Tips for Treating Pain in Hospitalized Patients

Larry Beresford


September 03, 2015

The Pain of Treating Pain

The Centers for Disease Control and Prevention recently highlighted an alarming rise in heroin addiction and death, with prescription opioid analgesics named as the greatest risk factor driving this epidemic.[1]

Add to that an accompanying epidemic of overdose deaths from prescription analgesics, which has quadrupled over the course of the decade ending in 2012,[2] hospitalists, like all clinicians, are challenged to heed the risks of abuse, misuse, and diversion of opioids as they try to address the pain that many of their patients suffer.

The Institute of Medicine has estimated that 100 million Americans suffer from chronic pain, while two recent studies[3,4] by Richard J. Lin, MD, and colleagues at Weill Cornell Medical College in New York City conclude that the quality of acute inpatient pain management remains suboptimal and poorly understood, with many patients having "frequent prolonged and unrelieved severe pain episodes."

Tips for Treating Pain

Judith Paice, PhD, RN, of the palliative and hospice care service at Northwestern University in Chicago, Illinois, agreed that many hospitalized patients do suffer and that many hospital-based physicians and pharmacists have not been adequately trained in pain treatment.

"What can hospitalists do to make sure the patient is safe, their license is safe, and the community is safe?" she questioned. "To meet those three goals, you must learn to do adequate pain assessments, including an assessment for the risk of misuse." Then, on the basis of the results of those assessments, risk-stratify the patients, she added.

Eric Roeland, MD, an oncology and palliative care physician at the University of California-San Diego, who has presented on pain management issues at recent national conferences of the Society of Hospital Medicine, urges hospitalists to take pain seriously and do a complex assessment of all patients who present with pain.

"Hospitalists see pain all the time, and these can be really tough cases. People who abuse opioids are a minority of the patients hospitalists will see—but they're a memorable minority," Dr Roeland says.

"I encourage my colleagues to [use pain assessment tools] with every patient. I set it up as routine practice with new patients. I've had patients with 'colorful' pasts who, when I go through the assessment process, say, 'Thanks, Doc,'" Dr Roeland said.

He encourages hospitalists to get comfortable with the opioid conversion charts, common titrations, and recommended starting doses for analgesics. "And know when maximum drug concentration occurs based on route of administration, because analgesia corresponds to concentration."

There are important differences between tolerance, when the body gets used to the drug; physical dependence; and withdrawal, when the drug is suddenly stopped. As well, there is a difference between addiction, "which to me is when people are willing to lie, cheat, or steal to get the drug," said Dr Roeland, and pseudo-addiction, when patients are focused on obtaining pain medications and may display aberrant behaviors in the setting of poorly controlled, undertreated pain.

"Our job is to ensure that patients who are labeled as addicts are not actually 'drug seeking' because their pain is so poorly treated," he said, comparing pain management to diabetes management, with a need to regularly reassess in response to changes in the patient's condition.”

Also remember to watch for side effects of opioid analgesics.

"The three most common side effects are nausea, for which a preventive antiemetic may be in order, especially with opioid-naive patients; pruritus, which should not be treated with diphenhydramine but with newer nonsedating antihistamines; and constipation," Dr Roeland explained.

Unlike the first two, which tend to fade as the patient gets used to the drug, Dr Roeland said, "We don't see that with constipation for patients on opioids." Constipation has to do with motility, he adds, so the key is to give stimulant laxatives such as senna or bisacodyl, not stool softeners.

Pain Assessment Tools

There are tools available for assessing the risk for misuse, including the Screener and Opioid Assessment for Patients with Pain (SOAPP) and the Opioid Risk Tool. Consulting state prescription drug monitoring programs, which have been established online in every state except Missouri, will help prescribing physicians identify patients who doctor-shop for drugs.

And a urine test can tell what drugs the patient is actually taking—or not taking—relative to what they have been prescribed. Even a quick phone call to the patient's pharmacist or primary care physician can help the hospitalist get to the bottom of patients' pain needs and issues, according to Dr Roeland.


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