Shoshana J. Herzig
ORLANDO, Fla. — Opioid prescribing parallels the increased rate of opioid deaths, and opioid stewardship is just as important in hospital setting as it is in the outpatient setting, Shoshana J. Herzig, MD, MPH, said here at Hospital Medicine 2018.
More than half of patients hospitalized after surgery received opioids according to a nationwide data set, Herzig said. The work of Hillary J. Mosher, MFA, MD, indicated that “about 50% of inpatient opioid use is use continued from prior hospitalization and about 50% is new use.”
Physicians tend to prescribe in high doses, she said, noting that one study indicated that the average dose received was 68 mg. She also noted there is significant geographical variations in prescribing.
“Hospitals that prescribe opioids more frequently have higher rates of opioid-related adverse events,” she said.
“Why do we care about hospital prescribing?” she asked the audience. She said that 15% to 25% of patients who were opioid-naive prior to admission filled an opioid prescription in the week after discharge.
Because opioid stewardship requires standardization, the Society of Hospital Medicine convened a working group and issued a consensus statement.
The consensus statement has 16 core recommendations, and Herzig discussed a few during Hospital Medicine 2018.
First, prescribe the lowest effective dose for the shortest duration possible, she said. Also, consider nonopioid analgesics before prescribing opioids.
Use the oral route whenever possible because more rapid onset of action increases addiction potential, she said.
Use an opioid equivalency table or calculator, Herzig said.
“Most errors that occur in the hospital, occur during the prescribing phase,” she said. “When changing from one opioid to another, you often don’t realize that even after you do the equivalency calculation you need to decrease the dose by at least 50% from that calculated dose because there can be interindividual variability in the response to opioids and possible tolerance issues.”
Herzig also said the consensus statement recommends limiting prescription duration at discharge to 3 to 5 days. She said the three reasons to limit the duration include patients should be reexamined for the issues that required hospitalization; “receiving higher intensity therapy in the form of higher dosing is associated with long-term risk of disability”; and the public health effect of “massive quantities of unused opioids.”
Most of the opioids patients are sent home with go unused and “when you talk to patients who have misused opioids ... they are getting them from friends, either taking them unbeknownst from a friend or relative or buying them,” she said.
The full consensus statement can be found here. – by Joan-Marie Stiglich, ELS
Herzig S. Improving the safety of opioid prescribing for acute non-cancer pain in hospitalized adults: Consensus statement and RADEO. Presented at: Hospital Medicine 2018. April 9-11; Orlando, Fla.
Disclosure: Herzig reports no relevant financial disclosures.