Author: Bob Kronemyer
A new consensus statement from the Society of Hospital Medicine on improving the safety of opioid prescribing for acute noncancer pain in hospitalized adults also addresses whether to use opioids in such a setting and how to enhance the safety of opioid dispensing at hospital discharge.
The statement’s 16 recommendations were published in the Journal of Hospital Medicine(2018;13:263-271).
“We all perceived there was a need for some degree of standardization in acute pain management practices across hospitals in the United States,” said Shoshana Herzig, MD, the director of hospital medicine research at Beth Israel Deaconess Medical Center in Boston, who was a member of the consensus working group. “We want to provide guidance to hospitalists, so that we have some standard of care and suggestions to try to make prescribing of opioids safer.”
Practitioners should be evaluating the risk-to-benefit ratio in all patients, and considering what risk factors the patient has for adverse outcomes associated with opioids as part of the decision to prescribe, according to Dr. Herzig. “We should be restricting use of opioids to pain that is either severe or moderate where alternative therapies have failed or are contraindicated,” she said.
Once the clinician has made the decision to prescribe opioids, several of the recommendations highlight prescribing practices to improve safety, including using the lowest dose possible for the shortest duration feasible, reevaluating the need for opioids on a daily basis and avoiding using intravenous opioids, unless necessary.
“Orally administered opioids are preferred in all circumstances where possible because intravenously administered opioids carry a higher risk for side effects, adverse events and medication errors,” Dr. Herzig said.
The recommendations for opioid prescribing at hospital discharge mainly revolve around providing patient education about risks and how to minimize those risks, plus prescribing the least amount of opioids necessary for the shortest duration needed.
Dr. Herzig believes that nearly all of the 16 recommendations should be common sense to any physician who is practicing in a hospital. Despite this, one recommendation that some hospitalists may not be so familiar with indicates that administering opioids orally is just as effective as those delivered intravenously, although the oral route takes 10 to 20 minutes longer for onset of effect.
Similarly, the recommendation to not initiate long-acting opioids for acute pain during hospitalization may be new to some physicians. “Most of the time, acute pain is expected to resolve over a period of days to weeks, so to start a long-acting opioid medication does not make a whole lot of sense because you want to be able to taper the opioids down as the pain improves, which is harder to do with a long-acting opioid,” Dr. Herzig said. “Also, patients in the hospital usually have a high likelihood for changes in renal function. A long-lasting opioid remains in the system [for] a prolonged period of time.”
Dr. Herzig anticipated that rates of opioid use will probably decline, due to adherence to the new guidelines and in light of the opioid crisis. “Providers are becoming increasingly cognizant of the risks associated with opioids, which previously had been underestimated. Hence, I believe opioids will be dispensed more judiciously.”
Ellen Battista, DNS, ANP, PNP, a nurse practitioner in private practice in Buffalo, N.Y., applauded the authors for attempting a generalized review of all acute pain and bringing to the floor some key issues. “However, my criticism is that not all acute pain is the same,” she said. “There are many operative surgeries that come with many types of outcome.”
For example, pain from a cholecystectomy may not have the same intensity for the same duration as a lumbar spine fusion surgery. “To state that acute pain resolves within the time framework of hospitalization is an overgeneralized statement of the fact,” Battista said.
The lack of adequate pain relief can hinder postoperative recovery and rehabilitation, according to Battista. “That being said, I am not a proponent of giving people large quantities of opioids, particularly without guidance.”
She said the process of postoperative pain management starts before the procedure, with expectations of the experience, methods to handle the pain, and the risks and benefits of treatment. “Thorough assessment of the individual/family prior to the operative procedure is imperative. This includes age of patient, history/current status of individual or family addiction, mental health risks, smoking history and a woman’s history of sexual abuse.”
Battista said tools for assessment of risk are valuable, even if they have not been thoroughly tested. “They serve to guide the clinician in evaluation. The consensus does not mention doing a urine toxicology in individuals for whom opioids may need to be prescribed.”
In addition, close follow-up of pain management after discharge is needed. “This has not been a common practice, but should occur to further mitigate risk and improve outcome,” she said.
Battista said the biggest problem with consensus statements is that their intended purpose can have a broader effect than what was intended. “These statements can be overgeneralized and placed as a pseudolaw with insurance carriers or made into real law. When this occurs, the decision no longer comes from the educated and licensed health care provider who has made a clinical decision based on the individual’s clinical situation. This puts the individual at risk for inadequate treatment of their acute pain.”