Changing approaches to pain

Treating inpatients' pain is challenging in an opioid addiction epidemic.

Hospitalists have had to adjust their approach to pain management significantly over the past decade in response to a surge in opioid-related overdoses. Whereas the drugs were once considered the most expedient and effective path to relieving pain and speeding the discharge process, they're now viewed with caution.

“As hospitalists, we have to figure out how we can best take care of patients and efficiently discharge them without doing wrong by them,” said Susan Calcaterra, MD, MPH, assistant professor of medicine at the University of Colorado Anschutz Medical Campus in Aurora, Colo. “That's really challenging when a patient says they need more pain medication.”

She was the lead author of a study, published in the August 2016 Journal of Hospital Medicine, revealing that many hospitalists struggle with how to offer patients adequate pain relief without contributing to future opioid dependence.

Illustration by Sarah Ferone
Illustration by Sarah Ferone

Opioids have long been the cornerstone of inpatient pain management, particularly in the postsurgical setting, but experts now recommend avoiding, limiting, and combining them with nonopioid and nondrug therapies.

“The use of nonopioid and nondrug management is extremely important,” said David Tauben, MD, FACP, chief of the division of pain medicine at the University of Washington in Seattle. “When opioids are necessary, we should be prescribing them at the lowest dose for the shortest time needed to control the pain.”

Another important change is an easing of the pressure physicians may have felt to boost patient satisfaction scores by prescribing opioids when patients requested them. CMS recently announced it would eliminate pain management questions from its satisfaction surveys.

“That's taken away some of the pressure to prescribe opioids,” said Dr. Calcaterra. “Physicians can now do what they think is right without worrying about how it will impact satisfaction scores down the road.”

Alternative approaches

According to guidelines on the management of postoperative pain issued by the American Pain Society (APS) in February 2016, physicians should limit the use of opioids whenever possible and combine them with other analgesic medications and nondrug interventions.

Studies cited in the APS guidelines suggest that a multimodal approach may lead to better pain relief than opioids alone because different medications act on different pain receptors. For example, clinicians should consider incorporating the anticonvulsants gabapentin or pregabalin into a postoperative pain care regimen.

The APS panel also recommended transcutaneous electric nerve stimulation, which delivers low-voltage electrical currents through the skin to activate opioid receptors, as an adjunctive treatment for pain. Other options include acupuncture, massage, cold and heat therapy, and immobilization or bracing, although there is no conclusive evidence on their effectiveness.

Determining the source of the patient's pain can guide decisions on which therapies to use, said Miles Belgrade, MD, a pain specialist at the Minneapolis VA Medical Center in Minnesota.

“Opioids are more of a general analgesic that aren't directed at specific types of pain,” he said. “By looking at the type of pain, it informs us as to what nonopioid treatment we should be using.”

For neuropathic pain, use drugs that have a specific effect on nociceptor irritability such as gabapentin, pregabalin, or tricyclic antidepressants, as well as the anesthetic ketamine, he advised. Pain caused by inflammation can often be relieved with nonsteroidal anti-inflammatory drugs (NSAIDs).

“Hospitalists tend to shy away from NSAIDs because of the small risk of acute renal failure, but that risk is quite low in comparison to the risks associated with opioids,” said ACP Member Shoshana Herzig, MD, MPH, assistant professor of medicine at Harvard Medical School and director of hospital medicine research at Beth Israel Deaconess Medical Center in Boston. “Opioids should be reserved for severe pain when other alternative therapies fail to offer adequate relief.”

Seeking alternatives is especially important in large urban hospitals that serve high-need or indigent patient populations, noted Ivan Lesnik, MD, chief of pain services at Harborview Medical Center, a tertiary trauma center in Seattle. These complex patients often have substance abuse disorders and other comorbid conditions that put them at higher risk for opioid-related adverse events.

Harborview encourages physicians to try nonpharmacological or nonopioid strategies whenever possible, especially when treating patients with a history of substance abuse, he said. In addition to drug alternatives, it's common for clinicians to employ nondrug therapies such as ice, heat, yoga, and massage, as well as psychological interventions, such as cognitive behavioral therapy.

When it's necessary to use opioids for high-risk patients, Dr. Lesnik's team often combines a short-acting opioid, such as oxycodone, with methadone, a long-acting opioid that helps reduce symptoms of withdrawal and drug cravings.

Finding the right treatment for pain requires a multidisciplinary approach, he said. At Harborview, clinicians work closely with psychologists, psychiatrists, spiritual care and addiction specialists, and pharmacists in order to address both medical and nonmedical issues that might be affecting the patient's ability to cope with pain, such as the death of a loved one.

“In many cases, we can help patients move away from a chemical coping strategy to dealing with whatever they are experiencing,” said Dr. Lesnik. “Using a team approach, we find we are using less opioids with similar results in terms of pain management and better long-term outcomes.”

When using opioids

While opioids are almost always part of the pain management strategy following surgery or trauma, some hospitals may be prescribing them inappropriately in nonsurgical patients, according to recent research.

In the study, just over half of all hospitalized nonsurgical patients over a one-year period were exposed to opioids, often at high doses, and half of those patients received a prescription at discharge. Overdoses and other severe opioid-related adverse events were significantly higher at hospitals with the highest prescribing rates. The results were published in the February 2014 Journal of Hospital Medicine.

“Our findings highlight the fact that we don't have standard guidelines for when to prescribe opioids and who should get them,” said Dr. Herzig, the study's lead investigator. “It's a gray area that speaks to the subjective nature of pain and the difficulty of assessing whether or not a patient's pain is severe enough to warrant opioids.”

While numerous well-powered trials exist to guide treatment of myocardial infarction or stroke, for example, nothing similar exists for pain management and prevention of addiction, noted the editors of a special section on the opioid epidemic in the January 2016 Substance Abuse. As a result, residents receive little training on how to manage these issues.

The decision to prescribe opioids often comes down to a process of elimination, said Dr. Herzig. Physicians first look for red flags signaling that a patient may be at higher risk for addiction, including previous dependence on opioids, a history of addiction, or use of other potentially addictive substances such as benzodiazepines, cocaine, or alcohol.

They should also note any physical comorbidities that contraindicate opioids, such as sleep apnea, which heightens the risk of respiratory depression. In addition, state prescription drug monitoring programs—electronic repositories for all prescriptions dispensed statewide—can be extremely useful in identifying patients who may be using the hospital visit as a way to procure opioids to feed their own addiction or illegally distribute, said Dr. Tauben.

“We always check the monitoring program at admission,” he said. “If a patient has been going around the state trying to fill prescriptions for opioids, we discharge them with a referral to addiction services.”

A preexisting addiction or high burden of comorbidities doesn't necessarily rule out opioids if a patient is experiencing severe pain, noted Dr. Belgrade. However, it's important to ensure that you have a well-defined management plan if opioids are used during hospitalization.

“Pain treatment needs to have a beginning, middle, and endpoint,” he explained. “If a patient has an existing addiction, I work with them to manage that and provide them with guidelines for tapering off opioids when the time comes. I hold their hand through the process while still being aggressive with pain treatment.”

For patients who were taking opioids before admission, the goal should be to return them to their preadmission status, noted Sean Mackey, MD, PhD, chief of pain medicine at Stanford University Medical Center in Palo Alto, Calif., and co-chair of the Interagency Pain Research Coordinating Committee task force that oversaw creation of the NIH's National Pain Strategy, which was released in March 2016.

When it's necessary to temporarily increase the dose to control significant postsurgical pain, patients should leave with detailed instructions for tapering back down to their original dose, including a calendar with an expected titration schedule, he said.

In addition, patients should receive no more than a two-week supply of opioids at discharge so that they will be forced to check in with their clinician for refills, said Dr. Tauben. At the University of Washington, patients considered at risk for addiction or abuse are referred to the hospital's postoperative clinic where they receive counseling on dose reduction.

“Patients at risk return to the clinic every couple of days and communicate regularly with a provider,” he said. “We try to prevent them from ending up in their primary care physician's office out of control with their opioid use and not knowing how to deal with it.”

The risks of long-term opioid use are changing the culture around pain management and shifting the ultimate goals of therapy, said Dr. Herzig. That message needs to be communicated clearly to patients.

“Patients shouldn't necessarily expect to be pain-free, which is unrealistic and potentially harmful,” she said. “We need to change the message to tolerability rather than absence of pain. That's a huge message we have to get out there.”