Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine
Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.
© 2018 Society of Hospital Medicine
9. SHM recommends that clinicians pair opioids with scheduled nonopioid analgesic medications, unless contraindicated, and always consider pairing with nonpharmacologic pain management strategies (ie, multimodal analgesia).
Concurrent receipt of opioids and nonopioid analgesic medications (including acetaminophen, NSAIDs, and gabapentin or pregabalin, depending on the underlying pathophysiology of the pain) has been demonstrated to reduce total opioid requirements and improve pain management.41,42 Clinicians should be familiar with contraindications and maximum dosage recommendations for each of these adjunctive nonopioid medications. We recommend separate orders for each, rather than using drug formulations that combine opioids and nonopioid analgesics in the same pill, due to the risk of inadvertently exceeding the maximum recommended doses of the nonopioid analgesic (particularly acetaminophen) with combination products. We recommend that nonopioid analgesics be ordered at a scheduled frequency, rather than as needed, to facilitate consistent administration that is not dependent on opioid administration. Topical agents, including lidocaine and capsaicin, should also be considered. Nonpharmacologic pain management strategies can include procedure-based (eg, regional and local anesthesia) and nonprocedure-based therapies depending on the underlying condition and institutional availability. Although few studies have assessed the benefit of nonpharmacologic, nonprocedure-based therapies for the treatment of acute pain in hospitalized patients, the lack of harm associated with their use argues for their adoption. Simple nonpharmacologic therapies that can usually be provided to patients in any hospital setting include music therapy, cold or hot packs, chaplain or social work visits (possibly including mindfulness training),43 and physical therapy, among others.
10. SHM recommends that, unless contraindicated, clinicians order a bowel regimen to prevent opioid-induced constipation in patients receiving opioids.
Constipation is a common adverse effect of opioid therapy and results from the activation of mu opioid receptors in the colon, resulting in decreased peristalsis. Hospitalized patients are already prone to constipation due to their often-limited physical mobility. To mitigate this complication, we recommend the administration of a bowel regimen to all hospitalized medical patients receiving opioid therapy, provided the patient is not having diarrhea. Given the mechanism of opioid-induced constipation, stimulant laxatives (eg, senna, bisacodyl) have been recommended for this purpose.44 Osmotic laxatives (eg, polyethylene glycol, lactulose) have demonstrated efficacy for the treatment of constipation more generally (ie, not necessarily opioid-induced constipation). Stool softeners, although frequently used in the inpatient setting, are not recommended due to limited and conflicting evidence for efficacy in prevention or treatment of constipation.45 Bowel movements should be tracked during hospitalization, and the bowel regimen modified accordingly.
11. SHM recommends that clinicians limit co-administration of opioids with other central nervous system depressant medications to the extent possible.
This combination has been demonstrated to increase the risk of opioid-related adverse events in multiple settings of care, including during hospitalization.1,18,19 Although benzodiazepines have received the most attention in this respect, other medications with CNS depressant properties may also increase the risk, including, but not limited to, nonbenzodiazepine sedative-hypnotics (eg, zolpidem, zaleplon, zopiclone), muscle relaxants, sedating antidepressants, antipsychotics, and antihistamines.18,19,46 For some patients, the combination will be unavoidable, and we do not suggest routine discontinuation of longstanding medications that preexisted hospitalization, given the risks of withdrawal and/or worsening of the underlying condition for which these medications are prescribed. Rather, clinicians should carefully consider the necessity of each medication class with input from the patient’s outpatient providers, taper the frequency and/or the dose of CNS depressants when appropriate and feasible, and avoid new coprescriptions to the extent possible, both during hospitalization and on hospital discharge.
12. SHM recommends that clinicians work with patients and families or caregivers to establish realistic goals and expectations of opioid therapy and the expected course of recovery.
Discussing expectations at the start of therapy is important to facilitate a clear understanding of how meaningful improvement will be defined and measured during the hospitalization and how long the patient is anticipated to require opioid therapy. Meaningful improvement should be defined to include improvement in both pain and function. Clinicians should discuss with patients 1) that the goal of opioid therapy is tolerability of pain such that meaningful improvement in function can be achieved and 2) that a decrease in pain intensity in the absence of improved function is not considered meaningful improvement in most situations and should prompt reevaluation of the appropriateness of continued opioid therapy as well as close follow-up with a clinician following hospital discharge. Discussions regarding the expected course of recovery should include that acute pain is expected to resolve as the underlying medical condition improves and that although pain may persist beyond the hospitalization, pain that is severe enough to require opioids will often be resolved or almost resolved by the time of hospital discharge.
