November 21, 2013
Opioids are overused and inappropriately prescribed for many hospitalized patients, which researchers said heightens risks of narcotic-related adverse events, accidental overdoses, and post-discharge addiction.
A review of 1.14 million nonsurgical admissions at 286 US hospitals published online in the Journal of Hospital Medicine revealed that 51% of patients were prescribed opioids during their hospitalizations, and 43% received multiple opioids. The researchers focused on prescribing practices to nonsurgical patients because individuals who undergo surgery have a clear reason to receive pain medications, and almost always do.
Nonsurgical patients received an average daily dose of 68 mg in oral morphine equivalents, and 23% of patients received total daily doses equal to or greater than 100 mg, putting them at increased risk of suffering breathing-related adverse events, according to study lead author Dr. Shoshana Herzig, a hospitalist in Beth Israel Deaconess Medical Center’s Division of General Medicine and Primary Care and an instructor of medicine at Harvard Medical School in Boston.
Notably, 26% of patients received opioids on the day they were discharged, which suggests they went home with prescriptions for potentially dangerous and addictive medications. Dr. Herzig said primary care physicians need to be diligent in checking patients’ opioid dosing histories to ensure multiple prescriptions aren’t given.
The study also identified a 37% relative difference in prescribing rates in the west (highest) and northeast (lowest) regions of the country, which the researchers said could have been caused by uncertainty about appropriate prescribing practices, a lack of objective measures of pain severity, and a lack of evidence-based recommendations on the use of opioids.
Relative risks of severe opioid-related adverse events were signiﬁcantly greater in hospitals with higher opioid-prescribing rates than in facilities with more restrictive prescribing practices, noted the researchers, who said the ﬁndings suggest that opportunities exist to make opioid prescribing safer for hospitalized patients.
For example, when asked to comment on the outcome of the study Dr. Herzig expressed the belief that hospitals need to identify and correct the prescribing practices that contribute to adverse events. “Perhaps a dosage threshold can be established, above which the rate of breathing problems is significantly higher,” she explained. “Hospitals could institute continuous respiratory monitoring for patients who are given doses above the threshold.”
She conceded that further research is needed to definitely determine how opioids can be utilized more effectively in the hospital setting, but said health-system pharmacists can promote appropriate prescribing practices by suggesting physicians try non-narcotic alternatives for pain control, such as acetaminophen or non-steroidal anti-inflammatory drugs, when there are no contraindications. Medication ordering systems could also be programmed to force physicians to document that they tried other pain therapies before prescribing opioids, suggested Dr. Herzig.
Ultimately, she called for increased communication between inpatient and outpatient caregivers, so primary care providers are more aware of which drugs their patients were exposed to during hospitalizations. She also said hospitals need to closely examine their opioid prescribing practices to “ensure patients are on the minimum amount of drug necessary to bring their pain to tolerable levels.”