Pain vs Overdose: Hospitalists Are Caught in the Middle

Larry Beresford

Disclosures

August 12, 2016

Advice for Hospitalists

In the past, pain management advocates, including hospice and palliative care physicians, had pushed for more aggressive medical responses to the millions of Americans suffering from chronic pain, leading hospitals and other health providers to adopt "pain as a fifth vital sign" initiatives and start regularly asking patients to rate their pain on a scale of 0-10.

"Before, the paradigm was that we were undertreating pain, so there was a push for increased prescribing for pain," says Jeanie Youngwerth, MD, MA, who is both a hospitalist and director of the Palliative Care Service at the University of Colorado Hospital. "Now, regulatory folks are saying that we have to cut back. Our patients have real pain, and their chronic pain is exacerbated when they're in the hospital."

Patients could be referred to pain clinics for full work-ups and multidisciplinary strategies, but those clinics are getting more difficult to find, Dr Youngwerth says. Patients may not get to see their primary care physician for weeks or more after discharge.

"Generally, there is a poor support system for patients with pain after discharge from the hospital." One possible answer when there are concerns about opioid abuse or misuse is a consult from an addiction medicine specialist.

"We now have addiction medicine as a service, and that has been a helpful resource," Dr Youngwerth says—acknowledging, however, that most hospitals don't have this resource.

Kaylin A. Klie, MD, MA, is one of those consultants who practices addiction medicine and family medicine in the Departments of Psychiatry and Family Medicine for Denver Health. She has worked with patients in both the outpatient and inpatient settings. Dr Klie recommends that, when opioids are involved, hospitalists make a reasonable effort to contact the primary care physician and discuss the inpatient and outpatient pain plans while the patient is still in the hospital.

"When I get a discharge summary from the hospital, that doesn't give me a chance to discuss the plan of care. I know it can be difficult to reach community physicians, but it's important to try to speak to the doctor who prescribed and might be expected to continue prescribing the opioid analgesic."

Dr Klie offers another suggestion that is not yet widely practiced: discharging patients on opioids with a prescription for the opioid antagonist naloxone and providing training in how to use it. It's "just like how we would give glucagon to a diabetic patient in danger of low blood sugar," Dr Klie says.

A nonrandomized intervention study[4] showed that providing naloxone in primary care settings may reduce opioid-related adverse events. Because the risk for negative outcomes is low and many deaths from opioid overdoses occur in people who are taking their analgesics as ordered, Dr Klie says that she and other addiction specialists are working to make naloxone an over-the-counter drug.

Dr Klie also points out that it is becoming easier in many states to verify patients' opioid history with an online check of the state's prescription drug monitoring program.

"Opioids are sometimes better at reducing anxiety than pain. If you can give the patient something else that is targeted to their associated symptoms, that's harm reduction," she says. "Can we increase our level of comfort with adjuvant therapies, such as injections, topical medications, and anticonvulsants? Sending someone home with 4 weeks of opioid analgesics in order to avoid a readmission is bad medicine."

Dr Calcaterra thinks it would also be helpful if hospitals used patient navigators. These are typically non-medical professionals who counsel patients with cancer or other conditions and help guide them through a complex treatment process, who could sit down and talk with patients about their pain, their expectations, and their goals for treatment.

"That way, somebody is listening to the patients and they feel that their pain is being addressed medically in the best way possible," she says. "The main thing is that we've got to change patients' expectations regarding pain."

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