5 Takeaways on Inpatient Pain Management Amid the Opioid Epidemic

Inpatient pain management in the era of the US opioid epidemic can undoubtedly be complex and highly variable from patient to patient. Although opioid pain medications can be a necessary component of a pain management plan, it is crucial to ensure that patients do not later become dependent or addicted to them after discharge.

Consultant360 spoke with Theresa Vettese, MD, associate professor of medicine at Emory University School of Medicine, who shared key insights and dispelled common myths related to inpatient pain management amid the opioid epidemic. Here are Dr Vettese’s 5 key takeaways from her evidence-based approach to pain management in the acute hospital setting¹:

1. Have a transparent conversation with your patients about the end goals of treatment for acute, severe pain.

Dr Vettese: When managing patients in the acute hospital setting, the goal is to treat acute pain, improve function, and ensure that the risks and benefits of opioid pain medications are discussed with patients who receive them. Explain to your patients from the start that you will work with them to treat their pain using several different modalities, including opioid pain medications, and that any opioid pain medications initiated while they are hospitalized will be tapered throughout their stay as their acute pain improves.

For each patient’s safety, patients should be switched from intravenous to oral opioid pain medications as soon as possible. Oral opioids should be titrated throughout their stay as their pain improves, and non-opioid and non-drug treatments should be emphasized.

It is also key to ensure patients who are newly prescribed opioids while hospitalized do not remain on them indefinitely after discharge, because leftover medications can lead to dependency, opioid use disorder, or diversion to family and friends. A 2016 study published in JAMA Internal Medicine found that, among 623,957 hospitalizations of Medicare beneficiaries in 2011, 14.9% of patients were discharged from the hospital with newly prescribed opioid pain medications. Of those patients, 42.5% continued to take opioids more than 90 days after discharge.²

2. Maintain consistent contact with your patients’ primary care physicians about their inpatient pain management plan.

Dr Vettese: Because acute pain management often requires a multidisciplinary approach, it is very important for hospitalists to engage primary care physicians of patients who receive opioid pain medications during their hospital stay. In my own practice, if I see that a patient’s primary care physician refills their opioid pain medications regularly, I will touch base with their physician and let them know that I will not refill those prescriptions while the patient is hospitalized. Likewise, when I discharge a patient who initially did not come in with an opioid prescription with new opioid pain medications, I always call the primary care physician and ensure we are on the same page with the patient’s pain management plan.

3. Avoid amending outpatient opioid prescriptions while patients are hospitalized.

Dr Vettese: Many patients come into the hospital with existing, long-term opioid prescriptions for chronic pain. In these cases, I see it as the hospitalist’s responsibility to verify that the patient is taking those medications as an outpatient so that we can ensure the correct dosage and that we do not discontinue them in the hospital for any reason.

Sometimes, hospital medicine physicians may think they need to reduce opioid prescriptions in these patients, but I do not see this as an appropriate action. If a patient comes into the hospital with an existing opioid prescription, it should be continued safely, and hospitalists should then ensure that these patients follow up with their primary care physician.

On the other hand, many patients who come into the hospital with acute health problems tend to experience a worsening of their chronic pain, and they may request more oral pain medications, higher doses, or intravenous doses of pain medication. In these cases, it is important to communicate to them that their current opioid prescriptions will be continued while they are hospitalized, and other pain management modalities will be used as well. However, patients also need to know that their chronic pain is a long-term problem that will ultimately not be fixed in the acute hospital setting. Remind patients that you are here to help manage their pain safely while they are in the hospital, and that they can work with their primary care physician on an appropriate pain management plan for their needs.

4. Treat pain aggressively in patients with opioid use disorder.

Dr Vettese: As a hospitalist, I see many patients with complications of injection drug use, which can be very painful. A common myth related to treating acute, severe pain in patients with opioid use disorder or heroin use disorder is that they should not be treated with opioid pain medications, whether due to concern of worsening their addiction or that a patient will not respond to opioid pain medications because of their heroin addiction.

However, data strongly show that patients with opioid use disorder need to have severe pain treated aggressively with modalities including opioid pain medications.³ Uncontrolled pain that goes untreated actually leads to relapse more frequently than prescribing opioid pain medications to these patients.³

5. Provide naloxone to opioid-treated patients with a high risk of accidental overdose.

Dr Vettese: It is crucial to ensure that naloxone is provided to certain patients being treated with opioids to prevent unintentional overdoses. Specifically, naloxone should be supplied to a family member or someone close to opioid-treated patients with opioid use disorder and patients receiving high doses of opioid pain medications, including cancer patients.

—Christina Vogt

References:

1. Vettese T. Inpatient pain management in the era of the opioid epidemic. Presented at: American College of Physicians Internal Medicine Meeting 2019; April 11, 2019; Philadelphia, PA.

2. Jena AB, Goldman D, Karaca-Mandic P, et al. Hospital prescribing of opioids to Medicare beneficiaries. JAMA Intern Med. 2016;176(7):990-997. doi:10.1001/jamainternmed.2016.2737.

3. Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127-134. doi: 10.7326/0003-4819-144-2-200601170-00010.