Rethinking Pain Can Help Hospitalists Fight Opioid Crisis

Marcia Frellick

May 03, 2017

LAS VEGAS — The goal of opioid treatment should be "tolerability, not absence of pain," said an expert here at the Society of Hospital Medicine 2017 Annual Meeting.

The traditional diagnostic and prescribing practices of hospitalists have inadvertently contributed to the increase in opioid overuse and overdoses, said Shoshana Herzig, MD, assistant professor of medicine at Harvard Medical School and director of hospital medicine research at Beth Israel Deaconess Medical Center in Boston.

"The message to patients should not be that the goal is to become pain free," she explained. "We should not be expecting opioids to decrease pain by more than 20% to 30%."

We should not be expecting opioids to decrease pain by more than 20% to 30%.

Hospitalists are starting to ask patients to rate pain in terms of how it affects physical or social function, such as getting out of bed, which is more informative than a straight 10-point pain scale, she said.

It is also important to determine whether patients have acute pain, chronic pain, or both, said Hilary Mosher, MD, from the Iowa City Veterans Affairs Health Care System in Iowa.

Chronic pain and acute pain require different treatments, she pointed out.

In a large study of hospitalized veterans, she and her team found that more than half of those hospitalized on a medical unit had a diagnosis of chronic pain.

Importantly, 40% of those patients had not taken opioids in the previous year, she reported, which indicates they were managing their pain in different ways. However, because they were likely to report pain in the hospital, they were at risk of being prescribed opioids during their stay.

The pattern of reflexively prescribing opioids when a patient in the hospital reports a high pain score needs to be broken, she said.

The three-item PEG scale — which evaluates average pain intensity (P), interference with enjoyment of life (E), and interference with general activity (G) — is recommended as a way to assess pain by the Centers for Disease Control and Prevention.

The patient intake form at her VA hospital has been adapted to differentiate acute from chronic pain, Dr Mosher reported.

On the new form, the first thing patients are asked is whether they are experiencing pain they would like the team to address that day. This reflects an understanding that patients live with pain, but it might not be new or acute. If they do report pain that needs to be addressed, they are asked about the nature, intensity, and location of the pain.

Their answers can help clinicians determine whether pain is chronic or acute and can help shape expectations for lowering pain in the hospital, she said.

It's a myth that opioids are the most effective medications to treat severe pain

To address abuse, prescribers should consider a nonopioid first. Some incorrectly assume that a patient who presents to the emergency department has probably failed alternative therapies, said Dr Herzig.

"It's a myth that opioids are the most effective medications to treat severe pain. In fact, for most pain, nonopioid analgesics are equally or more effective, with less risk for harm than opioids," she said.

Nonsteroidal anti-inflammatory drugs are among the most overlooked nonopioids, she added.

And every state except Missouri has a Prescription Drug Monitoring Program (PDMP), which can help raise red flags for substance abuse disorders and adverse events, she noted.

However, when Dr Herzig asked how many members of the audience check the PDMP database before prescribing, the response was lukewarm.

The low level of use is likely because "the interoperability just isn't there," she told Medscape Medical News. The PDMP is external to most medical record systems, requiring a separate login, and every state has designed its own database, some of which are very cumbersome, she explained.

Regulations that require prescribers to check the database differ in each state, but "regulations aside, we should be doing this," she said.

The PDMP can help physicians assess whether patients are doctor-shopping for opioids or have overlapping refills or rapid consumption, and can help them spot differences between patient-provided and PDMP-provided information.

Some hospitalists are unaware of the limitations of urine drug screens to detect opioids, Dr Herzig explained. In the emergency department, they are only useful if urine is obtained before opioid administration or if opioids are not administered.

And although the standard basic urine drug screen detects morphine, synthetic opioids, such as oxycodone, fentanyl, methadone, and buprenorphine, are not detected; those have to be requested separately. Hospitalists should know what drugs are in their hospital's standard panel, she advised.

Dr Herzig and Dr Mosher have disclosed no relevant financial relationships.

Society of Hospital Medicine (HM) 2017 Annual Meeting. Presented May 2, 2017.

Follow Medscape Internal Medicine on Twitter @MedscapeIM and Marcia Frellick @mfrellick


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