In the United States, we are currently experiencing an opioid epidemic. The rate of opioid-related overdose deaths has reached an all-time high. Hospitalists manage a large number of patients admitted to hospitals in the U.S., and pain is a frequent symptom among these patients.
My colleagues and I wanted to explore hospitalists’ attitudes, beliefs, and practices associated with opioid prescribing during hospitalization and at discharge. In this way, we can begin a conversation about how opioids have impacted the physician’s day to day clinical practice.
For our study, published in the Journal of Hospital Medicine ( doi: 10.1002/jhm.2602 ), we recruited and interviewed 25 hospitalists working in a variety of hospital settings, including two university hospitals, a safety-net hospital, a Veterans Affairs hospital, and a private hospital, located in Colorado and South Carolina. All 25 hospitalists were trained in internal medicine and the majority of them had completed residency within the past 5 to 10 years (48%).
Hospitalists perceived limited success in managing acute exacerbations of chronic pain with opioids, but felt confident in their ability to control acute pain with opioids. They recounted negative sentinel events with their patients that impacted their opioid prescribing practices. Hospitalists described prescribing opioids as a pragmatic tool to facilitate hospital discharges or prevent readmissions, which left them feeling conflicted about how this practice could impact their patients over the long term.
Hospitalists also described feeling uncomfortable treating hospitalized patients with acute exacerbations of a chronic pain condition. One physician said of his experience, “You never get an adequate level of pain control and you keep adding the doses up, and they get habituated.” Another physician described his challenge with controlling chronic pain in hospitalized patients. He said, “Of course their pain is not controlled, because their pain is never going to be less than 5 out of 10. And no opioid is going to get them there, unless they are unconscious.”
Negative sentinel events influenced how hospitalists prescribed opioids in their clinical practice. One physician reflected on an avoidable in-hospital overdose death, which left her more guarded when prescribing opioids. “I’ve had an experience where my patient overdosed,” she said. “She crushed up the oxycodone we were giving her in the hospital, shot it up in her central line, and died.”
Hospitalists described past experiences with patients who altered opioid prescriptions for personal gain. One hospitalist recounted such an experience, saying the patient had “forged my script and changed it from 18 pills to 180 pills.” The physician added, “I got a call from the DEA… I think she [the patient] is in prison now.”
These experiences inspired hospitalists to adopt strategies around opioid prescribing that would make it hard for a patient to jeopardize their DEA license. One physician said, “When I write the prescription, I put the name of the patient on the paper prescription with the patient’s sticker on top. I don’t want the patients to pull it off and sell the prescriptions. Especially when it is my license.”
Hospitalists felt institutional pressure to reduce hospital readmissions and to facilitate discharges. Uncontrolled pain often prolongs a hospital admission. Physicians viewed opioid prescriptions as a pragmatic tool to buffer against readmission or long hospital stays, in order to save health care dollars. On physician described his thoughts on opioid prescribing and efficiency: “If the patient comes back [to the hospital] and gets readmitted when they don’t have pain medicine, it’s a $3,000, 2-day stay in the hospital. When they have pain medicine, they stay out of the hospital. That is utterly pragmatic.”
While opioid prescribing at discharge may improve efficiency and reduce health care costs, one hospitalist also described his discomfort with the practice: “At times, especially when a patient lacks a diagnosis which is known to cause pain [opioid prescribing to prevent readmissions], it can feel cheap and dirty.”
Our study concluded that strategies to provide adequate pain relief to hospitalized patients, which allowed hospitalists to safely and optimally prescribe opioids while maintaining current standards of efficiency, are urgently needed.
Currently, our group is developing predictive tools to be embedded within the electronic medical record to inform physicians about their patient’s future risk for chronic opioid use or opioid use disorders. The goal is to inform physicians, to assist them in making safe, patient-centered, and informed opioid prescribing decisions.
Dr. Calcaterra practices in the Department of Hospital Medicine, Denver Health Medical Center, and is Assistant Professor of Medicine at the University of Colorado School of Medicine, Aurora. She reported having no financial disclosures.