The Centers for Disease Control and Prevention (CDC) issued 12 recommendations about opioid prescribing to treat chronic pain outside of active cancer treatment, palliative care, and end-of-life care.
The recommendations are intended to improve communication about the benefits and risks, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy. They were published in the April 19 Journal of the American Medical Association.
The recommendations focused on 3 areas: starting or continuing opioids for chronic pain; opioid selection, dosage, duration, follow-up, and discontinuation; and assessing risk and addressing harms of opioid use.
Recommendations relevant to hospitalists include:
- Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioids only if expected benefits for both pain and function outweigh risks to the patient.
- When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release or long-acting opioids.
- Clinicians should prescribe the lowest effective dosage to start. Clinicians should carefully reassess evidence of individual benefits and risks when increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid or carefully justify a decision to increase dosage to 90 MME or more per day.
- When opioids are used for acute pain, clinicians should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
- Clinicians should review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose.
- Clinicians should avoid prescribing opioids at the same time as benzodiazepines whenever possible.
- Clinicians should offer or arrange treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
The authors wrote that more research is needed to fill critical evidence gaps, but noted that “given that chronic pain is a significant public health problem, the risks associated with long-term opioid therapy, the availability of effective alternative treatment options for pain, and the potential for improvement in the quality of health care with the implementation of recommended practices, a guideline for prescribing is warranted with currently available evidence.”
ACP issued a statement of support for the guidelines. The CDC included a number of ACP recommendations made in response to a mid-January draft guideline, including acknowledgment of the current limited, but emerging evidence related to the treatment of pain using opioids, recognition of individual patient needs, and recognition of coverage and workforce barriers to non-opioid treatment of pain.
In response to public health concerns over the adverse impact of opioid misuse, ACP has developed new patient education resources related to chronic pain management and safe opioid use, available online. Choose “Browse Patient Education,” then browse by topic and condition.
Studies of resuscitation address timing of shocks, epinephrine
For patients having an inpatient cardiac arrest, second shocks may be coming too late and epinephrine too early, according to 2 recent studies based on Get With The Guidelines-Resuscitation data.
Guidelines previously called for “stacked” shocks with minimal time delay between the defibrillation attempts for persistent ventricular tachycardia or ventricular fibrillation (VT/VF), the first study noted. But in 2005, the guidelines were revised to recommend deferring a second attempt at defibrillation to allow time for chest compressions. To examine how clinical practice has changed over time, researchers examined 2,733 patients with persistent VT/VF after inpatient cardiac arrest and a defibrillation attempt in 172 hospitals.
Among patients with persistent VT/VF after the first defibrillation, 1,121 (41%) received a deferred second attempt, defined as occurring more than a minute after the first attempt. The proportion of patients receiving a deferred second defibrillation increased from 26% in 2004 to 57% in 2012 (P<0.001 for trend). Unadjusted patient outcomes were significantly worse when the second defibrillation was deferred instead of early (57.4% vs. 62.5% for return of spontaneous circulation, 38.4% vs. 43.6% for survival to 24 hours, and 24.7% vs. 30.8% for survival to hospital discharge; P<0.01 for all comparisons).
“These findings stand in contrast to current resuscitation guidelines that emphasize two minutes of chest compressions between defibrillation attempts as optimal care for persistent VT/VF in hospital,” the authors said. They questioned the specific benefit of deferred second defibrillation attempts for inpatients, noting that the study found the first defibrillation attempt to be successful in less than 70% of inpatients, compared to the greater than 90% rate observed outside the hospital. “As a result, understanding the appropriate balance between defibrillation for rhythm termination and minimization of interruptions to chest compression could have even greater implications for in hospital [arrests],” the authors said.
The second study looked at early administration of epinephrine for inpatients with cardiac arrest and a shockable rhythm. Currently, the American Heart Association (AHA) recommends epinephrine after the second defibrillation, while the European Resuscitation Council recommends it after the third defibrillation. Clinical practice patterns suggest that epinephrine is used even earlier, so an international team of researchers set out to describe the use of epinephrine during inpatient cardiac arrest and to assess compliance with AHA recommendations.
Researchers looked at data from 2,978 patients with cardiac arrest at more than 300 U.S. hospitals. In the study, 1,510 (51%) patients received epinephrine within 2 minutes after the first defibrillation, contrary to current AHA guidelines. Epinephrine given within the first 2 minutes after the first defibrillation was associated with decreased odds of survival in the propensity score matched analysis (odds ratio [OR], 0.70; 95% CI, 0.59 to 0.82; P<0.001). Early epinephrine administration was also associated with a decreased odds of return of spontaneous circulation (OR, 0.71; 95% CI, 0.60 to 0.83; P<0.001) and good functional outcome (OR, 0.69; 95% CI, 0.58 to 0.83; P<0.001).
An editorial stated that the results from the 2 studies should inform medical practice, continuing, “[T]he finding of widespread non-adherence with clinical guidelines should prompt those responsible for organizing or delivering advanced life support to review their practice and ensure that it is informed by the latest clinical guidelines.” The editorialists added that while “the jury remains out” on the safety or effectiveness of epinephrine in cardiac arrest, adrenaline [epinephrine] should be given “in accordance with current guidelines, and it should be deferred until at least after the second shock has been delivered.”
Both studies and the editorial were published online by The BMJ on April 6.
Factors and score identify preventable 30-day readmissions
Two recent studies offered data to inform efforts to prevent avoidable 30-day hospital readmissions.
The first was an observational study of 1,000 general medicine patients treated at 12 U.S. academic medical centers and readmitted within 30 days of discharge between April 1, 2012 and March 31, 2013. To determine whether these readmissions could have been prevented, researchers surveyed patients and physicians, reviewed documentation, and had 2 physicians review each case. Based on these factors, they concluded that 26.9% of the readmissions were potentially preventable.
Factors that the study found most strongly associated with preventable readmissions were ED decision making about readmission (adjusted odds ratio [aOR], 9.13; 95% CI, 5.23 to 15.95), failure to relay important information to outpatient clinicians (aOR, 4.19; 95% CI, 2.17 to 8.09), too-early discharge (aOR, 3.88; 95% CI, 2.44 to 6.17), and lack of discussion of care goals (aOR, 3.84; 95% CI, 1.39 to 10.64). The researchers found that ED decision making affected 9.0% of potentially preventable readmissions, followed by premature discharge (8.7%), inability to keep postdischarge appointments (8.3%), and lack of awareness of whom to contact after discharge (6.2%). Patient reports of care processes and satisfaction were not associated with admission preventability. Also, while functional status has been found to be a risk factor for readmission, it was not associated with potential preventability.
The authors calculated that about half of the potentially preventable admissions may have resulted from gaps in care during the initial inpatient stay. They noted that the finding regarding ED decision making is not a critique of ED clinicians “but a limitation of the health system itself.” The study's results should be used to prioritize and monitor the effects of efforts to reduce readmissions. “High-priority areas for improvement efforts include improved communication among health care teams and between health care professionals and patients, greater attention to patients' readiness for discharge, enhanced disease monitoring, and better support for patient self-management,” the authors said.
An accompanying editorial noted that future research should focus on “how to improve advanced care planning around the time of care transition” and “what factors contribute to discharge decision making.” The researchers' judgment that so many preventable readmissions resulted from ED decision making may have been affected by hindsight bias, the editorialists said, but it may also be valuable for readmission-prevention efforts to look at communities' overall hospital admission rates, which are highly variable.
Another recent study validated a score for predicting avoidable 30-day readmissions. The HOSPITAL score included 7 factors gathered at discharge: hemoglobin level <12 g/dL, discharge from an oncology service, sodium level <135 mEq/L, procedure during admission, type of admission (urgent or not), number of admissions in the past 12 months, and length of stay ≥5 days. To validate the score, researchers looked at 117,065 adult medical patients discharged from 9 hospitals in 4 countries in 2011, of whom 14.5% were readmitted in 30 days, with 9.7% being potentially preventable readmissions.
Based on the HOSPITAL score, patients were classified as low, intermediate, or high risk for readmission. The score predicted potentially avoidable readmissions with moderately high discrimination and excellent calibration, the study found. Other benefits include that it “is easy to use and can be calculated before discharge,” the authors said.
One limitation is that the predictors of readmission are not necessarily modifiable; for example, the authors “would not presume that transfusing a patient with a hemoglobin level less than 12 g/dL would be indicated to lower their readmission risk.” Still, the score “has the potential to easily identify patients in need of more intensive transitional care interventions to prevent avoidable hospital readmissions,” the authors concluded. Both studies and the editorial were published in the April JAMA Internal Medicine.