Pain management among hospitalized patients can be challenging. Patients may have unrealistic notions about how their pain should be controlled, while physicians carry their own biases and experiences that influence pain management strategies.
Control of patient-perceived pain is an important quality indicator for hospitals, and patient-reported metrics are used to calculate federal incentive payments to acute care hospitals.1,2 Such a system incentivizes hospitals to encourage physicians to aggressively treat patient pain, in order to achieve better patient-reported pain control scores.3-6 In effect, these initiatives may unintentionally contribute to excessive opioid prescribing when non-opioid alternatives exist.5,7Balancing the risks and benefits of opioid prescribing is difficult when the physician faces pressure from the patient and health care system.8
Further complicating pain management in the hospital setting is the lack of a previous relationship between the patient and the hospitalist (who, unlike a primary care physician, may only be seeing the patient for the first time). Increasingly, hospitalists care for the majority of hospitalized patients.9 In contrast to a primary care physician who commonly has an established relationship with the patient, a hospitalist who sees a patient for the first time at a different hospital may be unaware of a patient’s drug or alcohol use or mental illness, all risk factors for opioid abuse or misuse.10,11 Such complicated issues can lead to both improper treatment of pain among hospitalized patients.
These variable and excessive opioid prescribing practices by hospital-based physicians contribute to increased opioid availability for diversion and abuse.
Hospitals Must Do More
Hospitalized patients often have pain-related diagnoses, so prescribing opioids is a common practice in the hospital setting. However, to date, hospital-based guidelines addressing opioid prescribing for acute (non-surgical, non-traumatic pain) are lacking. Guidelines from the Centers for Disease Control and Prevention, published in 2016, only offer recommendations for opioid prescribing for chronic pain in the outpatient setting.12 Within these guidelines are limited statements regarding the management of acute pain.
For instance, the guidelines state, in part:
“Acute pain can often be managed without opioids. When the diagnosis and severity of non-traumatic, non-surgical pain are reasonably assumed to warrant the use of opioids, clinicians should prescribe no greater quantity than needed for the expected duration for pain severe enough to require opioids, often three days or less.”12
While applying these guidelines for acute pain among medical patients might be appealing, it may be detrimental to the patient’s medical course. Hospitalized patients are sicker, and often have a higher burden of disease, compared with patients cared for in an outpatient setting. If an average of three days of opioid therapy is adequate to manage patients seen in the clinic, what is the average amount of time adequate to treat hospitalized patients? Presently, no clear recommendations for acute pain management exist. Hospital-based physicians must rely on clinical judgment and understanding of the disease course, the information available to them in the electronic medical record, and the patient’s own perception of their pain control when deciding upon an appropriate course of opioid medications at the time of hospital discharge. Inconsistent opioid prescribing from one provider to another contributes to increased opioids available for diversion, overdose and death.
Hospital physicians play a role in creating opioid-dependent patients. A study of hospitalized patients demonstrated that patients with no prior opioid use who were discharged from the hospital with a new opioid prescription had almost five times greater odds of becoming a chronic opioid user in one year compared to patients not discharged with an opioid.13
According to recent studies, increasing an opioid dose, greater opioid days-supply and opioid type (long acting to short acting) are highly associated with probability of progressing from opioid naivety (new use) to chronic opioid use.14,15
Opioids are frequently indicated for acute pain management at the time of hospital discharge. Navigating these complicated issues is time intensive and can be emotionally draining when a patient becomes upset with the pain management plan. Hospital physicians should limit their opioid day supply to the shortest duration as possible while recognizing their patient may return to the emergency department or their primary care physician if they feel their pain is inadequately controlled.
These outcomes are not a reflection of poor care, but rather expected, and part of a spectrum of quality health care delivery.
- Quality AfHRa, Hospital Consumer Assessment of Healthcare Providers and Systems HCAHPS Fact Sheet,2015.
- Mehta SJ, Patient Satisfaction Reporting and Its Implications for Patient Care, AMA Journal of Ethics, 17(7):616-621, 2015.
- Gupta A, Daigle S, Mojica J and Hurley RW, Patient perception of pain care in hospitals in the United States, Journal of Pain Research, 2:157-164, 2009.
- Gupta A, Lee LK, Mojica JJ, Nairizi A and George SJ, Patient perception of pain care in the United States: a 5-year comparative analysis of hospital consumer assessment of health care providers and systems, Pain Physician, 17(5):369-377, 2014.
- Zgierska A, Miller M and Rabago D, Patient satisfaction, prescription drug abuse, and potential unintended consequences, JAMA,307(13):1377-1378, 2012.
- Scott A, Sivey P, Ait Ouakrim D, et al, the effect of financial incentives on the quality of health care provided by primary care physicians, The Cochrane Database of Systematic Reviews,(9):Cd008451, 2011.
- Zgierska A, Rabago D and Miller MM, impact of patient satisfaction ratings on physicians and clinical care, Patient Preference and Adherence, 8:437-446, 2014.
- Manary MP, Boulding W, Staelin R and Glickman SW, the patient experience and health outcomes, The New England Journal of Medicine, 368(3):201-203, 2013.
- Wachter RM and Goldman L. Zero to 50,000 — The 20th Anniversary of the Hospitalist, New England Journal of Medicine,;375(11):1009-1011, 2016.
- Price AM, Ilgen MA and Bohnert AS, prevalence and correlates of nonmedical use of prescription opioids in patients seen in a residential drug and alcohol treatment program, Journal of Substance Abuse Treatment, 41(2):208-214, 2011.
- Sullivan MD, Edlund MJ, Zhang L, Unutzer J, Wells KB. Association between mental health disorders, problem drug use, and regular prescription opioid use. Archives of internal medicine. 2006;166(19):2087-2093.
- Dowell D, Haegerich TM and Chou R, CDC Guideline for Prescribing Opioids for Chronic Pain --United States,JAMA,315(15):1624-1645,2016.
- Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW and Binswanger IA, Opioid Prescribing at Hospital Discharge Contributes to Chronic Opioid Use, Journal of General Internal Medicine, 31(5):478-485, 2016.
- Deyo RA, Hallvik SE, Hildebran C, et al. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naive Patients: A Statewide Retrospective Cohort Study. Journal of general internal medicine. 2017;32(1):21-27.
- Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of Long-Term Opioid Use - United States, 2006-2015. MMWR Morbidity and mortality weekly report. 2017;66(10):265-269.