Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine

Clear and concise patient instructions on home opioid dosing and administration will limit opioid-related adverse events and dosing errors upon hospital discharge. Each of these recommendations derive from one or more of the existing guidelines and reflect the transfer of responsibility for safe opioid use practices that occurs as patients transition from a closely monitored inpatient setting to the more self-regulated home environment.

This Consensus Statement reflects a synthesis of the key recommendations from a systematic review of existing guidelines on acute pain management, adapted for a hospital-specific scope of practice. Despite a paucity of data on the comparative effectiveness of different management strategies for acute pain, several areas of expert consensus emerged across existing guidelines, which were felt to be relevant and applicable to the hospital setting. The objective of these recommendations is to provide information that can be used to inform and support opioid-related management decisions for acute pain by clinicians practicing medicine in the inpatient setting.

Although these recommendations are not intended to apply to the immediate perioperative setting (ie, care in the postanesthesia care unit), many of the recommendations in the existing guidelines upon which this Consensus Statement was based were intended for the postoperative setting, and, as others have noted, recommendations in this setting are mostly comparable to those for treating acute pain more generally.²⁷ Those interested in pain management in the postoperative setting specifically may wish to review the recent guidelines released by the American Pain Society,⁵⁰ the content of which is in close alignment with our Consensus Statement.

Several important issues were raised during the extensive external feedback process undertaken as part of the development of this Consensus Statement. Although many issues were incorporated into the recommendations, there were several suggestions for which we felt the evidence base was not sufficient to allow a clear or valid recommendation to be made. For example, several reviewers requested endorsement of specific patient education tools and opioid equivalency calculators. In the absence of tools specifically validated for this purpose, we felt that the evidence was insufficient to make specific recommendations. Validating such tools for use in the inpatient setting should be an area of future investigation. In the meantime, we note that there are several existing and widely available resources for both patient education (ie, opioid information sheets, including opioid risks, safe containment and disposal, and safe use practices) and opioid equivalency calculations that clinicians and hospitals can adapt for their purposes.

Several individuals suggested recommendations on communication with outpatient continuity providers around opioid management decisions during hospitalization and on discharge. Although we believe that it is of paramount importance for outpatient providers to be aware of and have input into these decisions, the optimal timing and the method for such communication are unclear and likely to be institution-specific depending on the availability and integration of electronic records across care settings. We recommend that clinicians use their judgment as to the best format and timing for assuring that outpatient physicians are aware of and have input into these important management decisions with downstream consequences.

Concerns were also raised about the time required to complete the recommended practices and the importance of emphasizing the need for a team-based approach in this realm. We agree wholeheartedly with this sentiment and believe that many of the recommended practices can and should be automated and/or shared across the care team. For example, PDMPs allow prescribers to appoint delegates to check the PDMP on their behalf. Additionally, we suggest that hospitals work to develop systems to assist care teams with performance of these tasks in a standardized and streamlined manner (eg, integrating access to the PDMP and opioid equivalency tables within the electronic health record and developing standard patient educational handouts). Provision of written materials on opioid risks, side effects, and safety practices may be helpful in facilitating consistent messaging and efficient workflow for members of the care team.

Finally, the working group carefully considered whether to include a recommendation regarding naloxone prescribing at the time of hospital discharge. The provision of naloxone kits to laypersons through Overdose Education and Naloxone Distribution Programs has been shown to reduce opioid overdose deaths^51,52 and hospitalizations^53,54 and is both safe and cost-effective.⁵⁵ The Centers for Disease Control and Preventionrecommend that clinicians “consider offering naloxone to patients with a history of overdose, a current or past substance use disorder, receipt of ≥50 mg of morphine equivalents per day or concurrent benzodiazepine use.”¹ However, these recommendations are intended for patients on chronic opioid therapy; presently, no clear evidence exists to guide decisions about the benefits and costs associated with prescribing naloxone in the setting of short-term opioid therapy for acute pain. Further research in this area is warranted.

The greatest limitation of this Consensus Statement is the lack of high-quality studies informing most of the recommendations in the guidelines upon which our Consensus Statement was based. The majority of recommendations in the existing guidelines were based on expert opinion alone. Additional research is necessary before evidence-based recommendations can be formulated.

Accordingly, the working group identified several key areas for future research, in addition to those noted above. First, ongoing efforts to develop and evaluate the effectiveness of nonopioid and nonpharmacologic management strategies for acute pain in hospitalized patients are necessary. Second, studies identifying the risk factors for opioid-related adverse events in hospitalized patients would help inform management decisions and allow deployment of resources and specialized monitoring strategies to patients at heightened risk. The working group also noted the need for research investigating the impact of PDMP use on management decisions and downstream outcomes among hospitalized patients. Finally, conversations around pain management and concerns related to aberrant behaviors are often challenging in the hospital setting owing to the brief, high-intensity nature of the care and the lack of a longstanding therapeutic alliance. There is a great need to develop strategies and language to facilitate these conversations.