Guidance Recommends Hospitalized Patients With Acute Pain Try to Avoid Opioids

A new set of 16 recommendations released by the Society of Hospital Medicine (SHM) urges hospitalists, primary care physicians, nurse practitioners, physician assistants, and other clinicians to limit opioid use whenever possible for hospitalized patients with acute pain.

The consensus statements, published in the Journal of Hospital Medicine,¹ provide guidance about when to use opioids versus other pain methods. The journal is published by the SHM.

The recommendations suggest clinicians restrict the use of opioids to cases of severe pain or cases of moderate pain only in patients who do not respond to or cannot take non-opioid pain medications like acetaminophen or ibuprofen. The goal is to improve the safety of opioid use while in the hospital and upon discharge.

When using opioids, the recommendations call for prescribing the lowest effective doses for the shortest time possible, based on recent studies that demonstrate opioids' risks increase with dosage.

The recommendations also suggest using immediate-release opioid formulations and giving the drugs orally whenever possible.

Using long-acting opioids or administrating them intravenously have been shown to have greater risk of overdose and developing substance use disorder, the recommendations note.

Other recommendations stress the importance of educating patients, families, and caregivers about opioids as well as the risk of opioid diversion once the patient is home.

The recommendations also mention letting patients know that nondrug pain management alternatives may be available, such as cold or hot packs, chaplain or social work visits (possibly including mindfulness training), and physical therapy.

The SMH also recommends that providers order a bowel regimen to prevent opioid-induced constipation in patients receiving opioids, unless otherwise contraindicated.

Clinicians should also carefully consider the necessity of co-administration of opioids with other drugs that have sedative effects, whether benzodiazepines, nonbenzodiazepine sedative-hypnotics, muscle relaxants, sedating antidepressants, antipsychotics, or antihistamines.

The recommendations were developed after a review of almost a thousand opioid-prescribing guidelines.²

Excluded from the review were any guidelines that focused on palliative care, guidelines derived entirely from another guideline, and guidelines published before 2010. Also excluded were guidelines that focused on diseases like cancer, sickle cell anemia, low-back pain, or chronic pain.

Among the 4 remaining guidelines, the team found a lack of guidance specific to managing hospital patients with noncancer pain.

Pain is prevalent among hospitalized patients, occurring in 52% to 71% of patients in cross-sectional surveys. Opioid use is also common, with more than half of nonsurgical patients in US hospitals receiving at least 1 dose during a stay.

Studies have begun to examine how hospital prescribing contributes to long-term use. Among opioid-naïve patients admitted to the hospital, 15% to 25% fill an opioid prescription in the week after hospital discharge, 43% fill another opioid prescription 90 days postdischarge, and 15% meet the criteria for long-term use at 1 year.

With about 37 million discharges from US hospitals each year, these estimates suggest that hospitalization contributes to initiation of long-term opioid use in millions of adults each year.

"Hospital-based clinicians frequently treat patients with acute pain, and although opioids may sometimes be beneficial in this setting, they do carry the risk of adverse events including inadvertent overdose and physical dependence," said Shoshana J. Herzig, MD, MPH, lead author of both articles, in a statement. "This guidance is intended to help clinicians practicing medicine in the inpatient setting balance the benefits of opioid treatment against its risks."

"Clinicians tend to underestimate the benefit of non-opioid analgesics and overestimate the risks, while for opioids they overestimate the benefits and underestimate the risks,” said Herzig, an assistant professor of medicine at Harvard Medical School. “For most painful conditions, acetaminophen and non-steroidal anti-inflammatory drugs have been shown to be equally or more effective with less risk of harm than opioids."

References

1. Herzig SJ, Calcaterra SL, Mosher HJ, et al. Improving the safety of opioid use for acute noncancer pain in hospitalized adults: A consensus statement from the Society of Hospital Medicine. J Hosp Med. 2018(4):263-271. doi:10.12788/jhm.2980.

2. Herzig SJ, Calcaterra SL, Mosher HJ, et al. Safe opioid prescribing for acute noncancer pain in hospitalized adults: A systematic review of existing guidelines. J. Hosp. Med. 2018;13(4):256-262. doi:10.12788/jhm.2979.