Improving the Safety of Opioid Use for Acute Noncancer Pain in Hospitalized Adults: A Consensus Statement From the Society of Hospital Medicine
Hospital-based clinicians frequently treat acute, noncancer pain. Although opioids may be beneficial in this setting, the benefits must be balanced with the risks of adverse events, including inadvertent overdose and prolonged opioid use, physical dependence, or development of opioid use disorder. In an era of epidemic opioid use and related harms, the Society of Hospital Medicine (SHM) convened a working group to develop a consensus statement on opioid use for adults hospitalized with acute, noncancer pain, outside of the palliative, end-of-life, and intensive care settings. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants). To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines, composed a draft Statement based on extracted recommendations, and obtained feedback from external experts in hospital-based opioid prescribing, SHM members, the SHM Patient-Family Advisory Council, other professional societies, and peer-reviewers. The iterative development process resulted in a final Consensus Statement consisting of 16 recommendations covering 1) whether to use opioids in the hospital, 2) how to improve the safety of opioid use during hospitalization, and 3) how to improve the safety of opioid prescribing at hospital discharge. As most guideline recommendations from which the Consensus Statement was derived were based on expert opinion alone, the working group identified key issues for future research to support evidence-based practice.
© 2018 Society of Hospital Medicine
Since the initial reports of an emerging opioid epidemic in the early 2000s, intense focus on improving opioid prescribing in outpatient settings has culminated in new guidelines for chronic pain.1,2 Although opioid stewardship in the setting of chronic pain is of paramount importance in curbing the ongoing epidemic, long-term prescription opioid use often begins with treatment of acute pain.1 In addition to differences in recommended management strategies for acute and chronic pain, there are unique aspects and challenges to pain management in the acute-care setting.
Opioids are commonly used for the treatment of acute pain in hospitalized patients, often at high doses.3 Recent reports highlight that hospital use of opioids impacts downstream use.4-6 Additionally, opioid prescribing practices vary between hospital-based providers and hospitals,3,7 highlighting the need for prescribing standards and guidance. To our knowledge, there are no existing guidelines for improving the safety of opioid use in hospitalized patients outside of the intensive care or immediate perioperative settings.
The Society of Hospital Medicine (SHM) convened a working group to systematically review existing guidelines and develop a consensus statement to assist clinicians in safe opioid use for acute, noncancer pain in hospitalized adults.
Consensus Statement Purpose and Scope
The purpose of this Consensus Statement is to present clinical recommendations on the safe use of opioids for the treatment of acute, noncancer pain in hospitalized adults. The guidance is intended for clinicians practicing medicine in the inpatient setting (eg, hospitalists, primary care physicians, family physicians, nurse practitioners, and physician assistants) and is intended to apply to hospitalized adults with acute, noncancer pain (ie, pain that typically lasts <3 months or during the period of normal tissue healing) outside of the palliative, end-of-life, and intensive care settings.
Consensus Statement Development
Our working group included experts in opioid use in the hospital setting, defined by 1) engagement in the clinical practice of hospital medicine and 2) involvement in clinical research related to usage patterns and clinical outcomes of opioid use in hospitalized patients (see Appendix Table 1). The SHM provided administrative assistance with the project and funded the in-person working group meeting, but it had no role in formulating the recommendations. The SHM Board of Directors provided approval of the Consensus Statement without modification.
An overview of the sequential steps in the Consensus Statement development process is described below; details of the methods and results can be found in the Appendix (eMethods).
Performing the Systematic Review
Drafting the Consensus Statement
After performing the systematic review, the working group drafted and iteratively revised a set of recommendations using a variation of the Delphi Method8 to identify consensus among group members.
External Review
Following agreement on a draft set of recommendations, we obtained feedback from external groups, including 1) individuals involved in the SHM’s Reducing Adverse Drug Events Related to Opioids (RADEO) initiative, including those involved in the development of the implementation guide and site leads for the Mentored Implementation program, 2) SHM members, SHM Patient-Family Advisory Council (PFAC) members, and leaders of other relevant professional societies, and 3) peer-reviewers at the Journal of Hospital Medicine.
RESULTS
