Opioid Prescribing: The Hospitalist Perspective, A Qualitative Analysis
Commentary by Susan L. Calcaterra, MD, MPH and Steven Richeimer, MD, Professor, Anesthesiology and Psychiatry USC Keck School of Medicine.
A study published recently in the Journal of Hospital Medicine reveals some surprising factors that influence hospitalists' attitudes toward opioid prescribing during hospitalization and at discharge. The qualitative study by Susan L. Calcaterra, MD, MPH, Department of Hospital Medicine, Denver Health Medical Center and her colleagues identified three major influencers: 1) Past success with opioids for pain management and discomfort with using opioids for chronic pain exacerbations; 2) The impact of negative professional experiences with opioids on prescribing practices; 3) Conflicted feelings about using opioids to improve hospital efficiency.
"This is a [study] that is right on target in terms of pointing out the problem we are facing with managing pain in the hospital environment," comments Steven Richeimer, MD, Professor, Anesthesiology and Psychiatry USC Keck School of Medicine. "Many hospitals across the country are all struggling with this issue right now and exploring what types of models might help us deal with these issues and provide a better way of delivering care and expertise for a patient with a chronic pain problem who is now facing an acute issue on top of that. I think doctors, regardless of their specialty, will recognize these concerns and conflicts," he says, "I think they are just going to say, 'Oh yeah, I'm not alone.'"
Between January 2015 and August 2015, Dr. Calcaterra and her colleagues recruited a convenience sample via email from approximately 135 hospitalists practicing in hospitals in Denver, Colorado and Charleston, South Carolina. The hospitals included two university hospitals, a safety-net hospital, a Veteran's Affairs hospital and a private hospital. Of the 53 who responded, 25 hospitalists (n=25), were interviewed in person (n=16) or by phone (n =9) in semi-structured, in-depth interviews lasting about an hour each. Sixteen (64%) of those interviewed were female; 21 (84%) completed residency within the past ten years. All were trained in internal medicine.
1) Perceived Success, Satisfaction and Comfort When Prescribing Opioids for Pain Management
While hospitalists felt confident in their ability to control acute pain with opioids, their assuredness diminished, and they felt less successful in achieving adequate patient-perceived pain control when treating acute exacerbations of chronic pain. Moreover, concern about increasing opioid dosage in the absence of objective findings to explain the reported pain, led to feelings of discomfort and dissatisfaction when managing acute exacerbations of chronic pain with opioids. Dr. Calcaterra, a hospitalist herself, explains it this way: "A hospitalist doesn't have a long-standing relationship with the patient so it makes us feel very uncomfortable when the patient has chronic pain exacerbations, and we don't really know what conversations the patient has had with their primary care doctor about their opioid use."
2) Professional Experiences That Influenced Opioid Prescribing Practices
The physicians in the study reported little opioid-specific training during residency. Consequently, they relied on their clinical experiences to inform their opioid prescribing practices. A bad experience negatively impacted their confidence in prescribing opioids. For example, one study participant said: "I think past experiences inform what I do now. I mean it's not that I've murdered anybody, but there was a time when I took over a patient and didn't realize that while she had severe pain from restless leg syndrome, she also had severe pulmonary hypertension. I gave her 5 mg of oxycodone. She ended up somnolent with hypercarbic respiratory failure. I think that is something that will always stick in my head." Another participant related how a patient had crushed up the oxycodone she'd been given in the hospital "and shot it up through her central line and died."
These situations, along with worries that giving a prescription at discharge may lead to long-term use, and possible addictions are ever-present concerns. In addition, some physicians expressed concern about patients selling or modifying scripts given at discharge.
3) The Use of Opioids to Improve Institutional Efficiency
Hospitalists felt institutional pressure to reduce hospital readmissions and to facilitate discharges. And because uncontrolled pain often prolongs a hospital stay, some respondents confessed they use opioids as a tool to facilitate discharges and prevent readmissions even though doing so made then uneasy. "All hospitalists know that their job is to improve efficiency," says Dr. Calcaterra, "Still the way that some hospitalists blatantly described using opioids as a pragmatic tool to facilitate discharge surprised me."
That finding also surprised Dr. Richeimer. "I hadn't thought about some doctors feeling that they are under pressure to use opioids as a way to get the patient out of the hospital," he says, adding, "Once I read, I recognized it because the pressure to get patients out of the hospital and to prevent them from readmission within a certain time period goes into the guidelines for assessing hospital performance."
"This paper brings to light all these real conflicts," says Dr. Richeimer. "In my own hospital, I'm in the process right now of trying to draft a report that says basically that we have this problem and here are some different models that [show] how we can solve it. I'm thinking that I might attach this paper [to the report]. I think it will help open the eyes of people who are responsible for allocation of resources and education. We need to find a better way to deal with these issues."
Adds Dr. Calcaterra: There is an urgent need for clear and well-defined strategies that physicians can use to guide them in providing safe and successful patient-centered pain management while maintaining current standards of efficiency "And we need guidelines about appropriate prescribing at discharge to prevent long term [opioid] use," she says.