User login
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.
It’s the stuff of doctors’ nightmares. In a recent analysis of attitudes, beliefs, and practices regarding opioid prescribing, one hospitalist described how a patient had overdosed: “She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died.”1
Susan Calcaterra, MD, MPH, of the department of family medicine at the University of Colorado at Denver, Aurora; a hospitalist at Denver Health Hospital; and lead author of the recent study, says that the dramatic anecdotes don’t surprise her. “These are not uncommon events,” she said. “Across the country, you hear about overdose, you hear about people abusing fentanyl, and I think, when you have an addiction, your judgment of the dangers associated with your personal opioid use may be limited.”
Some critics have blamed the ubiquity of opioid prescriptions on the controversial movement to establish pain as a vital sign. Multiple investigations also have accused the pharmaceutical industry of aggressively promoting these prescription drugs while downplaying their risks. The CDC found that, in fact, so many opioid prescriptions were being written by 2012 that the 259 million scripts could have supplied every U.S. adult with his and her own bottle. In August 2017, President Trump declared the opioid crisis a national emergency, although opinions differ regarding the best ways forward.
Until recently, however, few studies had looked at how inpatient prescribing may be fueling a surging epidemic that already has exacted a staggering toll. So far, the early data paint a disturbing picture that suggests hospitals are both a part of the problem and a key to its solution.
Illuminating a ‘black box’
Changing the trajectory will be difficult. From 2002 to 2015, the nation’s overdose death rate from opioid analgesics, heroin, and synthetic opioids, such as fentanyl, nearly tripled, and studies suggest that prescription painkillers have become major gateway drugs for heroin.2 In the last 3 years alone, fentanyl-related deaths soared by more than 500%, and annual mortality from all drug overdoses has blown by the peak of the HIV/AIDS epidemic in 1995, when nearly 51,000 died from the disease.3
Amid the ringing alarm bells, hospitals have remained a largely neglected “regulatory dead zone” for opioids, said Shoshana Herzig, MD, MPH, of the department of medicine at Harvard Medical School, Boston, and director of hospital medicine research at Beth Israel Deaconess Medical Center, also in Boston. In an editorial accompanying the recent study of hospitalist perspectives, Dr. Herzig called the inpatient setting an opioid prescribing “black box.”4
In a previous analysis of 1.1 million nonsurgical hospital admissions, however, she and colleagues found that opioids were prescribed to 51% of all patients.5 More than half of those with inpatient exposure were still taking opioids on their discharge day. With other studies suggesting that such practices may be contributing to chronic opioid use long after hospitalization, Dr. Herzig wrote, “reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.”
A recent study led by Anupam Jena, MD, PhD, a health care policy expert at Harvard Medical School, echoes the refrain. “It’s kind of remarkable that the hospital setting hasn’t really been studied, and it’s an important setting,” he said. When he and colleagues did their own analysis of hospitalized Medicare beneficiaries, they found that 15% of previously opioid-naive patients were discharged with a prescription.6 Of those patients, more than 40% remained on opioids three months after discharge. The research also revealed a nearly two-fold variation in prescription rates across hospitals.
Some hospitalists have asserted that the increase in opioid prescriptions may partially be tied to pressure to reduce 30-day readmission rates; Dr. Jena and Dr. Karaca-Mandic’s work leaves open the possibility that such prescriptions may increase readmissions instead. The researchers, however, say a bigger driving force may be financial pressure tied to discharging patients earlier or scoring higher on quality measures that gauge factors, such as pain management. Hospitals that scored better on HCAHPS measures of inpatient pain control, their study found, were slightly more likely to discharge patients on opioids.
Keri Holmes-Maybank, MD, MSCR, FHM, an academic hospitalist at the Medical University of South Carolina, Charleston, says a lack of clear evidence and guidelines, unrealistic expectations, and variable patient responses to opioids are compounding a “very frustrating and very scary” situation for hospital medicine. Hospitalists who conclude that a patient-requested antibiotic will do more harm than good, for example, usually feel comfortable saying no. “But a patient can talk you into an opioid,” she said. “It’s much harder to stand your ground with that, even though we need to be viewing it the same way.”
The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
Pushing for proactive solutions
Kevin Vuernick, senior project manager of SHM’s Center for Hospital Innovation and Improvement, said the society’s Hospital Quality and Patient Safety Committee is actively exploring plans to develop pain prescribing guidelines for hospitalized patients based on the input of hospitalists and other medical specialists. The society also hopes to set up a website that compiles available resources, such as its own well-received Reducing Adverse Drug Events related to Opioids Mentored Implementation Program.
Dr. Mosher said SHM and other professional organizations also could assume leadership roles in setting a research agenda, establishing priorities for quality improvement efforts, and evaluating the utility of intervention programs. She and others have said additional help is sorely needed in educating providers, most of whom have never received formal training in pain management.
Talented and skilled physicians with the right language and approach could serve as role models in teaching providers how to appropriately bring up sensitive topics, such as concerns that a patient may be misusing opioids or that the pain may be more psychological than physical in nature. “We need a common language,” Dr. Herzig said.
More broadly, hospital medicine practitioners could serve as institutional role models. Many already sit on safety and quality improvement committees, meaning that they can help develop standardized protocols and help inform decisions regarding both prescribing and oversight to improve the appropriateness and safety of opioid prescriptions.
Matthew Jared, MD, a hospitalist at St. Anthony Hospital in Oklahoma City, said he and his colleagues have long worried about striking the right balance on opioids and about “trying to find an objective way to treat a subjective problem.” Because he and his hospitalist counterparts see 95% of St. Anthony’s inpatients, however, he said hospital medicine is uniquely positioned to help initiate a more holistic and consistent opioid management plan. “We’re key in the equation of trying to get this under control in a way that’s healthy and respectful to the patient and to the staff,” he said.
Bryn Nelson is a freelance writer in Seattle.
References
1. Calcaterra SL, Drabkin AD, Leslie SE, Doyle R, et al. The hospitalist perspective on opioid prescribing: A qualitative analysis. J Hosp Med. 2016 Aug;11(8):536-42.
2. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths – United States, 2010–2015. MMWR Morb Mortal Wkly Rep. 2016 Dec;65(50-51):1445-52; and https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.
3. Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. New York Times, Sept. 2, 2017. https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html?mcubz=1&_r=0
4. Herzig SJ. Opening the black box of inpatient opioid prescribing. J Hosp Med. 2016 Aug;11(8):595-6.
5. Herzig SJ, Rothberg MB, Cheung M, et al. Opioid utilization and opioid-related adverse events in nonsurgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73-81.
6. Jena AB, Goldman D, Karaca-Mandic P. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016 July;176(7):990-7.
7. Jena AB, Goldman D, Weaver L, Karaca-Mandic P. Opioid prescribing by multiple providers in Medicare: Retrospective observational study of insurance claims. BMJ. 2014;348:g1393.
8. Mosher HJ, Jiang L, Vaughan Sarrazin MS, et al. Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014 Feb;9(2):82-7.