White Coat Notes

Powerful painkillers widely used in hospitals for non-surgical patients

More than half of people hospitalized for medical reasons are given highly addictive prescription painkillers, often in large doses, according to Boston researchers who examined non-surgical treatment at 286 hospitals throughout the United States.

The study, led by researchers at Beth Israel Deaconess Medical Center, did not determine whether patients received the drugs unnecessarily. But it found that, in hospitals that prescribed the most opioids—medications such as morphine, fentanyl, or oxycodone—patients were more likely to overdose or suffer other errors related to the drugs.

“We need to take a closer look at opioid use in the hospital setting,” said Dr. Shoshana Herzig, lead author and a hospitalist at Beth Israel Deaconess.

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The study, published Wednesday in the Jouranl of Hospital Medicine, excluded people admitted to the hospital for surgery, who are commonly prescribed painkillers. Instead, the researchers looked at people being treated for medical conditions such as heart failure, pulmonary disease, pneumonia, or cancer. Those patients may or may not need pain management.

Herzig and other doctors were quick to point out that many do. But, the study found wide variation in the prescribing rates depending on where patients lived.

Overall, 51 percent of patients received opioids. In the Northeast, the rate was 40 percent, while 56 percent of patients in the West received them. That kind of regional variation often is a red flag for patient safety experts, because it may be due more to differences in hospital culture and standards of care than in patients’ needs.

The problem of hospital errors related to powerful painkillers is not a new one. A team of researchers led by Dr. David Bates, now senior vice president for safety at Brigham and Women’s Hospital, found in a 1995 study that 29 percent of all preventable adverse drug events were related to painkillers. That study, which evaluated admissions at two hospitals, included surgical patients.

“This is a topic that hasn’t gotten nearly enough attention,” said Dr. Ashish Jha, professor of health policy and management at Harvard School of Public Health. “It is not clear to me that hospitals have been doing very much in the past couple of decades, even though we’ve known about it.”

Doctors often think of opioid painkillers as relatively safe in the hospital, because patients there are closely monitored, Jha said. But he said these drugs, in addition to posing a risk of overdose,can make older patients in particular confused or unsteady, increasing the risk of falling or other problems. For a subset of patients, they can pose the long-term risk of addiction.

Most hospitals in the state participate in a voluntary federal program to track opioid prescribing and share educational resources, said Pat Noga, vice president of clinical affairs for the Massachusetts Hospital Association.

Dr. Kevin Hill, psychiatrist-in-charge of the drug abuse treatment program at McLean Hospital, said opioid painkillers can be dangerous, but he thinks doctors are mostly vigilant in their prescribing practices. The drugs “are probably more often used appropriately than not,” he said.

The US Centers for Disease Control and Prevention has called prescription painkiller abuse an epidemic. Overdose deaths from the drugs exceed those caused by heroin and cocaine combined.

The researchers were not able in this study to examine how many medical patients left the hospital with a prescription for an opioid. Instead, they found that 26 percent were administered the drug on the same day that they were discharged. Because the painkillers often are tapered rather than stopped immediately, Herzig said that figure provides a rough estimate of how many people might have left the hospital with a prescription.

The researchers also found that, among those people who received opioids, 43 percent were prescribed at least two different kinds, and nearly a quarter were prescribed at least 100 milligrams of morphine daily—which Herzig called “a whopping dose.”

There has been a push in recent years to make sure that patient pain is adequately treated. The Veterans Health Administration and others launched an effort in 1999 to have pain be considered the “fifth vital sign” monitored by caregivers and encouraged them to ask patients about their pain level on a scale of zero to 10.

Jha said, while the goal has been to get patients to zero, that might not be the right target. Doctors should have frank conversations with patients about the possible risks of opioids, how much pain they can tolerate, and other options, he said. For example, a patient who has been in bed for days and who has back pain may benefit more from receiving physical therapy than an opioid.

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