no documentation of this in the chart or reflection of these goals in the care plan. This was hospital day No. 32.

Two decades are behind us after being confronted with the impressive discord between what patients with advanced illnesses desire for themselves, what we think they want, and the actual care we deliver to them(JAMA 1995;274(20):1591-98). Where are we today when it comes to having dialogue with patients and families about advance care planning (ACP) or code status and our documentation of these critical decisions?

Recently, a study from 12 hospitals spanning Canada set out to see how often seriously ill elderly patients in the hospital were engaged in ACP (JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]). The mean age of the patients was 80 years, and they all had advanced illnesses that were not expected to be curable. Over 75% of the almost 300 patients enrolled reflected on end-of-life preferences prior to hospitalization, and only 12% were interested in life-prolonging care versus care that focused on quality of life. While in the prehospital period patients are completing advance directives (AD) and identifying a surrogate (48% and 73% respectively), the disconnect comes when looking at whether the documentation in the medical record is in agreement with patient preferences. It is not. The medical record accurately reflects the patient choice only 30% of the time. This led the invited commentary to declare that this disregard be classified as a medical error(JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]).

Are we the barriers to seeing ACP take place and properly chart the results?

Clearly that is part of the problem (the patient side of this equation will be explored in a future piece). In 2010, a group of hospitalists were audio-recorded during their initial encounter with a newly admitted patient (J. Gen. Intern. Med. 2011 26(4):359-66). During a total of 80 encounters, ACP was brought up less than 20% of the time. When it was addressed, the median length of a code status discussion was 1 minute. Prognosis was mentioned in only one encounter. No physician made a quantitative estimate of prognosis, nor did anyone make recommendations on whether or not CPR was medically appropriate.

Here is a sample from the recording with a hospitalist discussing code status with a patient diagnosed with cholangiocarcinoma:

Physician: "... If for some reason you got so sick that your heart stopped beating or your lungs got so sick that they couldn’t breathe on their own, would you want us to attempt to bring you back to life with electricity shocks and other things?"

Patient: "Yes."

Physician: "Yes. Okay. Okay. I think that’s all my questions."

How does the lack of ACP and documentation impact the hospitalist in 2013? Two big-ticket items come to mind: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and 30-day readmissions. Both of these will be explored in the next column, along with what we can do to make both immediate and long-term positive impacts on ACP.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Earlier today our team was consulted to see an 85-year-old gentleman. A request was made that we conduct a family meeting to elicit the goals of care.

The patient had several underlying illnesses including diastolic heart failure, chronic renal insufficiency, and COPD. He was admitted after experiencing a complication from an outpatient procedure aimed at alleviating his chronic low back pain. After paging through his chart, it was clear that he suffered multiple setbacks throughout his admission, and that over the last 12 hours he was rapidly decompensating from hospital-acquired pneumonia and subsequent sepsis.

Though I was quite certain that his family had been approached about treatment goals, there was no documentation of this in the chart or reflection of these goals in the care plan. This was hospital day No. 32.

Two decades are behind us after being confronted with the impressive discord between what patients with advanced illnesses desire for themselves, what we think they want, and the actual care we deliver to them(JAMA 1995;274(20):1591-98). Where are we today when it comes to having dialogue with patients and families about advance care planning (ACP) or code status and our documentation of these critical decisions?

Recently, a study from 12 hospitals spanning Canada set out to see how often seriously ill elderly patients in the hospital were engaged in ACP (JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]). The mean age of the patients was 80 years, and they all had advanced illnesses that were not expected to be curable. Over 75% of the almost 300 patients enrolled reflected on end-of-life preferences prior to hospitalization, and only 12% were interested in life-prolonging care versus care that focused on quality of life. While in the prehospital period patients are completing advance directives (AD) and identifying a surrogate (48% and 73% respectively), the disconnect comes when looking at whether the documentation in the medical record is in agreement with patient preferences. It is not. The medical record accurately reflects the patient choice only 30% of the time. This led the invited commentary to declare that this disregard be classified as a medical error(JAMA Intern. Med. 2013 April 1 [doi: 10.1001/jamainternmed.2013.203]).

Are we the barriers to seeing ACP take place and properly chart the results?

Clearly that is part of the problem (the patient side of this equation will be explored in a future piece). In 2010, a group of hospitalists were audio-recorded during their initial encounter with a newly admitted patient (J. Gen. Intern. Med. 2011 26(4):359-66). During a total of 80 encounters, ACP was brought up less than 20% of the time. When it was addressed, the median length of a code status discussion was 1 minute. Prognosis was mentioned in only one encounter. No physician made a quantitative estimate of prognosis, nor did anyone make recommendations on whether or not CPR was medically appropriate.

Here is a sample from the recording with a hospitalist discussing code status with a patient diagnosed with cholangiocarcinoma:

Physician: "... If for some reason you got so sick that your heart stopped beating or your lungs got so sick that they couldn’t breathe on their own, would you want us to attempt to bring you back to life with electricity shocks and other things?"

Patient: "Yes."

Physician: "Yes. Okay. Okay. I think that’s all my questions."

How does the lack of ACP and documentation impact the hospitalist in 2013? Two big-ticket items come to mind: HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) and 30-day readmissions. Both of these will be explored in the next column, along with what we can do to make both immediate and long-term positive impacts on ACP.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin.

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.

Recently, a colleague from the pharmacy in our hospital system presented the results of an antibiotic stewardship initiative. The rationale for focus on antibiotic prescribing is compelling: antibiotic misuse leads to the development of resistance with negative consequences, including but not limited to: increased mortality, increased incidence of Clostridium difficile colitis, increased costs, increased length of stay, and decreased infection cure rates.

As our colleague reviewed her data, it dawned upon us – we need opioid stewardship (OS). As with antibiotics, there is wide variation in the way opioids are prescribed, particularly in inpatient settings. The pharmacology of opioids is well defined, as are the adverse effects. The patient safety teams in our hospitals monitor opioid-related events. The national news is replete with the rise in accidental overdose death attributed to opioids. The Food and Drug Administration, in response to emerging trends of opioid misuse, has proposed to change hydrocodone to a Schedule II designation and adopted Risk Evaluation and Mitigation Strategies (REMS) for selected opioids. The Joint Commission and HCAHPS focus on pain management presses us from the opposite direction, making pain management efforts pivotal for accreditation and incentive reimbursement. How can we keep our patients as pain free as possible and keep them safe? We believe opioid stewardship efforts, modeled after antibiotic stewardship, are the path forward.

Opioid stewardship is built on a foundation of rational prescribing. Prescribers will need to be familiar with the selection and pharmacology of opioids, equianalgesic dosing, and the risks and benefits as well as cost. As with antibiotics, one must consider the indication, route, and duration of therapy. Opioids are indicated for moderate to severe pain.

For acute pain states, the use of opioids is fairly straightforward, and the dose can be tapered as the underlying cause of the pain improves. For chronic pain states, the use of opioids is complicated and when used should be only one aspect of a multimodal, multidisciplinary pain management program (including risk assessment for substance abuse). This is difficult to initiate in an acute care setting. Outcome measures for chronic pain should be focused on functional improvement, safety, and tolerability rather than the pain scale mandated by Joint Commission, as the pain scale may not change appreciably even when the patient’s function improves significantly. When a chronic pain patient is admitted to the hospital, it is critical that the outpatient pain physician be involved – to set reasonable goals and provide post-acute follow up care.

The evidence for use of opioids in chronic pain is mixed at best. When opioids are prescribed, the parenteral route should be reserved for patients who are unable to take oral medications. The duration of analgesia for oral opioids is 4 hours for immediate-release preparations, compared with intravenous opioid duration of 1-2 hours. The efficacy of oral opioids is equal to that of parenteral opioids when equianalgesic doses are administered. Oral opioids are less likely to cause an adverse event in the hospital or to delay discharge. Duration of therapy for acute pain mirrors the duration of the underlying illness. For chronic pain, duration of therapy is contingent upon favorable outcome measures, namely improved function. Chronic pain patients who do not improve functionally despite opioids should be managed with other measures.

Anticipatory guidance and patient education is an important aspect of opioid stewardship. Just as many patients believe that an antibiotic is indicated for any infection, opioids are often the first thought for patients in pain. When an opioid is not the best initial therapy, clinicians will need to be prepared to discuss the evidence base and counsel patients accordingly.

Additionally, for chronic pain patients, expectations will need to be addressed. Improvements in pain control for chronic pain patients are incremental and generally reflected in functional improvement rather than in lowered pain rating. When patients with chronic pain are counseled not to expect "zero" pain, they are more satisfied with our efforts to control their pain.

Applying the principles of antibiotic stewardship to opioid prescribing has the potential to lower cost, improve safety and outcomes, and avoid more onerous regulatory requirements for prescribers while improving the quality of overall pain management. As with antibiotic stewardship, it will require collaboration between all the members of the healthcare team; particularly physicians, advance practice nurses, and pharmacists. Caring for medically complicated patients in a delivery system in which new measures of success and safety are evolving makes opioid stewardship a concept worthy of development.

Dr. Bekanich and Dr. Fredholm are codirectors of Seton Health Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. Their respective backgrounds are internal medicine and family medicine. Between the two of them, they have extensive hospital medicine experience. Their ongoing work within one of the nation’s Pioneer Accountable Care Organizations puts them in constant collaboration with their hospitalist, general internist, and family medicine colleagues.