Opening the black box of inpatient opioid prescribing

Since initial reports describing an emerging opioid epidemic in the early 2000s, we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide. However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting, rendering the inpatient setting somewhat of an opioid prescribing “black box.” Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization, the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization. Among opioid na€ıve patients admitted to the hospital, one-quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge. Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid na€ıve prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole. In this issue of the Journal of Hospital Medicine, Calcaterra et al., in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission, while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm. At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin. This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions. There are several important implications arising from each of these 3 identified emergent themes. First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid na€ıve patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid na€ıve patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines, prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a *Address for correspondence and reprint requests: Shoshana J. Herzig, MD, 1309 Beacon Street, 2nd Floor, Brookline, MA 02446; Telephone: 617-754-1413; Fax: 617-754-1440; E-mail: sherzig@bidmc.harvard.edu