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. 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. Despite guidelines recommending careful prescribing and monitoring of hospitalized patients who are receiving opioids, evidence suggests that patient safety risks persist, including over-sedation leading to respiratory depression and possible death. In addition, the widespread use in hospitals and discharging patients on opioids can lead to long term use, misuse, and potential dependence and addiction. For more information on risks of dependence/addiction, visit our section on community and outpatient use and abuse of opioids risks for opioid use.
Opioids: frequently used in the inpatient setting
Opioids are commonly used – and at relatively high doses – during hospitalization. A Premier national study found that opioids were used in more than half of hospital admissions of non-surgical patients at the 286 US hospitals studied (Herzig 2014). 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. Additional Premier research found that among pediatric inpatients, two specific opioids, fentanyl and morphine, are among the top 10 most administered medications (Lasky 2011). 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.
Opioid side effects and adverse events
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 (Davies 2009). A study of post-surgical patients found that almost 14 percent of those who received opioids experienced an adverse event (Kessler 2013). 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 using the Premier Inc. database 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 (Herzig 2014). 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 (Oderda 2013).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.
Alternatives to opioids for inpatient pain management
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. 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. An additional advantage of a multimodal regimen is the synergistic effects on analgesia when drugs with different mechanisms of action are combined.
Opioids – Role of PCA
Patient-controlled analgesia (PCA) provides an effective tool for the delivery of opioid pain medication in the inpatient setting and allows patients to achieve better pain management. However, the safety of PCA is highly dependent on the practices surrounding its use. Because opioids can also sedate the part of the brain that controls breathing, causing it to be dangerously slow or stop, patients on PCA need to be monitored closely.
Certain patients that are at higher risk for opioid-related respiratory depression, and include those who have never had opioids, are elderly, overweight, or have sleep apnea, asthma or on other drugs with sedative effects. But even risk assessment tools to identify these risks are not universally used and do not catch all patients with such risks.
Spot checking is one method used to assess patients on opioids and PCA machines. Yet spot checking, even every two hours, does not reliably detect early onset of respiratory depression. The patient may appear alert during the spot check and quickly lapse back into a dangerous sleep with respiratory depression. Spot checking is not always consistently practiced. A recent study on the monitoring practices of eight hospitals testing an e-quality measure for the Centers for Medicare and Medicaid Services (CMS) found that only 25 percent of hospitalized patients receiving opioids are monitored according to guidelines. The recommended protocol is to monitor blood oxygen saturation, respiratory rate and level of sedation every two to four hours for the first 24 hours after surgery or the onset of opioid administration.
Electronic monitoring of patients on opioids
A promising and effective measure to assess patients on opioids is with continuous electronic monitoring, which can detect early and subtle signs of respiratory depression that eludes a spot check of vital signs. Many safety and professional organizations recommend continuous monitoring of oxygenation and/or ventilation of patients receiving opioids postoperatively, including the Anesthesia Patient Safety Foundation (APSF) and the Institute for Safe Medication Practices (ISMP).
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 hospitals using electronic monitoring for all patients on IV opioids are proving that continuous monitoring technologies are cost-effective and create a return on investment by reducing patient harm, length of stayand 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.
The Association for the Advancement of Medical Instrumentation® (AAMI) is a nonprofit organization founded in 1967. Its mission—the development, management, and use of safe and effective health technology. AAMI is the primary source of consensus standards, both national and international, for the medical device industry, as well as practical information, support, and guidance for healthcare technology and sterilization professionals.
The AAMI Foundation web contains many resources/on-demand webinars in the area of Patient Safety and the application of continuous monitoring.
CMS: “Continuously monitor patients on opioids”
Since 2014, CMS has set expectations regarding safer pain management using IV opioids. 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 replaces Pain Management questions with new ones on“communication about pain”
Many clinicians have reported 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, CMS is replacing HCAHPS pain management questions with new questions that focus on communication about pain. Beginning with the July 2018 Public Report, The HCAHPS survey questions comprising Pain Management Composite 4 were removed from the HCAHPS Survey in the FY 2018 IPPS/LTCH PPS Final Rule (81 FR 38342) and will no longer be reported on Hospital Compare . In addition, Pain Management is no longer included in the calculation of the HCAHPS Summary Star Rating or the Hospital Compare Overall Hospital Quality Star Rating. CMS announced plans to replace the current Pain Management questions (items 12, 13 and 14 on the HCAHPS Survey) with three new questions that focus on communication about pain. The new pain items will be required on all surveys administered to patients discharged from January 1, 2018 and forward. The new Pain Management items will comprise a new composite measure, “Communication About Pain.” This change will affect all survey translations and all survey modes. The new Pain Management items include:
- During this hospital stay, did you have any pain?
- During this hospital stay, how often did hospital staff talk with you about how much pain you had?
- During this hospital stay, how often did hospital staff talk with you about how to treat your pain?
Joint Commission new pain management standards
The Joint Commission revised their pain assessment and management standards, effective January 1, 2018, for its accredited hospitals. Effective January 1, 2019 there are new standards for Ambulatory settings. The revised standards focus effective pain management and opioid prescribing, to include identifying a program leader/team, involving patients in their treatment plans, identifying and monitoring high risk patients, facilitating clinician access to prescription drug monitoring programs, and conducting performance improvement activities on pain assessment and management.
Hospital leadership’s role in safer pain management
To be successful, hospital leadership in collaboration with the medical, nursing and pharmacy staff should establish safer pain management for patients as an organizational priority.
Top 10 strategies for hospitals to prevent opioid-related adverse events
Premier Safety Institute 2017
- Designate a leader/team responsible for pain management and safe opioid prescribing across the continuum of care and ensure availability of pain management experts to help providers with opioid conversion and dosing.
- Educate and promote use of multi-modal pain treatment, including non-opioid medications, nerve blocks, and alternative modalities, such as physical, relaxation or chiropractic therapy.
- Educate staff at all levels and provide resources on safe opioid use, including pain assessment and management, the risks associated with opioids (adverse drug reactions such as respiratory depression), and potential risks of physical dependence and addiction.
- Ensure that oxygen and reversal agents are available wherever opioids are administered.
- Assess patients using standardized tools on admission for pain or risk of pain based on diagnosis, planned treatments or procedures, and risks for respiratory depression.
- Educate patients on pain management treatment, including realistic expectations and goals for pain reduction, and risks related to opioid use.
- Use technology to support safe opioid use through decision support, alert systems in the electronic medical record, and continuous electronic monitoring during use of patient-controlled analgesia (PCA) devices.
- Collect data on pain assessment and management, including type and efficacy of pain interventions and timing of reassessments and investigate potential misuse, including adverse events, use of high doses, and duration of opioid prescriptions and assist prescribers and pharmacists with access to Prescription Drug Monitoring Programs.
- Provide written and oral education to patients and caregivers on safe opioid use, including risks, side effects, potential for sedation, danger of use in combination with alcohol or sedating drugs, and safe storage and disposal at home.
- Establish clear procedures for evaluating and addressing suspected and identified instances of drug diversion.
Tools and resources
Download a copy of Premier’s Top 10 strategies for hospitals to prevent opioid-related adverse events.
Visit our opioid tools and resources section for Premier research, and opioid-related guidelines, checklists, toolkits, webinars and CE/CME education on safer opioid use in hospitals and outpatient/community settings