Pain vs Overdose: Hospitalists Are Caught in the Middle

Larry Beresford


August 12, 2016

Hospitalists are struggling amidst a growing national clamor to tighten controls on prescribing opioid analgesics, particularly for patients who have chronic nonterminal or nonmalignant pain, hospital medicine leaders told Medscape.

The Centers for Disease Control and Prevention and other groups have documented a national epidemic of prescription opioid overdoses, which have quadrupled in number since 1999.[1] Hospitalists, who treat pain in hospitalized patients and must often include pain management as part of their discharge plans, find themselves stuggling with how to balance pain relief with the risk that a patient will overdose, a recent study reports. A survey of hospitalists' attitudes regarding opioid prescribing, published in August in the Journal of Hospital Medicine, found that although hospitalists felt confident in their ability to control acute pain using opioids, they felt less success and satisfaction when managing acute exacerbations of chronic pain in hospitalized patients.[2]

New CDC guidelines[3] focus on when to initiate or continue opioids for chronic pain outside of active treatment, palliative care, or end-of-life care and how to assess risk and address harms of opioid use. However, they "may be at odds with the priorities of current hospital care, which focus on patient-perceived pain control rather than potential long-term consequences of opioid use," hospitalist Susan L. Calcaterra, MD, MPH, from Denver Health Medical Center, writes in the Journal of Hospital Medicine article.

In 2015, Dr Calcaterra and colleagues conducted 25 in-depth, semistructured interviews on a convenience sample—a type of nonprobability sampling made up of people who are easy to reach—of hospitalists and found that opioids may be prescribed as a tool to improve efficiency in the hospital and prevent readmission of patients who run out of their pain medications.[2]

"I think physicians overprescribe opioids because we don't want people to bounce back to the hospital," noted a survey participant. "We don't want them to have acute pain at home and have to go back to the emergency department to be readmitted."

Dr Calcaterra tells Medscape that she wanted to better understand hospitalists' perspectives on opioid prescribing.

"Sometimes it goes beyond treating pain. Some physicians said that it was their impression that the patient is more likely to come back to the hospital because of uncontrolled pain, so it would save the system money to give a few extra opioid tablets at discharge."

She emphasizes the essential distinctions made in the new CDC guidelines between chronic and acute pain, such as postsurgical pain,and between cancer-related pain and chronic, noncancer pain—such as low back pain or fibromyalgia, for example—for which there is less evidence that opioids are safe or effective.

"We're probably doing a disservice to some patients," she says, by exposing them to medications that have not been shown to be effective but come with serious risks.

The study's authors called for the development of new strategies for providing adequate pain relief to hospitalized patients. "As a hospitalist, you do the best you can. You talk to the patient and try to get an understanding of their goals of care, and go forward from there. It's very uncomfortable for the hospitalist who doesn't know the patient's history," Dr Calcaterra ays.

Hospitalists are also pressured to generate high patient satisfaction scores—which can be difficult to achieve if the doctor doesn't give patients pain medications on demand, because pain management is a key indicator in hospital quality measures, Dr Calcaterra says.


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