Shoshana J. Herzig, MD, MPH, and Hillary J. Mosher, MFA, MD, FHM
The growth in opiate prescribing and associated increases in adverse events has created unique challenges for hospitalists, including how best to assess pain and opiate use disorders and how to safely prescribe opiates during hospitalization and at discharge.
These challenges are compounded by patient and system factors and a paucity of evidence-based guidelines to help guide safe administration of opiates in hospitalized patients. This can mean frustration for hospitalists and harm for patients.
Key takeaways for HM
- When assessing patients’ pain, it is crucial to differentiate between acute and chronic pain (or both) and whether it is nociceptive or neuropathic. Misclassification of pain contributes to inappropriate exposure and escalation of opiate therapy during hospitalization.
- Always consider nonopioid analgesics such as NSAIDs first and pair them with opiates. Studies in a variety of conditions have demonstrated that these are equally, if not more, effective, even for severe pain, such as with renal colic. Reserve opiates for moderate to severe pain.
- Always assess whether the benefits of initiating or continuing opioid therapy outweigh the risks for individual patients. There is no validated tool to predict risk for adverse events and/or opioid abuse disorder but a careful review of patient history can identify established risk factors (such as a history of mental illness or substance abuse disorders, renal impairment, or other comorbidities). In addition, nearly all states now have Prescription Drug Monitoring Programs, and hospitalists should consult these routinely when prescribing opiates.
- Always clearly discuss expectations and risks of opioid therapy, including the potential for development of opioid use disorders with hospitalized patients prior to initiation. Emphasize pain reduction rather than elimination and focus on functional goals such as improved mobility. Also, set expectations for stepping down treatment up front.
- Use the lowest effective dose of immediate-release opioids (preferably oral route) for shortest duration possible. Long acting opiates are associated with increased risk of adverse events, and their initiation should generally be avoided in hospitalized patients with noncancer pain.
- Minimize risk by avoiding concurrent administration of other medications with sedative properties, especially benzodiazepines, which have been found to significantly increase the risk of adverse events, including overdose.
- Recognize that chronic opioid use often begins with treatment of acute pain during hospitalization. Adopt best practice for discharge, including prescribing shorter courses whenever possible, discussing initiation, and changes or modifications in opiate therapy with patients’ primary care provider, and ensure timely postdischarge follow-up. Also consider coprescription of naloxone at discharge for higher risk patients.
Dr. Stella is a hospitalist in Denver and an editorial board member of The Hospitalist.