The pain paradox
The desire to alleviate pain, as doctors are discovering, often has replaced one harm with another inadvertently. Perhaps the single largest contributing factor, Dr. Herzig said, is the subjectivity of pain and the difficulty in discerning whether a patient’s self-reporting can be trusted. “We want to relieve suffering,” she said, “but we also don’t want to give a patient a drug to which they may develop an addiction or to which they may already be addicted, and so therein lies the conundrum.”
Dr. Susan Calcaterra
Dr. Calcaterra said she and many other hospitalists struggle with the issue regularly. Most physicians are comfortable addressing a “very obvious source of pain,” such as trauma, heart attack, or surgery, she said. But treating more nebulous pain from chronic conditions or syndromes that lack clear supporting data can be tricky. Bridging the potential divide between patients’ understanding of how their pain might be managed and what options are realistically available, she noted, may depend upon establishing clear up-front expectations and effectively communicating the treatment plan and goals.
Some medical providers are also beginning to focus less on visual pain assessments and more on clinically meaningful functional improvements. “For example, instead of asking, ‘What level is your pain today?’ we might say, ‘Were you able to get up and work with physical therapy today?’ and ‘Were you able to get out of the bed to the chair while maintaining your pain at a tolerable level?’ ” Dr. Herzig said.
In addition, providers are recognizing that they should be clearer in telling patients that a complete absence of pain is not only unrealistic but also potentially harmful. “It takes time to have those discussions with patients, where you’re trying to explain to them, ‘Pain is the body’s way of telling you don’t do that, and you need to have some pain in order to know what your limitations are,’ ” Dr. Herzig said.
Dr. Shoshana Herzig
She strongly emphasized the importance of trying nonopioid analgesics first, especially given their superior effectiveness for certain types of pain. “And then, if you do go on to prescribe opioids, you should always pair them with nonopioid analgesics,” she said.
From talking with hospitalized patients, Dr. Mosher and her colleagues found that pain-related suffering can be manifested in or exacerbated by poor sleep or diet, boredom, physical discomfort, immobility, or inability to maintain comforting activities. In other words, how can the hospital improve sleeping conditions or address the understandable anxiety around health issues or being in a strange new environment and losing control? “One of the upsides of all this is that it may drive us to really think about, and make thoughtful investments in, changing the hospital to be a more therapeutic environment,” Dr. Mosher said.
Chronic use and discharge dilemmas
What about patients who already used opioids regularly before their hospital admission? In a 2014 study, Dr. Mosher and her colleagues found that among patients admitted to Veterans Affairs hospitals between 2009 and 2011, more than one in four were on chronic opioid therapy in the 6 months prior to their hospitalization.8 That subset of patients, the study suggested, was at greater risk for both 30-day readmission and death.
Determining whether an opioid prescription is appropriate or not, though, takes time. “Hospitalists are often terribly busy,” Dr. Mosher said. “There’s a lot of pressure to move people through the hospital. It’s a big ask to say, ‘How will hospitalists do what might be ideal?’ versus ‘What can we do?’ ” A workable solution, she said, may depend upon a cultural shift in recognizing that “pain is not something you measure by numbers,” but rather a part of a patient’s complex medical condition that may require consultations and coordination with specialists both within and beyond the hospital.
Sometimes, relatively simple questions can go a long way. When Dr. Mosher asks patients on opioids whether they help, she said, “I’ve had very few patients who will say it makes the pain go away.” Likewise, she contends that very few patients have been informed of potential side effects such as decreased muscle mass, osteoporosis, and endocrinopathy. Men on opioids can have a significant reduction in testosterone levels that negatively affects their sex life. When Dr. Mosher has talked to them about the downsides of long-term use, more than a few have requested her help in weaning them off the drugs.
If given the time to educate such patients and consider how their chronic pain and opioid use might be connected to the hospitalization, she said, “We can find opportunities to use that as a change moment.”
Discharging a patient with a well-considered opioid prescription can still present multiple challenges. The best-case scenario, Dr. Calcaterra said, is to coordinate a plan with the patient’s primary care provider. “A lot of patients that we take care of, though, don’t have a follow-up provider. They don’t have a primary care physician,” she said.
The opioid epidemic also has walloped many communities that lack sufficient resources for at-risk patients, whether it’s alternative pain therapy or a buprenorphine clinic. “If you look at access to medication-assisted therapies, the lights are out for a lot of America. There just isn’t access,” Dr. Mosher said. The limited options can set up a frustrating quandary: Hospitalists may be reluctant to wean patients off opioids and get them on buprenorphine if there’s no reliable resource to continue the therapy after a postdischarge handoff.
Until better safety nets and evidence-based protocols are woven together, hospitalists may need to make judgment calls based on their experience and available data and be creative in using existing resources to help their patients. Although electronic prescribing may help reduce the potential for tampering with a doctor’s script, Dr. Calcaterra said, diversion of opioid pills remains a “huge issue across the United States.” Several states now limit the amount of opioids that can be prescribed upon discharge, and hospitalists in many states can access prescription drug monitoring programs to determine whether patients are receiving opioids from other providers.
