A Commentary on Evaluation of Hospitalized Patients Receiving High Versus Low-Dose Opioids for Non-Cancer Painy

Description

Acute pain is considered by many to be the fifth vital sign.  Treating acute pain in the hospital is necessary to maintain patient function, improve quality of life, prevent progression to chronic pain and to achieve positive patient satisfaction scores [1],but this must be balanced with utilizing treatments that do not lead to significant adverse effects or an increase in overprescribing of opioids [2]. Moore et al. discuss treating acute non-cancer pain in hospitalized patients and how the dose may impact outcomes [3]. Previous literature has shown that opioid use disorders as well as morbidity and mortality increase with higher doses of opioids [4-6]. While these studies evaluated the effects of high dose opioids in patient populations with chronic pain, Moore et al. reviewed hospitalized patients that were admitted with a diagnosis (acute myocardial infarction, chronic obstructive pulmonary disease, heart failure, pneumonia, diabetes and sepsis) that does not typically require significant amounts of opioids for treatment of acute pain. In this study, they point out that treatment of acute pain with high doses of opioids may lead to more adverse events in hospitalized patients [3].

Additionally, it was noted that >30% of opioid-naïve patients were discharged on opioids. This finding is particularly alarming since it is known that new opioid prescriptions originating from treatment of an acute pain episode in the inpatient setting can be the nidus of long term opioid use [7,8]. These studies, along with the one by Moore et al. highlight the clinical conundrum of treating acute pain in hospitalized patients appropriately, while not setting the patient up for long-term adverse effects or complications. Similarly, the CDC noted in their most recent “Clinical Practice Guideline for Prescribing Opioids for Pain–United States, 2022” [9] that pain is a complex phenomenon and that the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain led to laws and regulations that may have had a positive impact for some in the opioid crisis, while negatively impacting others due to the rigid interpretation of the guidelines. Some of the concerns with this strict interpretation and implementation mentioned within the 2022 Guideline update revolve around untreated or undertreated pain as well as serious adverse effects from withdrawal, overdose, and psychological issues, including suicidal behavior [10-15]. While the misapplication of the 2016 CDC Opioid Prescribing Guideline led to harm in certain patients, the 2022 Guidelines challenge the previous approach given the new evidence that has surfaced related to treating both acute and chronic pain.

The practice of treating acute and chronic pain with opioid medications varies across the United States. Despite the decline in opioid misuse and opioid use disorders with the 2016 CDC Opioid Prescribing Guideline, opioid medications remain a common therapeutic medication used for pain management. It is important to continue to evaluate the risks and benefits associated with the use of opioids in the treatment of acute pain. As pointed out by Moore et al. there is a need for opioid stewardship to reduce some of the long-term ramifications of starting opioid treatment in the hospitalized setting, and in having opioid-naïve populations continue these opioids beyond the acute setting [3]. There is no panacea for the opioid crisis, and going too far one way by restricting therapy or the opposite direction with wanton use can have significant detrimental effects; however, being apathetic to the crisis potentially leads to an even broader negative impact on the general population. It is imperative for clinicians to use opioid stewardship best practices and lessons learned from continued research, the 2022 CDC Update on Clinical Practice Guideline for Prescribing Opioids for Pain, and to ensure an individualized approach to caring for the patient with pain is utilized, while also putting into place broader mitigation strategies that are flexible enough to support patient-centered care.

References

1. NEJM Catalyst Innovations in Care Delivery. Patient Satisfaction Surveys.2018.
2. The Interagency Pain Research Coordinating Committee. National pain strategy: a comprehensive population health level strategy for pain. Bethesda, MD: National Institutes of Health.2016.
3. Moore CH, et al. Evaluation of hospitalized patients receiving high versus low-dose opioids for non-cancer pain. J Pain Palliat Care Pharmacother. 2022;36:71-78.

   [Crossref] [Google Scholar] [PubMed]

4. Merrill JO, et al. Prescribed opioid difficulties, depression and opioid dose among chronic opioid therapy patients. Gen Hosp Psychiatry. 2012;34:581-587.

   [Crossref] [Google Scholar] [PubMed]

5. Morasco BJ, et al. Higher prescription opioid dose is associated with worse patient-reported pain outcomes and more health care utilization. J Pain. 2017;18:437-445.

   [Crossref] [Google Scholar] [PubMed]

6. Gomes T, et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med. 2011;171:686-691.

   [Crossref] [Google Scholar] [PubMed]

7. Jones CM, et al. Changes in synthetic opioid involvement in drug overdose deaths in the United States, 2010-2016. external icon  JAMA. 2018;319:1819-1821.

   [Crossref] [Google Scholar]

8. Edlund MJ, et al. The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 2014;30:557-564.

   [Crossref] [Google Scholar] [PubMed]

9. Dowell D, et al. CDC clinical practice guideline for prescribing opioids for pain-United States, 2022. MMWR Recomm Rep. 2022;71:1-95.

   [Crossref] [Google Scholar]

10. Kroenke K, et al. Challenges with implementing the centers for disease control and prevention opioid guideline: a consensus panel report. Pain Med. 2019;20:724-735. 

    [Crossref] [Google Scholar] [PubMed]

11. Dowell D, et al. No shortcuts to safer opioid prescribing. N Engl J Med. 2019;380:2285-2287.

    [Crossref] [Google Scholar] [PubMed]

12. Food and Drug Administration. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering. Silver Spring, MD: US Department of Health and Human Services, Food and Drug Administration. 2019.
13. Demidenko MI, et al. Suicidal ideation and suicidal self-directed violence following clinician-initiated prescription opioid discontinuation among long-term opioid users. Gen Hosp Psychiatry. 2017;47:29-35. 

    [Crossref] [Google Scholar]

14. Coffin PO, et al. Illicit opioid use following changes in opioids prescribed for chronic non-cancer pain. PLoS One. 2020;15:e0232538. 

    [Crossref] [Google Scholar]

15. Mark TL, et al. Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 2019;103:58-63.

    [Crossref] [Google Scholar] [PubMed]