Quality

Serious Complications from Opioid Overuse in Hospitalized Patients Prompts Nationwide Alert


 

Opioid overuse can spell the onset of onerous consequences. The analgesics can slow breathing to dangerous levels and lead to dizziness, nausea, and falls.

Citing these concerns, The Joint Commission issued a Sentinel Event Alert in August 2012 that urged hospitals to take specific measures to help avoid serious complications and even deaths from the use of such opioids as morphine, oxycodone, and methadone.

“The Joint Commission recognizes that there is an opportunity to improve the care of patients on opioids in acute-care settings,” spokeswoman Elizabeth Eaken Zhani says. “Healthcare workers need to be aware of the risks to patients in prescribing opioids.”

Adverse events involving opioids include dosing errors and improper monitoring of patients and drug interactions. Patients who have sleep apnea, are obese, or very ill—with such conditions as pulmonary disease, congestive heart failure, or impaired renal function—might be at higher risk for harm from opioids.

Getting opioid pain relief right is critically important, as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.

—Beth B. Murinson, MS, MD, PhD, associate professor, director of pain education, department of neurology, The Johns University Hopkins School of Medicine, Baltimore

“The alert was issued in response to concerns that opioid analgesics are among the top three drugs in which medication-related adverse events are reported to The Joint Commission,” Zhani says. “They also rank among the drugs most frequently associated with adverse drug events.”

Opioids are associated with numerous problems—underprescribing, overprescribing, tolerance, dependence, and drug abuse. To prevent accidental overuse, The Joint Commission recommends that healthcare organizations provide ongoing oversight of patients receiving these drugs. Pain-management specialists or pharmacists should review treatment plans and also track incidents involving opioids.

Harnessing available technology also helps improve prescribing safety. In addition to creating alerts for dosing limits, The Joint Commission suggests using “tall man” lettering in electronic ordering systems, conversion support to calculate correct dosages, and patient-controlled analgesia. Education and training in the safe use of opioids should be provided for clinicians, staff, and patients. And standardized tools should be employed to screen patients for risk factors, such as oversedation and respiratory depression.

Dr. Liao

“Opioids aren’t dangerous in themselves,” says Solomon Liao, MD, FAAHPM, a hospitalist and director of palliative-care services at the University of California at Irvine. “Opioids are dangerous when prescribers don’t know what they’re doing. It’s like the old saying, ‘Guns don’t kill people; people kill people.’”

Overdose deaths from opioid pain relievers have escalated, nearly quadrupling from 1999 to 2008. These deaths now exceed fatalities due to heroin and cocaine combined. In 2008, drug overdoses in the United States caused 36,450 deaths; opioid analgesics were involved in 14,800 (73.8%) of 20,044 prescription drug overdose deaths, according to the Centers for Disease Control and Prevention.1

Vital statistics data suggest that methadone is involved in one-third of opioid pain-reliever-related overdose deaths, even though it accounts for only a small percentage of prescriptions for opioid analgesics. The rate of methadone overdose deaths in the U.S. in 2009 was 5.5 times the rate in 1999, prompting an urgent call for interventions to address misuse and abuse.2

“The greatest safety concern The Joint Commission’s report cites is that sedation precedes respiratory depression in many cases, and clinicians need to pay more attention to that side effect and patients who are inherently at risk for developing respiratory problems related to opioids,” says Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar and clinical nurse specialist for pain relief at Massachusetts General Hospital in Boston.

A Double-Edged Sword

Opioids deliver good pain control with minimal adverse effects for some patients but not for others, and there is insufficient evidence to foresee who will fare well and who won’t. “What we can predict,” Arnstein says, “is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects.”

The risk of respiratory depression also mounts in those who are opioid-naïve, as well as in an increasingly obese population.

“This does not mean we withhold pain relief,” says Judith A. Paice, PhD, RN, a contributor to The Joint Commission’s alert and director of the cancer pain program in the hematology-oncology division at Northwestern University’s Feinberg School of Medicine. Instead, “we need to determine the most effective monitoring techniques in a setting where hospitals are cutting back on staffing,” she adds.

Other risk factors for respiratory depression include sleep apnea (correlated with obesity but also possible in the absence of excess weight), large thoracic or abdominal incisions, and use of other sedating drugs. Among patients in the chronic cancer pain or palliative-care setting, respiratory depression is highly unusual because dosages are increased gradually, Paice says. Strong consensus supports prescribing opioids for acute episodes of pain, as well as chronic management of cancer and other life-threatening illnesses, including HIV/AIDS and cardiac and neuromuscular conditions.

Considerable variations exist in screening for risk of opioid-induced sedation and hospital monitoring practices. There is also a shortage of information and no consensus on the advantages of costly technology-supported monitoring, such as pulse oximetry (measuring oxygen saturation) and capnography (measuring end-tidal carbon dioxide), in hospitalized patients receiving opioids for pain therapy, according to guidelines from the American Society for Pain Management Nursing.3

Jarzyna

Although technological monitoring adds valuable data to patient status, it does not replace frequent assessments—the most important intervention in detecting sedation before respiratory depression. Technological monitoring should be considered for patients at high risk for decline, says the guidelines’ lead author, Donna Jarzyna, MS, RN-BC, CNS-BC, an adult health clinical nurse specialist consulting in an alumna role for the University of Arizona Medical Center in Tucson. “Many organizations are currently making an effort,” she says, “to determine which patients should be monitored with a higher degree of intensity and with greater frequency.”

Patient-controlled analgesia (PCA) also has some limitations. In theory, it offers built-in safety features—if patients become too sedated, they can’t push a button for extra doses—but that isn’t always the case. For instance, some patients may have “stacked” three to four doses before sedation and respiratory depression develop. “When things go wrong with PCA, patients are four times more likely to be seriously harmed than when nurses administer the medications,” says Arnstein, who is a past president of the American Society for Pain Management Nursing. “Thus, vigilant nurse-supervised opioid therapy is vitally important.”

What we can predict is that certain patients—the very old, very young, very ill, and those receiving medicines that interact with opioids—are vulnerable to some of the more dangerous effects of the drug.

—Paul Arnstein, RN, PhD, FAAN, Connell Nursing Research Scholar, clinical nurse specialist for pain relief, Massachusetts General Hospital, Boston

Simple Steps Save Lives

Most critical events associated with opioids occur during the first 24 hours of post-operative care. Combined with close monitoring, understanding the risk factors for respiratory depression and making adjustments based on an individual’s needs and response helps prevent a precarious situation in which a patient vacillates quickly from a wide-awake status to a sleepy state.

“There’s a very progressive amount of sedation,” says Deb Gordon, RN, DNP, FAAN, a contributor to The Joint Commission’s alert and a teaching associate in the department of anesthesiology and pain medicine at the University of Washington in Seattle.

Dr. Gordon

Developing a pain treatment plan with a reassessment component is essential to exercising caution against potential harm from opioids.

“The Joint Commission’s guidance is wonderfully helpful and will benefit patients,” says Beth B. Murinson, MS, MD, PhD, associate professor and director of pain education in the department of neurology at Johns Hopkins University School of Medicine in Baltimore. “Getting opioid pain relief right is critically important as lives are hanging in the balance on both sides of this problem: Too little pain relief and millions will suffer; too much and lives are at risk.”

Hospitalists should be familiar with a few opioids that they feel comfortable prescribing, Dr. Murinson says. Be prepared to easily identify the major idiosyncratic effects and ordinary side effects of these medications and become well versed in opioid conversion.

“This is a classic problem in the field because, although the opioids are generally similar in their efficacy against pain, they have markedly different potencies against pain,” she explains. “A dose of 2 mg of morphine may need to be ‘converted’ to X mg of another opioid, depending on local practice patterns and preferences.”

Some drugs pose special risks. For example, transdermal fentanyl is “appropriate only for use in people who need opioid-level analgesia for an extended period of time and whose analgesic requirements are stable. This is not the case for folks with acute pain or who are just starting on opioids,” cautions Scott Strassels, PhD, PharmD, BCPS, assistant professor in the College of Pharmacy at the University of Texas in Austin and a board member of the American Pain Society. “Similarly, methadone is a good analgesic, but it requires very careful use due to its pharmacokinetic profile.”

Healthcare professionals from a variety of disciplines should be involved in pain-management efforts within a hospital setting. As for who takes the initiative, “it probably should be the person who is most qualified—be it a physician, nurse, or pharmacist,” Strassels says. “I’ve seen pharmacist-led teams, nurse-led teams, and those with physicians leading the effort.”

Clinicians who prescribe pain medications should be cognizant of nonpharmacologic alternatives to opioids. Multimodal options include physical therapy, acupuncture, manipulation or massage, and non-narcotic analgesics, such as acetaminophen and muscle relaxants. Non-narcotics may lower the dose of opioids needed to effectively manage pain, according to The Joint Commission.

The alert also provides information on suggested actions to avoid unintended consequences of using opioids. Hospitals should fully inform and provide written instructions to the patient and family or caregiver about the potential risks of tolerance, addiction, physical dependency, and withdrawal from opioids. When providing this information at discharge, the hospital also should list phone numbers to call if there are any questions.

In some unfortunate cases, opioids prescribed for pain also are used by patients’ family members, friends, and others. In such instances, says Northwestern’s Paice, usage occurs commonly with polypharmacy and without monitoring, and this contributes to an increased risk of death associated with opioids.

“There is concern that drugs prescribed for legitimate purposes are reaching the wrong hands,” Paice says. “We need to make the public, particularly patients and their family members, aware of safety strategies.”


Susan Kreimer is a freelance writer in New York City.

More Info for Hospitalists

Educational Options in Pain Medicine

  • The American Academy of Pain Medicine (www.painmed.org/store) offers a selection of pain education modules for a fee that can be studied for continuing medical education (CME) credits.
  • The American Pain Society (www.ampainsoc.org/education) provides reference materials (CME is not currently available) that are relevant to hospitalists seeking to incorporate strategies into practice.
  • The FDA’s “Blueprint for Prescriber Education for Extended-Release and Long-Acting Opioid Analgesics” helps clinicians balance the benefits of treating pain against the risks of serious adverse outcomes. Visit www.fda.gov and search “drug safety.”
  • The American Medical Association is in the process of re-releasing materials on pain education. The materials have undergone expert review and are geared toward the CME accreditation process. Visit www.ama-assn.org and click on the CME microsite.

—Susan Kreimer

References

  1. Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487-1492.
  2. Centers for Disease Control and Prevention. Vital signs: risk for overdose from methadone used for pain relief—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2012;61(26):493-497.
  3. Jarzyna D, Jungquist CR, Pasero C, et al. American Society for Pain Management Nursing guidelines on monitoring for opioid-induced sedation and respiratory depression. Pain Manag Nurs. 2011;12(3):118-145.

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