Clinical

Hospitalists struggle with opioid epidemic’s rising toll


 

Pushing for proactive solutions

Anupam Jena, MD, PhD, is a health care policy expert at Harvard Medical School, Boston.

Dr. Anupam Jena

One of the biggest unmet needs, according to multiple hospitalists, is a clear and uniform set of inpatient prescribing guidelines. A consensus document might address some of the high variability in opioid prescribing practices seen by experts, such as Dr. Jena. “That’s a big issue because it’s that variability that leads to adverse consequences for patients when the opioids are inappropriately prescribed either in terms of the frequency or terms of their dose,” he said.

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.

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