Hospitalization frequently requires pain management for trauma-related injuries, for underlying conditions such as cancer, or in the post-surgical setting. In addition, evidence suggests that inadequate management of acute pain, which was recognized as an issue beginning in the 1990s, can progress to chronic pain.1,2 Opioids provide effective dose-dependent pain relief with minimal toxic effects and can be administered via a variety of delivery systems, including oral, parenteral, transdermal, epidural, and spinal. However, there is increasing recognition of errors in the prescribing, administration, and inadequate monitoring of patients on opioid therapy leading to serious side effects and adverse events. And despite guidelines recommending careful prescribing and monitoring of hospitalized patients who are receiving opioids, evidence suggests that patient safety risks persist, including oversedation, respiratory depression and death. In addition, the widespread use in hospitals can lead to long term use, misuse, and potential addiction. For more information, visit our section on outpatient and community risks for opioid use.
Opioids are commonly used – and at relatively high doses – during hospitalization. A 2013 national study found that opioids were used in more than half of hospital admissions of non-surgical patients at the 286 US hospitals studied.3 After adjusting for patient characteristics, the mean prescribing rate of opioids ranged from 33 percent to 64 percent. Patients received a mean daily dose of 68 mg of oral morphine equivalents. More than half of the patients who received opioids during hospitalization were still receiving the drugs at hospital discharge. More on opioid use in community and outpatient setting Among pediatric inpatients two specific opioids, fentanyl and morphine, are among the top 10 most administered medications.4 Each of these drugs was used for about 6 percent of hospitalized children. Fentanyl was in the top five and its prevalence increased linearly with age group.
Even when used as prescribed, opioids are associated with a range of side effects and potentially serious adverse events. In the inpatient setting, opioids are among the drugs most frequently associated with adverse events. In one large study, opioids were responsible for 16 percent of drug-related adverse effects.5 A study of post-surgical patients found that almost 14 percent of those who received opioids experienced an adverse event.6 The study also found that the risk of death while hospitalized was more than 3 times higher among the patients who experienced an adverse effect associated with opioids compared with patients who did not. The researchers in the study of 268 US hospitals previously mentioned found that patients who were treated in hospitals with higher prescribing rates had a higher adjusted relative risk of experiencing a severe adverse event related to opioids than patients treated in hospitals with lower prescribing rates.3 Several studies have demonstrated a statistically significant relationship between the use of opioids and adverse drug events, such as nausea and ileus, and increases in costs, lengths of stay and 30-day readmission rates. A study using the Premier Inc. database found that about 12 percent of post-surgical patients experienced an opioid-related adverse event.7 Those who did were significantly more likely to incur greater cost, have a longer length of stay, and experience re-admission. For example, patients who experienced an adverse event related to opioid use had an average length of stay of 9.0 days compared with 4.2 days for patients without such events.
To minimize the risks associated with opioids, clinicians should implement multimodal pain plans for short- and long-term pain management, shifting from an opioid-based to an opioid-sparing approach. To reduce the use of opioids, clinicians should consider the use or addition of non-narcotic medications, such as NSAIDS, acetaminophen, regional infusions of local anesthetics, steroids, ketamine, and gabapentinoids. According to a task force of the American Society of Anesthesiologists, pain management therapy should be multimodal whenever possible.8 The task force recommended that pain management plans include continuous regimens with NSAIDS, COX-2 inhibitors, or acetaminophen, unless there is a patient contraindication. The use of multimodal, or “balanced,” pain management allows for lower doses of each analgesic and may reduce the severity of side effects associated with each drug. 9,10 An additional advantage of a multimodal regimen is the synergistic effects on analgesia when drugs with different mechanisms of action are combined.11
Opioids – Role of PCA
Patient-controlled analgesia (PCA) provides an effective tool for the delivery of pain medication in the inpatient setting. PCA can reduce the risk of over-sedation associated with opioids.12 However, the safety of PCA is highly dependent on the practices surrounding its use. Patients who are administered analgesia via PCA by others (“PCA by proxy”) are at increased risk for serious adverse events.13 A recent national survey of PCA practices highlights several areas of concern about the safety of PCA.14 The study found:
- A large variation, and many gaps, in the risk factors that clinicians consider before initiating PCA.
- Almost 20 percent of hospitals fail to assess patients’ previous exposure to opioids.
- About 15 percent of hospitals fail to consider obesity as a risk factor.
- About 15 percent fail to consider patient age as a risk factor.
- Despite recommendations by the Anesthesia Patient Safety Foundation, at least 16 percent of hospitals patients on PCA are not monitored with either pulse oximetry or capnography.
- About 10 percent of hospitals failed to perform adequate double checking to ensure that the correct patient is receiving the correct dosage from a PCA pump.
- More than 15 percent of hospitals reported that they are not using “smart” pumps for any of their patients. (Smart pumps contain specific software for improved safety.)
Also concerning is the fact that many of the hospitals surveyed reported concern about “alarm fatigue,” with less than 5 percent reported that they were “not concerned at all.” With the documented gaps in safety practices related to PCA, the failure of clinicians to respond to PCA alarms, or to silence them, represents a serious patient safety concern.
Electronic monitoring can be cost effective.
In addition to the tragedy of lives cut short by preventable mortality, opioid-associated adverse events are costly. However, studies from early adopters of electronic monitoring are proving that continuous monitoring technologies are cost-effective and create a return on investment by reducing patient harm, length of stay, follow-up care. Two of the monitoring technologies that are being used are pulse oximetery to measure the oxygen saturation in blood with a non-invasive sensor, usually a finger probe and capnography to measure respiratory rate and concentration of exhaled carbon dioxide with a sensor connected to a nasal cannula.
CMS, Joint Commission: “Continuously monitor patients on opioids”
In addition to many safety and profession organizations, The Joint Commission in a sentinel event alert on opioids and CMS in Memo to States and in CMS Conditions for Participation guidance for medication administration call for continuous monitoring for patients receiving IV opioids.
CMS to address Medicare payments tied to pain management scores
Many clinicians report feeling pressure to overprescribe opioids because scores on the HCAHPS patient satisfaction survey about pain management are tied to Medicare payments to hospitals. To reduce any potential link of financial pressure to overprescribe opioids, in July 2016, the CMS proposed removing the HCAHPS survey pain management questions from the hospital payment scoring calculation. This means that hospitals would continue to use the questions to survey patients about their in-patient pain management experience, but these questions would not affect the level of payment hospitals receive.
Ten Strategies for Preventing Opioid-Related Adverse Events in Hospitals
- Educate staff at all levels regarding safe opioid use, including the appropriate use of non-narcotic analgesia, the risks associated with opioids, and assessment for respiratory depression and other adverse drug reactions.
- Ensure the availability of pharmacists or pain management experts to help providers with opioid conversion and dosing.
- Create policies and procedures to ensure ongoing electronic monitoring of patients on opioid therapy.
- Require the use of standardized screening tools to assess the risk of respiratory depression.
- Ensure that oxygen and reversal agents are available wherever opioids are administered.
- Track and investigate opioid-related adverse events.
- Create oversight committees and systems to identify and deter drug diversion by staff.
- Establish clear policies and procedures for evaluating and addressing identified instances of drug diversion.
- Provide written and oral education to patients on opioid therapy or to their caregivers, including risks and side effects, potential for sedation, the danger of use in combination with alcohol or other sedating drugs, and safe storage at home.
- Use technology to support safe opioid use through decision support and alert systems in the electronic medical record and the use of patient-controlled analgesia (PCA) devices.
Visit our opioid tools and resources section for guidelines, checklists, news, toolkits, research, webinars and CE/CME education on safer opioid use in hospitals and outpatient/community settings
Nelson LS, Perrone J. Curbing the opioid epidemic in the United States: the risk evaluation and mitigation strategy (REMS). JAMA. 2012;308 (5): 457-8.
Woolf CJ. Pain: moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med. 2004;140(6):441-51.
Herzig SJ, Rothberg MB, Cheung M, Ngo LH, Marcantonio,ER. (2014), Opioid utilization and opioid-related adverse events in nonsurgical patients in US hospitals. J Hosp Med. 9: 73-81.
Lasky T, Ernst FR, Greenspan J, Wang S, Gonzalez L.Estimating pediatric inpatient medication use in the United States. Pharmacoepidemiol Drug Saf. 2011;20(1):76-82.
Davies EC, Green CF, Taylor S, Williamson PR, Mottram DR, Pirmohamed M. Adverse drug reactions in hospital in-patients: a prospective analysis of 3695 patient-episodes. PLoS One. 2009;4(2):e4439.
Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 2013;33(4):383-91.
Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62-70.
American 8. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2012;116(2):248-73.
Elia N1, Lysakowski C, Tramèr MR. Does multimodal analgesia with acetaminophen, nonsteroidal antiinflammatory drugs, or selective cyclooxygenase-2 inhibitors and patient-controlled analgesia morphine offer advantages over morphine alone? Meta-analyses of randomized trials. Anesthesiology. 2005;103(6):1296-304.
Maund E1, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth. 2011;106(3):292-7.
Fernández-Dueñas V1, Poveda R, Sánchez S, Ciruela F. Synergistic interaction between fentanyl and a tramadol: paracetamol combination on the inhibition of nociception in mice. J Pharmacol Sci. 2012;118(2):299-302.
Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. 2012;49:1-5.
Joint Commission. Patient controlled analgesia by proxy. Sentinel Event Alert. 2010;33:1-2.
Wong M, Mabuyi A, Gonzalez B. First national survey of patient-controlled analgesia practices. Physician-Patient Alliance for Health & Safety. 2013. Available at: http://ppahs.files.wordpress.com/2013/10/first-national-survey-of-patient-controlled-analgesia-practices.pdf . Accessed February 26, 2014.