New guidance for inpatient opioid prescribing

 

ORLANDO – A new guidance statement for opioid prescribing for hospitalized adults who have acute noncancer pain has been issued by the Society for Hospital Medicine.

The statement comes after an exhaustive systematic review that found just four existing guidelines met inclusion criteria, though none focused specifically on acute pain in hospitalized adults.

Among the key issues taken from the existing guidelines and addressed in the new SHM guidance statement are deciding when opioids – or a nonopioid alternative – should be used, as well as selection of appropriate dose, route, and duration of administration. The guidance statement advises that clinicians prescribe the lowest effective opioid dose for the shortest duration possible.

Mike Stanczyk/MDedge News

Best practices for screening and monitoring before and during opioid initiation is another major focus, as is minimizing opioid-related adverse events, both by careful patient selection and by judicious prescribing.

Finally, the statement acknowledges that, when a discharge medication list includes an opioid prescription, there is potential risk for misuse or diversion. Accordingly, the recommendation is to limit the duration of outpatient prescribing to 7 days of medication, with consideration of a 3-5 day prescription.

An interactive session at the 2018 SHM annual meeting presenting the guidance statement focused less on marching through the guidance’s 16 specific statements, and more on teasing out the why, when, how – and how long – of inpatient opioid prescribing.

 

The well-attended session, led by two of the guideline authors, Shoshana Herzig, MD, MPH, and Teryl K. Nuckols, MD, FHM, began with Dr. Herzig, director of hospital medicine research at Beth Israel Deaconess Medical Center, Boston, making a compelling case for why guidance is needed for inpatient opioid prescribing for acute pain.

“Few would disagree that, at the end of the day, we are the final common pathway” for hospitalized patients who receive opioids, said Dr. Herzig. And there’s ample evidence that troublesome opioid prescribing is widespread, she said, adding that associated problems aren’t limited to such inpatient adverse events as falls, respiratory arrest, and acute kidney injury; plenty of opioid-exposed patients who leave the hospital continue to use opioids in problematic ways after discharge.

Of patients who were opioid naive and filled outpatient opioid prescriptions on discharge, “Almost half of patients were still using opioids 90 days later,” Dr. Herzig said. “Hospitals contribute to opioid initiation in millions of patients each year, so our prescribing patterns in the hospital do matter.”

“We tend to prescribe high doses,” said Dr. Herzig – an average of a 68-mg oral morphine equivalent (OME) dose on days that opioids were received, according to a 2014 study she coauthored. Overall, Dr. Herzig and her colleagues found that about 40% of patients who received opioids had a daily dose of at least 50 mg OME, and about a quarter received a daily dose at or exceeding 100 mg OME (Herzig et al. J Hosp Med. 2014 Feb;9[2]:73-81).

 

Further, she said, “We tend to prescribe a bit haphazardly.” The same study found wide variation in regional inpatient opioid-prescribing practices, with inpatients in the U.S. Midwest, South, and West seeing adjusted relative rates of exposure to opioids of 1.26, 1.33, and 1.37, compared with the Northeast, she said.

Mike Stanczyk/MDedge News

Among the more concerning findings, she said, was that “hospitals that prescribe opioids more frequently appear to do so less safely.” In hospitals that fell into the top quartile for inpatient opioid exposure, the overall rate of opioid-related adverse events was 0.39%, compared with 0.21% for hospitals in the bottom quartile of opioid prescribing, for an overall adjusted relative risk of 1.23 in opioid-exposed patients in the hospitals with the highest prescribing, said Dr. Herzig.

Dr. Nuckols, director of the division of general internal medicine at Cedars-Sinai Medical Center, Los Angeles, engaged attendees to identify challenges in acute pain management among hospitalized adults.

 

The audience was quick and prolific with answers, which included varying physician standards for opioid prescribing; patient expectations for pain management – and sometimes denial that opioid use has become a disorder; varying expectations for pain management among care team members who may be reluctant to let go of pain as “the fifth vital sign;” difficulty accessing and being reimbursed for nonpharmacologic strategies; and, acknowledged by all, patient satisfaction scores.

To this last point, Dr. Nuckols said that there have been “a few recent changes for the better.” The Joint Commission is revising its standards to move away from pain as a vital sign, toward a focused assessment of pain that considers how patients are responding to pain, as well as functional status. However, she said, “There aren’t any validated measures yet for how we’re going to do this.”

Similar shifts are underway with pain-related HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) questions, which have undergone a “big pullback” from an emphasis on complete control of pain, and now put more focus on whether caregivers asked about pain and talked with inpatients about ways to treat pain, said Dr. Nuckols.

Speaking to the process of developing the guidance statement, Dr. Nuckols said that “I think it’s important to note that the empirical literature about managing pain for inpatients … is almost nonexistent.” Of the four criteria that met inclusion criteria – “and we were tough raters when it comes to the guidelines” – most were based on expert consensus, she said, and most had primarily an outpatient focus.

 

Themes that emerged from the review process included consideration of a nonopioid strategy before initiating an opioid. These might include pharmacologic interventions such as acetaminophen or a nonsteroidal anti-inflammatory for nociceptive pain, pregabalin, gabapentin, or other medication to manage neuropathic pain, or nonpharmacologic interventions such as heat, ice, or distraction. All of these should also be considered as adjuncts to minimize opioid dosing as well, said Dr. Nuckols, citing well-documented synergy with multiple modalities of pain treatment.

Careful patient selection is also key, said Dr. Nuckols. She noted that she asks herself, “How likely is this patient to get into trouble?” with inpatient opioid administration. A concept that goes hand-in-hand, she said, is choosing the appropriate dose and route.

Dr. Herzig picked up this theme, noting that route of administration matters. A speedy route, such as intravenous administration, has been shown to reinforce the potentially addictive effect of opioids. There are times when IV is the route to use, such as when the patient can’t take medication by mouth or when immediate pain control truly is needed. However, oral medication is just as effective, albeit slightly slower acting, she said.

Conversion from IV to oral opioids is a potential time for trouble, said Dr. Herzig. “Always use an opioid conversion chart,” she said. Cross-tolerance can be incomplete between opioids, so safe practice is to begin with about 50% of the OME dose with the new medication and titrate up. And don’t use a long-acting opioid for acute pain, she said, noting that not only will there be a long half-life and washout period if the dose is too high, but patient risk for later opioid use disorder is also upped with this strategy. “You can always add more, but it’s hard to take away,” said Dr. Herzig.

 

On discharge, consider whether an opioid should be prescribed at all, said Dr. Herzig. The guidance statement advises generally prescribing less than a 7-day supply, with the rationale that, if posthospitalization acute pain is severe enough to require an opioid at that point, the patient should have outpatient follow-up.

This approach doesn’t undertreat outpatient pain, said Dr. Herzig, pointing to studies that show that, at discharge, “the majority of opioids that patients are getting, they are not taking – which tells us that by definition we are overprescribing.”

The authors of the guidance statement wanted to address two important topics that were not sufficiently evidence backed, Dr. Herzig said. They had hoped to give clear guidance about best practices for communication and follow-up with outpatient providers after hospital discharge. Though they didn’t find clear guidance in this area, “We do believe that outpatient providers need to be kept in the loop.”

A second area, currently a hot button topic both in the medical community and in the lay press, is whether a naloxone prescription should accompany an opioid prescription at discharge. “There just aren’t studies for this,” said Dr. Herzig.

The full text of the guidance statement may be found here: https://www.journalofhospitalmedicine.com/jhospmed/article/161927/hospital-medicine/improving-safety-opioid-use-acute-noncancer-pain.

 

ORLANDO – A new guidance statement for opioid prescribing for hospitalized adults who have acute noncancer pain has been issued by the Society for Hospital Medicine.

The statement comes after an exhaustive systematic review that found just four existing guidelines met inclusion criteria, though none focused specifically on acute pain in hospitalized adults.

Among the key issues taken from the existing guidelines and addressed in the new SHM guidance statement are deciding when opioids – or a nonopioid alternative – should be used, as well as selection of appropriate dose, route, and duration of administration. The guidance statement advises that clinicians prescribe the lowest effective opioid dose for the shortest duration possible.

Mike Stanczyk/MDedge News

Best practices for screening and monitoring before and during opioid initiation is another major focus, as is minimizing opioid-related adverse events, both by careful patient selection and by judicious prescribing.

Finally, the statement acknowledges that, when a discharge medication list includes an opioid prescription, there is potential risk for misuse or diversion. Accordingly, the recommendation is to limit the duration of outpatient prescribing to 7 days of medication, with consideration of a 3-5 day prescription.

An interactive session at the 2018 SHM annual meeting presenting the guidance statement focused less on marching through the guidance’s 16 specific statements, and more on teasing out the why, when, how – and how long – of inpatient opioid prescribing.

 

The well-attended session, led by two of the guideline authors, Shoshana Herzig, MD, MPH, and Teryl K. Nuckols, MD, FHM, began with Dr. Herzig, director of hospital medicine research at Beth Israel Deaconess Medical Center, Boston, making a compelling case for why guidance is needed for inpatient opioid prescribing for acute pain.

“Few would disagree that, at the end of the day, we are the final common pathway” for hospitalized patients who receive opioids, said Dr. Herzig. And there’s ample evidence that troublesome opioid prescribing is widespread, she said, adding that associated problems aren’t limited to such inpatient adverse events as falls, respiratory arrest, and acute kidney injury; plenty of opioid-exposed patients who leave the hospital continue to use opioids in problematic ways after discharge.

Of patients who were opioid naive and filled outpatient opioid prescriptions on discharge, “Almost half of patients were still using opioids 90 days later,” Dr. Herzig said. “Hospitals contribute to opioid initiation in millions of patients each year, so our prescribing patterns in the hospital do matter.”

“We tend to prescribe high doses,” said Dr. Herzig – an average of a 68-mg oral morphine equivalent (OME) dose on days that opioids were received, according to a 2014 study she coauthored. Overall, Dr. Herzig and her colleagues found that about 40% of patients who received opioids had a daily dose of at least 50 mg OME, and about a quarter received a daily dose at or exceeding 100 mg OME (Herzig et al. J Hosp Med. 2014 Feb;9[2]:73-81).

 

Further, she said, “We tend to prescribe a bit haphazardly.” The same study found wide variation in regional inpatient opioid-prescribing practices, with inpatients in the U.S. Midwest, South, and West seeing adjusted relative rates of exposure to opioids of 1.26, 1.33, and 1.37, compared with the Northeast, she said.

Mike Stanczyk/MDedge News

Among the more concerning findings, she said, was that “hospitals that prescribe opioids more frequently appear to do so less safely.” In hospitals that fell into the top quartile for inpatient opioid exposure, the overall rate of opioid-related adverse events was 0.39%, compared with 0.21% for hospitals in the bottom quartile of opioid prescribing, for an overall adjusted relative risk of 1.23 in opioid-exposed patients in the hospitals with the highest prescribing, said Dr. Herzig.

Dr. Nuckols, director of the division of general internal medicine at Cedars-Sinai Medical Center, Los Angeles, engaged attendees to identify challenges in acute pain management among hospitalized adults.

 

The audience was quick and prolific with answers, which included varying physician standards for opioid prescribing; patient expectations for pain management – and sometimes denial that opioid use has become a disorder; varying expectations for pain management among care team members who may be reluctant to let go of pain as “the fifth vital sign;” difficulty accessing and being reimbursed for nonpharmacologic strategies; and, acknowledged by all, patient satisfaction scores.

To this last point, Dr. Nuckols said that there have been “a few recent changes for the better.” The Joint Commission is revising its standards to move away from pain as a vital sign, toward a focused assessment of pain that considers how patients are responding to pain, as well as functional status. However, she said, “There aren’t any validated measures yet for how we’re going to do this.”

Similar shifts are underway with pain-related HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) questions, which have undergone a “big pullback” from an emphasis on complete control of pain, and now put more focus on whether caregivers asked about pain and talked with inpatients about ways to treat pain, said Dr. Nuckols.

Speaking to the process of developing the guidance statement, Dr. Nuckols said that “I think it’s important to note that the empirical literature about managing pain for inpatients … is almost nonexistent.” Of the four criteria that met inclusion criteria – “and we were tough raters when it comes to the guidelines” – most were based on expert consensus, she said, and most had primarily an outpatient focus.

 

Themes that emerged from the review process included consideration of a nonopioid strategy before initiating an opioid. These might include pharmacologic interventions such as acetaminophen or a nonsteroidal anti-inflammatory for nociceptive pain, pregabalin, gabapentin, or other medication to manage neuropathic pain, or nonpharmacologic interventions such as heat, ice, or distraction. All of these should also be considered as adjuncts to minimize opioid dosing as well, said Dr. Nuckols, citing well-documented synergy with multiple modalities of pain treatment.

Careful patient selection is also key, said Dr. Nuckols. She noted that she asks herself, “How likely is this patient to get into trouble?” with inpatient opioid administration. A concept that goes hand-in-hand, she said, is choosing the appropriate dose and route.

Dr. Herzig picked up this theme, noting that route of administration matters. A speedy route, such as intravenous administration, has been shown to reinforce the potentially addictive effect of opioids. There are times when IV is the route to use, such as when the patient can’t take medication by mouth or when immediate pain control truly is needed. However, oral medication is just as effective, albeit slightly slower acting, she said.

Conversion from IV to oral opioids is a potential time for trouble, said Dr. Herzig. “Always use an opioid conversion chart,” she said. Cross-tolerance can be incomplete between opioids, so safe practice is to begin with about 50% of the OME dose with the new medication and titrate up. And don’t use a long-acting opioid for acute pain, she said, noting that not only will there be a long half-life and washout period if the dose is too high, but patient risk for later opioid use disorder is also upped with this strategy. “You can always add more, but it’s hard to take away,” said Dr. Herzig.

 

On discharge, consider whether an opioid should be prescribed at all, said Dr. Herzig. The guidance statement advises generally prescribing less than a 7-day supply, with the rationale that, if posthospitalization acute pain is severe enough to require an opioid at that point, the patient should have outpatient follow-up.

This approach doesn’t undertreat outpatient pain, said Dr. Herzig, pointing to studies that show that, at discharge, “the majority of opioids that patients are getting, they are not taking – which tells us that by definition we are overprescribing.”

The authors of the guidance statement wanted to address two important topics that were not sufficiently evidence backed, Dr. Herzig said. They had hoped to give clear guidance about best practices for communication and follow-up with outpatient providers after hospital discharge. Though they didn’t find clear guidance in this area, “We do believe that outpatient providers need to be kept in the loop.”

A second area, currently a hot button topic both in the medical community and in the lay press, is whether a naloxone prescription should accompany an opioid prescription at discharge. “There just aren’t studies for this,” said Dr. Herzig.

The full text of the guidance statement may be found here: https://www.journalofhospitalmedicine.com/jhospmed/article/161927/hospital-medicine/improving-safety-opioid-use-acute-noncancer-pain.

 

ORLANDO – A new guidance statement for opioid prescribing for hospitalized adults who have acute noncancer pain has been issued by the Society for Hospital Medicine.

The statement comes after an exhaustive systematic review that found just four existing guidelines met inclusion criteria, though none focused specifically on acute pain in hospitalized adults.

Among the key issues taken from the existing guidelines and addressed in the new SHM guidance statement are deciding when opioids – or a nonopioid alternative – should be used, as well as selection of appropriate dose, route, and duration of administration. The guidance statement advises that clinicians prescribe the lowest effective opioid dose for the shortest duration possible.

Mike Stanczyk/MDedge News

Best practices for screening and monitoring before and during opioid initiation is another major focus, as is minimizing opioid-related adverse events, both by careful patient selection and by judicious prescribing.

Finally, the statement acknowledges that, when a discharge medication list includes an opioid prescription, there is potential risk for misuse or diversion. Accordingly, the recommendation is to limit the duration of outpatient prescribing to 7 days of medication, with consideration of a 3-5 day prescription.

An interactive session at the 2018 SHM annual meeting presenting the guidance statement focused less on marching through the guidance’s 16 specific statements, and more on teasing out the why, when, how – and how long – of inpatient opioid prescribing.

 

The well-attended session, led by two of the guideline authors, Shoshana Herzig, MD, MPH, and Teryl K. Nuckols, MD, FHM, began with Dr. Herzig, director of hospital medicine research at Beth Israel Deaconess Medical Center, Boston, making a compelling case for why guidance is needed for inpatient opioid prescribing for acute pain.

“Few would disagree that, at the end of the day, we are the final common pathway” for hospitalized patients who receive opioids, said Dr. Herzig. And there’s ample evidence that troublesome opioid prescribing is widespread, she said, adding that associated problems aren’t limited to such inpatient adverse events as falls, respiratory arrest, and acute kidney injury; plenty of opioid-exposed patients who leave the hospital continue to use opioids in problematic ways after discharge.

Of patients who were opioid naive and filled outpatient opioid prescriptions on discharge, “Almost half of patients were still using opioids 90 days later,” Dr. Herzig said. “Hospitals contribute to opioid initiation in millions of patients each year, so our prescribing patterns in the hospital do matter.”

“We tend to prescribe high doses,” said Dr. Herzig – an average of a 68-mg oral morphine equivalent (OME) dose on days that opioids were received, according to a 2014 study she coauthored. Overall, Dr. Herzig and her colleagues found that about 40% of patients who received opioids had a daily dose of at least 50 mg OME, and about a quarter received a daily dose at or exceeding 100 mg OME (Herzig et al. J Hosp Med. 2014 Feb;9[2]:73-81).

 

Further, she said, “We tend to prescribe a bit haphazardly.” The same study found wide variation in regional inpatient opioid-prescribing practices, with inpatients in the U.S. Midwest, South, and West seeing adjusted relative rates of exposure to opioids of 1.26, 1.33, and 1.37, compared with the Northeast, she said.

Mike Stanczyk/MDedge News

Among the more concerning findings, she said, was that “hospitals that prescribe opioids more frequently appear to do so less safely.” In hospitals that fell into the top quartile for inpatient opioid exposure, the overall rate of opioid-related adverse events was 0.39%, compared with 0.21% for hospitals in the bottom quartile of opioid prescribing, for an overall adjusted relative risk of 1.23 in opioid-exposed patients in the hospitals with the highest prescribing, said Dr. Herzig.

Dr. Nuckols, director of the division of general internal medicine at Cedars-Sinai Medical Center, Los Angeles, engaged attendees to identify challenges in acute pain management among hospitalized adults.

 

The audience was quick and prolific with answers, which included varying physician standards for opioid prescribing; patient expectations for pain management – and sometimes denial that opioid use has become a disorder; varying expectations for pain management among care team members who may be reluctant to let go of pain as “the fifth vital sign;” difficulty accessing and being reimbursed for nonpharmacologic strategies; and, acknowledged by all, patient satisfaction scores.

To this last point, Dr. Nuckols said that there have been “a few recent changes for the better.” The Joint Commission is revising its standards to move away from pain as a vital sign, toward a focused assessment of pain that considers how patients are responding to pain, as well as functional status. However, she said, “There aren’t any validated measures yet for how we’re going to do this.”

Similar shifts are underway with pain-related HCAHPS (the Hospital Consumer Assessment of Healthcare Providers and Systems) questions, which have undergone a “big pullback” from an emphasis on complete control of pain, and now put more focus on whether caregivers asked about pain and talked with inpatients about ways to treat pain, said Dr. Nuckols.

Speaking to the process of developing the guidance statement, Dr. Nuckols said that “I think it’s important to note that the empirical literature about managing pain for inpatients … is almost nonexistent.” Of the four criteria that met inclusion criteria – “and we were tough raters when it comes to the guidelines” – most were based on expert consensus, she said, and most had primarily an outpatient focus.

 

Themes that emerged from the review process included consideration of a nonopioid strategy before initiating an opioid. These might include pharmacologic interventions such as acetaminophen or a nonsteroidal anti-inflammatory for nociceptive pain, pregabalin, gabapentin, or other medication to manage neuropathic pain, or nonpharmacologic interventions such as heat, ice, or distraction. All of these should also be considered as adjuncts to minimize opioid dosing as well, said Dr. Nuckols, citing well-documented synergy with multiple modalities of pain treatment.

Careful patient selection is also key, said Dr. Nuckols. She noted that she asks herself, “How likely is this patient to get into trouble?” with inpatient opioid administration. A concept that goes hand-in-hand, she said, is choosing the appropriate dose and route.

Dr. Herzig picked up this theme, noting that route of administration matters. A speedy route, such as intravenous administration, has been shown to reinforce the potentially addictive effect of opioids. There are times when IV is the route to use, such as when the patient can’t take medication by mouth or when immediate pain control truly is needed. However, oral medication is just as effective, albeit slightly slower acting, she said.

Conversion from IV to oral opioids is a potential time for trouble, said Dr. Herzig. “Always use an opioid conversion chart,” she said. Cross-tolerance can be incomplete between opioids, so safe practice is to begin with about 50% of the OME dose with the new medication and titrate up. And don’t use a long-acting opioid for acute pain, she said, noting that not only will there be a long half-life and washout period if the dose is too high, but patient risk for later opioid use disorder is also upped with this strategy. “You can always add more, but it’s hard to take away,” said Dr. Herzig.

 

On discharge, consider whether an opioid should be prescribed at all, said Dr. Herzig. The guidance statement advises generally prescribing less than a 7-day supply, with the rationale that, if posthospitalization acute pain is severe enough to require an opioid at that point, the patient should have outpatient follow-up.

This approach doesn’t undertreat outpatient pain, said Dr. Herzig, pointing to studies that show that, at discharge, “the majority of opioids that patients are getting, they are not taking – which tells us that by definition we are overprescribing.”

The authors of the guidance statement wanted to address two important topics that were not sufficiently evidence backed, Dr. Herzig said. They had hoped to give clear guidance about best practices for communication and follow-up with outpatient providers after hospital discharge. Though they didn’t find clear guidance in this area, “We do believe that outpatient providers need to be kept in the loop.”

A second area, currently a hot button topic both in the medical community and in the lay press, is whether a naloxone prescription should accompany an opioid prescription at discharge. “There just aren’t studies for this,” said Dr. Herzig.

The full text of the guidance statement may be found here: https://www.journalofhospitalmedicine.com/jhospmed/article/161927/hospital-medicine/improving-safety-opioid-use-acute-noncancer-pain.