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Helicobacter Pylori Treatment is Associated with a Short-term Increase in the Risk of Neuropsychiatic Events
NEW YORK (Reuters Health) - Helicobacter pylori treatment containing clarithromycin is associated with a short-term increase in the risk of neuropsychiatric events, according to a study from Hong Kong.
Neuropsychiatric events following clarithromycin therapy have been reported previously, but no population-based study had assessed the neuropsychiatric risk associated with clarithromycin.
Dr. Esther W. Chan, from Li Ka Shing Faculty of Medicine, University of Hong Kong, and colleagues used data from the University of Hong Kong Clinical Data Analysis and Reporting System to investigate the association between H. pylori therapy containing clarithromycin and acute neuropsychiatric events.
Current use of clarithromycin as part of the H. pylori regimen was associated with a 4.12-fold increased risk of neuropsychiatric events, including a 5.42-fold increase in psychotic events and a 2.63-fold increase in cognitive impairment, compared with baseline.
These increased risks appear to be limited to days 2 to 14 since the prescription start date, according to the May 2 online report in JAMA Internal Medicine.
The crude absolute risks per 1000 prescriptions were 0.45 for neuropsychiatric events, 0.12 for psychotic events, and 0.12 for cognitive impairment during current use of therapy.
"Given the low absolute neuropsychiatric risk, an abrupt change in prescribing practice based on the observed increase in neuropsychiatric events is not suggested, particularly in the absence of better treatment alternatives," the researchers conclude.
"Such transient neuropsychiatric events will usually resolve spontaneously after treatment cessation and psychiatric interventions can be avoided," the authors note.
"Because we investigated H. pylori therapy as the exposure, we could not pinpoint which drug in the regimen contributed to the neuropsychiatric events in our study," they caution. "We hypothesized that clarithromycin is the most probable drug because very limited evidence suggested that neuropsychiatric
events are associated with amoxicillin or proton pump inhibitors."
Dr. Chan was unable to provide comments in time for publication.
The authors reported no funding or disclosures.
NEW YORK (Reuters Health) - Helicobacter pylori treatment containing clarithromycin is associated with a short-term increase in the risk of neuropsychiatric events, according to a study from Hong Kong.
Neuropsychiatric events following clarithromycin therapy have been reported previously, but no population-based study had assessed the neuropsychiatric risk associated with clarithromycin.
Dr. Esther W. Chan, from Li Ka Shing Faculty of Medicine, University of Hong Kong, and colleagues used data from the University of Hong Kong Clinical Data Analysis and Reporting System to investigate the association between H. pylori therapy containing clarithromycin and acute neuropsychiatric events.
Current use of clarithromycin as part of the H. pylori regimen was associated with a 4.12-fold increased risk of neuropsychiatric events, including a 5.42-fold increase in psychotic events and a 2.63-fold increase in cognitive impairment, compared with baseline.
These increased risks appear to be limited to days 2 to 14 since the prescription start date, according to the May 2 online report in JAMA Internal Medicine.
The crude absolute risks per 1000 prescriptions were 0.45 for neuropsychiatric events, 0.12 for psychotic events, and 0.12 for cognitive impairment during current use of therapy.
"Given the low absolute neuropsychiatric risk, an abrupt change in prescribing practice based on the observed increase in neuropsychiatric events is not suggested, particularly in the absence of better treatment alternatives," the researchers conclude.
"Such transient neuropsychiatric events will usually resolve spontaneously after treatment cessation and psychiatric interventions can be avoided," the authors note.
"Because we investigated H. pylori therapy as the exposure, we could not pinpoint which drug in the regimen contributed to the neuropsychiatric events in our study," they caution. "We hypothesized that clarithromycin is the most probable drug because very limited evidence suggested that neuropsychiatric
events are associated with amoxicillin or proton pump inhibitors."
Dr. Chan was unable to provide comments in time for publication.
The authors reported no funding or disclosures.
NEW YORK (Reuters Health) - Helicobacter pylori treatment containing clarithromycin is associated with a short-term increase in the risk of neuropsychiatric events, according to a study from Hong Kong.
Neuropsychiatric events following clarithromycin therapy have been reported previously, but no population-based study had assessed the neuropsychiatric risk associated with clarithromycin.
Dr. Esther W. Chan, from Li Ka Shing Faculty of Medicine, University of Hong Kong, and colleagues used data from the University of Hong Kong Clinical Data Analysis and Reporting System to investigate the association between H. pylori therapy containing clarithromycin and acute neuropsychiatric events.
Current use of clarithromycin as part of the H. pylori regimen was associated with a 4.12-fold increased risk of neuropsychiatric events, including a 5.42-fold increase in psychotic events and a 2.63-fold increase in cognitive impairment, compared with baseline.
These increased risks appear to be limited to days 2 to 14 since the prescription start date, according to the May 2 online report in JAMA Internal Medicine.
The crude absolute risks per 1000 prescriptions were 0.45 for neuropsychiatric events, 0.12 for psychotic events, and 0.12 for cognitive impairment during current use of therapy.
"Given the low absolute neuropsychiatric risk, an abrupt change in prescribing practice based on the observed increase in neuropsychiatric events is not suggested, particularly in the absence of better treatment alternatives," the researchers conclude.
"Such transient neuropsychiatric events will usually resolve spontaneously after treatment cessation and psychiatric interventions can be avoided," the authors note.
"Because we investigated H. pylori therapy as the exposure, we could not pinpoint which drug in the regimen contributed to the neuropsychiatric events in our study," they caution. "We hypothesized that clarithromycin is the most probable drug because very limited evidence suggested that neuropsychiatric
events are associated with amoxicillin or proton pump inhibitors."
Dr. Chan was unable to provide comments in time for publication.
The authors reported no funding or disclosures.
Group isolates Tregs to treat GVHD
Image by Kathryn T. Iacono
Researchers say they have devised a method for harvesting regulatory T cells (Tregs) on a large scale, and they are currently testing these Tregs in a trial of patients with graft-versus-host disease (GVHD).
The team described the harvesting method in the Journal of Immunotherapy.
“A Tregs-based therapy could help reduce the risk of GVHD, but Tregs are a very rare population amongst blood cells,” said study author Sebastian Bertin-Maghit, PhD, of the Agency for Science, Technology and Research (A*STAR) in Singapore.
“For our therapy to work, we needed a large supply of pure, ‘untouched’ Tregs that are uncontaminated with other cell types.”
However, when it came to isolating pure Tregs on a large scale, the researchers found existing isolation methods inefficient.
So rather than isolating the cells by “plucking” them out of a donor sample—a method that comes with the risk of unwanted modification or activation of some cells—the team devised a depletion method for selecting Tregs in their pure, untouched state.
“We depleted all unwanted cells in donor samples using isolation reagents,” Dr Bertin-Maghit said. “This allowed us to harvest Tregs in their natural state. We took great care to wash out the isolation reagents in the final product.”
The researchers have since proven that this single-step depletion process can be scaled up to harvest highly pure Tregs at levels suitable for clinical trials, and their procedure complies with current trial standards.
Furthermore, while previous attempts to collect Tregs produced a final product with 60% pure Tregs, this new method generates over 90% pure Tregs.
“The first clinical trial using our Treg product is currently ongoing at the Singapore General Hospital,” Dr Bertin-Maghit said. “We are assessing the safety of Tregs in the treatment of GVHD in 12 leukemia patients. We believe our procedure will open doors to a new era in cell therapy.” 
Image by Kathryn T. Iacono
Researchers say they have devised a method for harvesting regulatory T cells (Tregs) on a large scale, and they are currently testing these Tregs in a trial of patients with graft-versus-host disease (GVHD).
The team described the harvesting method in the Journal of Immunotherapy.
“A Tregs-based therapy could help reduce the risk of GVHD, but Tregs are a very rare population amongst blood cells,” said study author Sebastian Bertin-Maghit, PhD, of the Agency for Science, Technology and Research (A*STAR) in Singapore.
“For our therapy to work, we needed a large supply of pure, ‘untouched’ Tregs that are uncontaminated with other cell types.”
However, when it came to isolating pure Tregs on a large scale, the researchers found existing isolation methods inefficient.
So rather than isolating the cells by “plucking” them out of a donor sample—a method that comes with the risk of unwanted modification or activation of some cells—the team devised a depletion method for selecting Tregs in their pure, untouched state.
“We depleted all unwanted cells in donor samples using isolation reagents,” Dr Bertin-Maghit said. “This allowed us to harvest Tregs in their natural state. We took great care to wash out the isolation reagents in the final product.”
The researchers have since proven that this single-step depletion process can be scaled up to harvest highly pure Tregs at levels suitable for clinical trials, and their procedure complies with current trial standards.
Furthermore, while previous attempts to collect Tregs produced a final product with 60% pure Tregs, this new method generates over 90% pure Tregs.
“The first clinical trial using our Treg product is currently ongoing at the Singapore General Hospital,” Dr Bertin-Maghit said. “We are assessing the safety of Tregs in the treatment of GVHD in 12 leukemia patients. We believe our procedure will open doors to a new era in cell therapy.”
Image by Kathryn T. Iacono
Researchers say they have devised a method for harvesting regulatory T cells (Tregs) on a large scale, and they are currently testing these Tregs in a trial of patients with graft-versus-host disease (GVHD).
The team described the harvesting method in the Journal of Immunotherapy.
“A Tregs-based therapy could help reduce the risk of GVHD, but Tregs are a very rare population amongst blood cells,” said study author Sebastian Bertin-Maghit, PhD, of the Agency for Science, Technology and Research (A*STAR) in Singapore.
“For our therapy to work, we needed a large supply of pure, ‘untouched’ Tregs that are uncontaminated with other cell types.”
However, when it came to isolating pure Tregs on a large scale, the researchers found existing isolation methods inefficient.
So rather than isolating the cells by “plucking” them out of a donor sample—a method that comes with the risk of unwanted modification or activation of some cells—the team devised a depletion method for selecting Tregs in their pure, untouched state.
“We depleted all unwanted cells in donor samples using isolation reagents,” Dr Bertin-Maghit said. “This allowed us to harvest Tregs in their natural state. We took great care to wash out the isolation reagents in the final product.”
The researchers have since proven that this single-step depletion process can be scaled up to harvest highly pure Tregs at levels suitable for clinical trials, and their procedure complies with current trial standards.
Furthermore, while previous attempts to collect Tregs produced a final product with 60% pure Tregs, this new method generates over 90% pure Tregs.
“The first clinical trial using our Treg product is currently ongoing at the Singapore General Hospital,” Dr Bertin-Maghit said. “We are assessing the safety of Tregs in the treatment of GVHD in 12 leukemia patients. We believe our procedure will open doors to a new era in cell therapy.”
Warfarin indication, TTR linked to dementia risk
Photo courtesy of NIGMS
SAN FRANCISCO—Patients with atrial fibrillation (AF) who are on warfarin long-term have a higher risk of dementia than non-AF patients on long-term warfarin therapy, according to a new study.
The AF patients studied had higher rates of dementia, Alzheimer’s disease, and vascular dementia than their non-AF counterparts.
However, both groups of patients had a greater risk of dementia if they had lower percentages of time in therapeutic range (TTR).
“Our study results are the first to show that there are significant cognitive risk factors for patients treated with warfarin over a long period of time, regardless of the indication for anticoagulation,” said T. Jared Bunch, MD, of the Intermountain Medical Center Heart Institute in Salt Lake City, Utah.
Dr Bunch and his colleagues presented this research at the Heart Rhythm Society’s 37th Annual Scientific Sessions (abstract MP01-04).
The researchers enrolled 10,537 patients, age 18 and older, with no history of dementia prior to the study. They were receiving long-term warfarin for AF (n=4460), thromboembolism (n=5868), or mechanical heart valves (n=209).
The AF patients were older and had higher rates of hypertension, diabetes, heart failure, and stroke than the non-AF patients.
During a follow-up of approximately 7 years, the researchers found that all types of dementia increased in the AF group more than the non-AF group.
AF patients experienced higher rates of total dementia (5.8% vs 1.6%, P<0.0001), Alzheimer’s disease (2.8% vs 0.9%, P<0.0001), and vascular dementia (1.0% vs 0.2%, P<0.0001).
The researchers performed a propensity analysis of 6030 patients to account for the differences in baseline characteristics. And the risk of dementia remained significantly higher in AF patients than non-AF patients.
The hazard ratio (HR) was 2.42 for all types of dementia (P<0.0001), 2.04 for Alzheimer’s disease (P<0.0001), and 2.46 for senility (P<0.0001).
However, both AF and non-AF patients saw an increase in the risk of dementia if they had a low percent TTR.
In multivariate analysis, with the TTR >75% group as the reference, the HR for dementia in AF patients was:
- 1.30 for the 51%-75% TTR group (P=0.10)
- 1.57 for the 26%-50% TTR group (P=0.02)
- 1.92 for the ≤25% TTR group (P=0.005).
The HR for dementia in non-AF patients was:
- 1.57 for the 51%-75% TTR group (P=0.13)
- 2.69 for the 26%-50% TTR group (P=0.002)
- 3.87 for the ≤25% TTR group (P<0.0001).
Dr Bunch and his colleagues believe these findings have implications for treatment.
“First, as physicians, we have to understand that, although we need to use anticoagulants for many reasons, including to prevent stroke in AF patients, at that same time, there are risks that need to be considered, some of which we are only right now beginning to understand,” Dr Bunch said.
“In this regard, only those that absolutely need blood thinners should be placed on them long-term. Second, other medications like aspirin that may increase the blood thinner’s effect should be avoided unless there is a specific medical need. Finally, in people that are on warfarin in which the levels are erratic or difficult to control, switching to newer agents that are more predictable may lower risk.”
Photo courtesy of NIGMS
SAN FRANCISCO—Patients with atrial fibrillation (AF) who are on warfarin long-term have a higher risk of dementia than non-AF patients on long-term warfarin therapy, according to a new study.
The AF patients studied had higher rates of dementia, Alzheimer’s disease, and vascular dementia than their non-AF counterparts.
However, both groups of patients had a greater risk of dementia if they had lower percentages of time in therapeutic range (TTR).
“Our study results are the first to show that there are significant cognitive risk factors for patients treated with warfarin over a long period of time, regardless of the indication for anticoagulation,” said T. Jared Bunch, MD, of the Intermountain Medical Center Heart Institute in Salt Lake City, Utah.
Dr Bunch and his colleagues presented this research at the Heart Rhythm Society’s 37th Annual Scientific Sessions (abstract MP01-04).
The researchers enrolled 10,537 patients, age 18 and older, with no history of dementia prior to the study. They were receiving long-term warfarin for AF (n=4460), thromboembolism (n=5868), or mechanical heart valves (n=209).
The AF patients were older and had higher rates of hypertension, diabetes, heart failure, and stroke than the non-AF patients.
During a follow-up of approximately 7 years, the researchers found that all types of dementia increased in the AF group more than the non-AF group.
AF patients experienced higher rates of total dementia (5.8% vs 1.6%, P<0.0001), Alzheimer’s disease (2.8% vs 0.9%, P<0.0001), and vascular dementia (1.0% vs 0.2%, P<0.0001).
The researchers performed a propensity analysis of 6030 patients to account for the differences in baseline characteristics. And the risk of dementia remained significantly higher in AF patients than non-AF patients.
The hazard ratio (HR) was 2.42 for all types of dementia (P<0.0001), 2.04 for Alzheimer’s disease (P<0.0001), and 2.46 for senility (P<0.0001).
However, both AF and non-AF patients saw an increase in the risk of dementia if they had a low percent TTR.
In multivariate analysis, with the TTR >75% group as the reference, the HR for dementia in AF patients was:
- 1.30 for the 51%-75% TTR group (P=0.10)
- 1.57 for the 26%-50% TTR group (P=0.02)
- 1.92 for the ≤25% TTR group (P=0.005).
The HR for dementia in non-AF patients was:
- 1.57 for the 51%-75% TTR group (P=0.13)
- 2.69 for the 26%-50% TTR group (P=0.002)
- 3.87 for the ≤25% TTR group (P<0.0001).
Dr Bunch and his colleagues believe these findings have implications for treatment.
“First, as physicians, we have to understand that, although we need to use anticoagulants for many reasons, including to prevent stroke in AF patients, at that same time, there are risks that need to be considered, some of which we are only right now beginning to understand,” Dr Bunch said.
“In this regard, only those that absolutely need blood thinners should be placed on them long-term. Second, other medications like aspirin that may increase the blood thinner’s effect should be avoided unless there is a specific medical need. Finally, in people that are on warfarin in which the levels are erratic or difficult to control, switching to newer agents that are more predictable may lower risk.”
Photo courtesy of NIGMS
SAN FRANCISCO—Patients with atrial fibrillation (AF) who are on warfarin long-term have a higher risk of dementia than non-AF patients on long-term warfarin therapy, according to a new study.
The AF patients studied had higher rates of dementia, Alzheimer’s disease, and vascular dementia than their non-AF counterparts.
However, both groups of patients had a greater risk of dementia if they had lower percentages of time in therapeutic range (TTR).
“Our study results are the first to show that there are significant cognitive risk factors for patients treated with warfarin over a long period of time, regardless of the indication for anticoagulation,” said T. Jared Bunch, MD, of the Intermountain Medical Center Heart Institute in Salt Lake City, Utah.
Dr Bunch and his colleagues presented this research at the Heart Rhythm Society’s 37th Annual Scientific Sessions (abstract MP01-04).
The researchers enrolled 10,537 patients, age 18 and older, with no history of dementia prior to the study. They were receiving long-term warfarin for AF (n=4460), thromboembolism (n=5868), or mechanical heart valves (n=209).
The AF patients were older and had higher rates of hypertension, diabetes, heart failure, and stroke than the non-AF patients.
During a follow-up of approximately 7 years, the researchers found that all types of dementia increased in the AF group more than the non-AF group.
AF patients experienced higher rates of total dementia (5.8% vs 1.6%, P<0.0001), Alzheimer’s disease (2.8% vs 0.9%, P<0.0001), and vascular dementia (1.0% vs 0.2%, P<0.0001).
The researchers performed a propensity analysis of 6030 patients to account for the differences in baseline characteristics. And the risk of dementia remained significantly higher in AF patients than non-AF patients.
The hazard ratio (HR) was 2.42 for all types of dementia (P<0.0001), 2.04 for Alzheimer’s disease (P<0.0001), and 2.46 for senility (P<0.0001).
However, both AF and non-AF patients saw an increase in the risk of dementia if they had a low percent TTR.
In multivariate analysis, with the TTR >75% group as the reference, the HR for dementia in AF patients was:
- 1.30 for the 51%-75% TTR group (P=0.10)
- 1.57 for the 26%-50% TTR group (P=0.02)
- 1.92 for the ≤25% TTR group (P=0.005).
The HR for dementia in non-AF patients was:
- 1.57 for the 51%-75% TTR group (P=0.13)
- 2.69 for the 26%-50% TTR group (P=0.002)
- 3.87 for the ≤25% TTR group (P<0.0001).
Dr Bunch and his colleagues believe these findings have implications for treatment.
“First, as physicians, we have to understand that, although we need to use anticoagulants for many reasons, including to prevent stroke in AF patients, at that same time, there are risks that need to be considered, some of which we are only right now beginning to understand,” Dr Bunch said.
“In this regard, only those that absolutely need blood thinners should be placed on them long-term. Second, other medications like aspirin that may increase the blood thinner’s effect should be avoided unless there is a specific medical need. Finally, in people that are on warfarin in which the levels are erratic or difficult to control, switching to newer agents that are more predictable may lower risk.”
E-cigarettes fuel increase in nicotine exposures in young children
The incidence of exposure to nicotine and tobacco products in children less than 6 years old increased significantly from 2012 to 2015, according to Alisha Kamboj and her associates.
From January 2012 to April 2015, the National Poison Data System received 29,141 reports of nicotine and tobacco product exposure in children under 6 years of age, averaging 729 children per month. The annual rate of exposure increased from 3.0/100,000 children in 2012 to 4.2/100,000 in 2014. A dramatic increase in exposure to e-cigarettes drove the overall increase, with monthly reports of e-cigarette use rising nearly 1,500% from January 2012 to April 2015.
Nearly 80% of children exposed were younger than 2 years old, and the median age of exposed children was 1.1 years. Children younger than 2 accounted for 44.1% of e-cigarette exposures, 91.6% of cigarette exposures, and 75.4% of exposures to other tobacco products, the investigators noted.
Children exposed to e-cigarettes were significantly more likely to be admitted to a health care facility and to have severe outcomes than were children exposed to cigarettes, with odds ratios of 5.19 and 2.6, respectively. One death – of a 1-year-old child – was associated with nicotine liquid.
“Educating child caregivers about potential clinical effects and outcomes associated with nicotine exposure may help motivate adoption of safety behaviors and aid in identification of symptoms in the event of an exposure. Adults in households with children [younger than] 6 years should be counseled on vaping cessation and strongly encouraged not to use or store e-cigarettes, e-liquid, and related products in the home,” the investigators recommended.
Find the full study in Pediatrics (doi: 10.1542/peds.2016-0041).
The incidence of exposure to nicotine and tobacco products in children less than 6 years old increased significantly from 2012 to 2015, according to Alisha Kamboj and her associates.
From January 2012 to April 2015, the National Poison Data System received 29,141 reports of nicotine and tobacco product exposure in children under 6 years of age, averaging 729 children per month. The annual rate of exposure increased from 3.0/100,000 children in 2012 to 4.2/100,000 in 2014. A dramatic increase in exposure to e-cigarettes drove the overall increase, with monthly reports of e-cigarette use rising nearly 1,500% from January 2012 to April 2015.
Nearly 80% of children exposed were younger than 2 years old, and the median age of exposed children was 1.1 years. Children younger than 2 accounted for 44.1% of e-cigarette exposures, 91.6% of cigarette exposures, and 75.4% of exposures to other tobacco products, the investigators noted.
Children exposed to e-cigarettes were significantly more likely to be admitted to a health care facility and to have severe outcomes than were children exposed to cigarettes, with odds ratios of 5.19 and 2.6, respectively. One death – of a 1-year-old child – was associated with nicotine liquid.
“Educating child caregivers about potential clinical effects and outcomes associated with nicotine exposure may help motivate adoption of safety behaviors and aid in identification of symptoms in the event of an exposure. Adults in households with children [younger than] 6 years should be counseled on vaping cessation and strongly encouraged not to use or store e-cigarettes, e-liquid, and related products in the home,” the investigators recommended.
Find the full study in Pediatrics (doi: 10.1542/peds.2016-0041).
The incidence of exposure to nicotine and tobacco products in children less than 6 years old increased significantly from 2012 to 2015, according to Alisha Kamboj and her associates.
From January 2012 to April 2015, the National Poison Data System received 29,141 reports of nicotine and tobacco product exposure in children under 6 years of age, averaging 729 children per month. The annual rate of exposure increased from 3.0/100,000 children in 2012 to 4.2/100,000 in 2014. A dramatic increase in exposure to e-cigarettes drove the overall increase, with monthly reports of e-cigarette use rising nearly 1,500% from January 2012 to April 2015.
Nearly 80% of children exposed were younger than 2 years old, and the median age of exposed children was 1.1 years. Children younger than 2 accounted for 44.1% of e-cigarette exposures, 91.6% of cigarette exposures, and 75.4% of exposures to other tobacco products, the investigators noted.
Children exposed to e-cigarettes were significantly more likely to be admitted to a health care facility and to have severe outcomes than were children exposed to cigarettes, with odds ratios of 5.19 and 2.6, respectively. One death – of a 1-year-old child – was associated with nicotine liquid.
“Educating child caregivers about potential clinical effects and outcomes associated with nicotine exposure may help motivate adoption of safety behaviors and aid in identification of symptoms in the event of an exposure. Adults in households with children [younger than] 6 years should be counseled on vaping cessation and strongly encouraged not to use or store e-cigarettes, e-liquid, and related products in the home,” the investigators recommended.
Find the full study in Pediatrics (doi: 10.1542/peds.2016-0041).
FROM PEDIATRICS
Inpatient Opioid Prescribing
Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.
Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.
In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.
At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.
This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.
There are several important implications arising from each of these 3 identified emergent themes.
First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.
Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.
Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.
In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.
Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.
- , . Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31(6):506–511.
- . A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363(21):1981–1985.
- , , . CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.
- , , , , . Opioid utilization and opioid‐related adverse events in nonsurgical patients in US hospitals. J Hosp Med. 2014;9(2):73–81.
- , , , , , . Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478–485.
- , , , et al. The hospitalist perspective on opioid prescribing: a qualitative analysis. J Hosp Med. 2016;11(8):536–542.
- The Joint Commission. Facts about pain management. Available at: http://www.jointcommission.org/pain_management. Accessed April 3, 2016.
- Drug Enforcement Administration, Department of Justice. Electronic prescriptions for controlled substances. Available at: http://www.deadiversion.usdoj.gov/fed_regs/rules/2010/fr0331.htm. Published March 31, 2010. Accessed April 3, 2016.
Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.
Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.
In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.
At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.
This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.
There are several important implications arising from each of these 3 identified emergent themes.
First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.
Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.
Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.
In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.
Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.
Since initial reports describing an emerging opioid epidemic in the early 2000s,[1] we have seen a flurry of studies characterizing the scope and impact of the problem and calling for actions to stem the rising tide.[2] However, most of these studies, even the recently issued Centers for Disease Control and Prevention (CDC) guidelines, have focused on the outpatient setting,[3] rendering the inpatient setting somewhat of an opioid prescribing black box.
Recently, however, several studies have highlighted both the scope and downstream impact of opioid prescribing in the inpatient setting. We now know that more than half of hospitalized patients in the United States are exposed to opioid medications during their hospitalization,[4] the majority of which are new initiations in patients without opioid receipt in the year preceding their hospitalization.[5] Among opioid nave patients admitted to the hospital, one‐quarter go on to receive a script for an opioid in the 72 hours after hospital discharge, and 4% have ongoing use 1 year after discharge.[5] Although this may seem like a relatively small percentage, when you consider that there are about 40 million discharges from US medical centers each year, the majority of which are opioid nave prior to hospitalization, this becomes a large absolute number. Taken together, these studies suggest that inpatient prescribing contributes substantially to more chronic opioid use. Accordingly, reigning in inpatient prescribing may be a crucial step in curbing the opioid epidemic as a whole.
In this issue of the Journal of Hospital Medicine, Calcaterra et al.,[6] in a qualitative analysis of hospitalist perceptions of opioid prescribing, draw attention to the bidirectional pull exerted on physicians by the need to adequately treat pain as mandated by the Joint Commission,[7] while minimizing exposure to medications fraught with a wide array of adverse effects, ranging from constipation to addiction to death. What often ensues is a haphazardly choreographed negotiation between 2 parties, 1 of which, in the setting of addiction, may not know what is best for him/herself, and the other of which is caught between the desire to relieve suffering and the desire to do no harm.
At the center of all this is the fact that pain itself is a nebulous concept, defined and experienced in a multitude of different ways by different people and cultures. For some, there is no distinction between psychological and physical pain. Without sufficient objective measures of pain, we must rely on the patient to convey their degree of suffering, and then use our clinical judgment to decide whether pain is severe enough and risks are low enough to use medications with physiological effects that are identical to heroin.
This study adds important information to the opioid prescribing equation, in that understanding the drivers of physician decision making in this realm is an important prelude to developing strategies that effectively promote more standardized and appropriate opioid prescribing. This is the first study to specifically investigate perceptions of hospitalists. Although their study involved only 25 hospitalists, raising questions of validity and generalizability, as a practicing hospitalist, I anticipate that their findings will resonate widely with other hospitalists across the country. First, although the hospitalists in their study were generally comfortable using opioids for acute pain, they found managing acute pain exacerbations in patients with chronic pain more challenging. Second, negative prior experiences related to opioid prescribing strongly inform future prescribing. Third, opioids are often used as a tool to facilitate discharges and prevent readmissions.
There are several important implications arising from each of these 3 identified emergent themes.
First, although hospitalists felt generally comfortable in prescribing opioids for acute pain in patients not on chronic opioids, in reality, prescribing opioids for acute pain, even in opioid nave patients, is neither straightforward nor done safely. It is important we recognize that our prescribing practices as hospitalists, even for acute pain in opioid nave patients, contribute to adverse events, and promote and propagate addiction. We can do better. Akin to the recent CDC guidelines,[3] prescribing guidelines specifically directed at the hospital setting are necessary. An effective set of guidelines would both promote more standardized and safer prescribing practices, as well as provide support for physician decision making in this realm. Such guidelines would help provide ground rules and a framework from which physicians could draw during those challenging discussions with patients suffering from chronic pain.
Second, many of the negative prior experiences described by the hospitalists in this study as shaping future behavior could have been avoided with enhanced, system‐wide safety measures directed at each of the steps in the medication use continuum, from prescribing to administration. For example, mandatory use of electronic prescribing of controlled substances can prevent patients from tampering with prescriptions.[8] Monitored ingestion can prevent misuse and diversion. Additional safety measures that should be widely adopted in the inpatient setting include integration and mandatory review of the State Prescription Drug Monitoring Program when prescribing opioids on admission and discharge, and clinical decision support to promote safe prescribing decisions related to dose, route, and monitoring practices. Incorporation of these and other safety measures in a systematic way will ultimately improve the experience and outcomes for both patients and physicians.
Finally, opioids are used as a tool to facilitate discharge, in part because it is much harder to discuss a decision not to prescribe opioids with a patient expressing suffering than it is to just provide a limited supply and get them back to their longitudinal provider. Physicians often lack the vocabulary necessary to effectively navigate such discussions. We need to make these discussions easier, through physician education and training regarding how to speak to patients about pain management. A shared, standard vocabulary specific to the inpatient setting should be developed and disseminated for discussing with patients (1) expectations related to pain management, (2) potential benefits and risks of opioids, (3) concerns over addiction, and (4) discontinuing/tapering opioids.
In conclusion, if we are to effectively curb the opioid epidemic, the inpatient setting cannot remain a black box. Standardizing opioid prescribing in the hospital will require a concerted effort by hospitalists and other physicians, nurses, pharmacists, and regulatory bodies, with important input from patients as well as longitudinal providers in the outpatient setting, to assure appropriate navigation during transitions of care. Together, we can turn haphazard negotiation into coordinated comanagement, ultimately promoting individual and public health.
Disclosures: Dr. Herzig was funded by grant number K23AG042459 from the National Institute on Aging. The article contents are solely the responsibility of the author and do not necessarily represent the views of the funding organization. Dr. Herzig has no conflicts to disclose.
- , . Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31(6):506–511.
- . A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363(21):1981–1985.
- , , . CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.
- , , , , . Opioid utilization and opioid‐related adverse events in nonsurgical patients in US hospitals. J Hosp Med. 2014;9(2):73–81.
- , , , , , . Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478–485.
- , , , et al. The hospitalist perspective on opioid prescribing: a qualitative analysis. J Hosp Med. 2016;11(8):536–542.
- The Joint Commission. Facts about pain management. Available at: http://www.jointcommission.org/pain_management. Accessed April 3, 2016.
- Drug Enforcement Administration, Department of Justice. Electronic prescriptions for controlled substances. Available at: http://www.deadiversion.usdoj.gov/fed_regs/rules/2010/fr0331.htm. Published March 31, 2010. Accessed April 3, 2016.
- , . Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31(6):506–511.
- . A flood of opioids, a rising tide of deaths. N Engl J Med. 2010;363(21):1981–1985.
- , , . CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–1645.
- , , , , . Opioid utilization and opioid‐related adverse events in nonsurgical patients in US hospitals. J Hosp Med. 2014;9(2):73–81.
- , , , , , . Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478–485.
- , , , et al. The hospitalist perspective on opioid prescribing: a qualitative analysis. J Hosp Med. 2016;11(8):536–542.
- The Joint Commission. Facts about pain management. Available at: http://www.jointcommission.org/pain_management. Accessed April 3, 2016.
- Drug Enforcement Administration, Department of Justice. Electronic prescriptions for controlled substances. Available at: http://www.deadiversion.usdoj.gov/fed_regs/rules/2010/fr0331.htm. Published March 31, 2010. Accessed April 3, 2016.
Perspective on Opioid Prescribing
Pain is a frequent symptom among patients seen in the hospital.[1, 2, 3] Hospitalized patients often suffer before they come to the hospital and are commonly prescribed opioids in the months preceding their hospital stay.[4] Adequate pain control is important because uncontrolled pain is associated with higher levels of depression and anxiety among hospitalized patients.[5] In 2011, the Institute of Medicine called on healthcare providers to improve pain assessment and management in healthcare delivery.[6] Since then, pain management has become a key quality indicator for hospitals, and providers are encouraged to frequently assess and treat pain.[7, 8, 9, 10] Although the use of opioids for pain management among hospitalized patients is routine, the amount of opioids prescribed per patient varies widely between institutions.[11] In‐hospital guidelines for the optimal management of acute exacerbations of chronic pain are lacking.
Pain management also carries risks. Recently, the Centers for Disease Control and Prevention urged clinicians to prevent opioid overdoses by following best prescribing practices including screening patients for substance use disorders, mental health issues, and avoiding combinations of opioids and sedatives.[12, 13] These guidelines may be at odds with the priorities of current hospital care, which focus on patient‐perceived pain control rather than potential long‐term consequences of opioid use.[7, 8, 14] In light of the competing demands to provide adequate pain relief to hospitalized patients while optimally prescribing opioids, we sought to understand physicians' attitudes, beliefs, and experiences that inform opioid prescribing practices during hospitalization and at discharge.
METHODS
Study Design, Setting, and Participants
Between January 2015 and August 2015, we recruited a convenience sample via e‐mail solicitation from approximately 135 hospitalists practicing in Colorado and South Carolina.[15] Fifty‐three physicians responded. We conducted 25 in‐depth, semistructured interviews with physicians who represented the average hospitalist practicing in the United States in terms of years in practice and gender.[16] We enrolled physicians working in 4 distinct types of hospital settings, including 2 university hospitals, a safety‐net hospital, a Veterans Affairs hospital, and a private hospital. We used purposive sampling to achieve an even distribution with respect to gender and years in practice.[17] Interviews were either face‐to‐face (n = 16) or over the telephone (n = 9) and were performed outside of the physician's clinical shift. Informed consent was obtained from study participants, and the interview duration was approximately 1 hour. The study was approved by the Colorado Multiple Institutional Review Board.
Interview Guide Development and Content
Members of our multidisciplinary team (S.L.C., I.A.B., S.K.) developed an interview guide designed to explore hospitalists' attitudes and practices about opioid prescribing during hospitalization and at discharge (see Supporting Information, Appendix 1, in the online version of this article). Initial interview questions were developed with input from health sciences researchers (S.E.L., A.D.D., R.D.) and qualitative researchers (I.A.B., S.K.). During data collection, we occasionally edited or added questions to our guide to more fully explore new issues or information emerging from our interviews. Through open‐ended interviews, we sought to capture a qualitative narrative in which hospitalists would describe their attitudes and practices that may influence opioid prescribing within 3 major domains pertinent to clinical practice: patient factors,[18, 19, 20, 21, 22, 23] physician factors,[24, 25, 26, 27] and institutional factors.[27, 28, 29, 30, 31, 32] These domains were based on prior literature. All participants received a $25 gift card.
Data Analysis
Interview transcripts and a demographic survey were our primary data sources. Transcript files were entered into qualitative data analysis software (ATLAS.ti; Scientific Software Development GmbH, Berlin, Germany). We used a mixed inductive and deductive,[33] participatory, team‐based approach to explore patterns and themes related to attitudes and practices around opioid prescribing.[34, 35] A deductive or top‐down approach was used to link text to predefined codes and categories based on literature, prior knowledge, and our interview guide. An inductive or bottom‐up approach was used to identify new codes and categories that emerged from the data, including unanticipated information relevant to our research questions.
Team members included 2 hospitalists (S.L.C., A.D.D.), 2 research assistants with experience in qualitative methods (S.E.L., R.D.), an addiction medicine physician and researcher (I.A.B.), and a medical anthropologist (S.K.). S.L.C. performed initial coding using an a priori template that reflected the primary areas of interest in the study. The codes were categorized as patient, physician, and institutional factors. Using this template as a guide, 3 other team members (S.E.L., A.D.D., R.D.) independently coded 3 transcripts by assigning predefined codes to text and assigning new codes to emergent findings. Using this subset of 4 transcripts, the team reached a consensus on initial codes to be applied to the remaining transcripts. In weekly meetings, team members discussed and modified the codebook based on inconsistencies noted among team members to refine the coding scheme and to ensure consensus. Through group consensus, codes were condensed into a list of categories, subcategories, and emergent themes (ie, themes that did not originate from summarized answers to specific interview questions). The team identified emergent themes represented across all major domains (Table 1). Three of the most prevalent themes representing physicians' personal opioid prescribing practices are reported here. The study team determined that thematic saturation was reached after 25 interviews, as additional interview data created little change to the codebook and no new patterns or themes emerged.
|
| Perceived success, satisfaction, comfort, and the use of opioids for pain management* |
| Professional experiences influenced opioid prescribing practices* |
| The use of opioids to improve efficiency* |
| Skepticism between other physician subspecialty types and opioid prescribing practices |
| Unintended consequences of patient‐perceived pain control metrics and opioid prescribing |
| Lack of trust with patients when reported pain level was not supported with objective data |
| Resident burnout contributed to a lack of empathy and undertreatment of pain |
| Limited perceived risk of personal opioid prescribing practices and patient overdose with short‐acting opioids |
| Unreal expectations by patients to have complete pain eradication contributes to overprescribing |
| Recognition that patient profiling impacts personal opioid‐prescribing practices |
RESULTS
Of the 25 hospitalist participants who were all trained in internal medicine, 16 (64%) were women. The majority were non‐Hispanic white (21 [84%]). Nine physicians (36%) completed residency within the past 5 years, 12 (48%) completed residency within the past 5 to 10 years, and 4 (16%) completed residency >10 years ago. Sixteen (64%) hospitalists practiced medicine in Colorado, where 8 (32%) worked in a safety‐net hospital, 5 (20%) worked in a university hospital, and 3 (12%) worked in a Veterans Affairs hospital. Nine hospitalists (36%) practiced in South Carolina, where 2 (8%) worked in a university hospital and 7 (28%) worked in a private hospital (Table 2).
| Female, no. (%) | 16 (64) |
| Race/ethnicity, no. (%) | |
| White, non‐Hispanic | 21 (84) |
| Asian, non‐Hispanic | 4 (16) |
| Years postresidency, no. (%) | |
| <5 | 9 (36) |
| 510 | 12 (48) |
| >10 | 4 (16) |
| State of practice, no. (%) | |
| Colorado | 16 (64) |
| South Carolina | 9 (36) |
| Private hospital, no. (%) | 7 (28) |
| Academic institution, no. (%) | |
| Safety‐net hospital | 8 (32) |
| Veteran Affairs hospital | 3 (12) |
| University hospital | 7 (28) |
Emergent themes described here include: (1) hospitalists' perceived success, satisfaction, and comfort when prescribing opioids for their patients' pain management; (2) the influence of physicians' professional sentinel experiences on opioid prescribing practices; and (3) opioid prescribing as a tool to improve efficiency in the hospital. Additional quotations to support emergent themes are listed in Table 3.
| Theme | Illustrative Quote |
|---|---|
| |
| Perceived success, satisfaction, comfort, and the use of opioids for pain management | Acute pain: I'm more comfortable treating acute pain. With chronic pain, it depends on the circumstance. There are certain people who have objective reasons to have chronic pain, for instance they have severe degenerate disc disease, for example. With chronic painlet me just say, getting their pain under control is quite challenging. Acute pain is much more straight forward to treat. |
| Chronic pain; If I am treating an exacerbation of someone's chronic pain, it makes me a little less comfortable as far as sending people out on large doses of opioids because of the whole addiction thought behind it. And you don't want to start or feed people's addiction. Or, you know, lead them to it, in the future, requiring increased doses of opioids. | |
| Chronic pain: I have a hard time feeling like I'm very successful with people who have chronic noncancer pain who come in for an exacerbation. Unless I can figure out clear reasons for that exacerbation, I feel I rarely succeed in having the patient, the providers, and the caregivers be happy. It is an unrewarding situation all around. | |
| Chronic pain: I'm less comfortable treating chronic pain because we don't know the patients as well, I think, in the hospital, and you just worry about people abusing the system to get their needs met while they are in the hospital. We don't have much objective data in terms of assessing pain, and you know, they are on chronic narcotics, you don't really know what to believe, I guess. | |
| Professional experiences that influenced opioid prescribing practices | In the hospital: I had 1 horrible experience. I had a young woman who came in with chronic abdominal pain. She told me how much opioids she took. It was before there was a statewide database and I couldn't verify her doses. I gave her what she told me she was taking. I hadn't put a pulse ox on her which I always do now because it makes me feel better. Later the nurse called and said she wasn't responsive. I put her on Pulse Ox and she was sating 30% and blue. A code was called and we brought her back. That was in my mind for ever, I almost killed a 23 year old. |
| In the hospital: I think past experiences inform what I do now. I mean it's not that I've murdered anybody, but there was a time when I took over a patient and didn't realize that, while she had terrible pain from her restless leg syndrome, she also had severe pulmonary hypertension. I gave her 5 mg of oxycodone. She ended up somnolent with hypercarbic respiratory failure. I think that is something that will always stick in my head. | |
| Discharge: When discussing what type of opioids prescribed at dischargeI worry about, not just deliberate diversion, but for the patient being robbed, for the type of opioid I might choose. So I might do oxycodone instead of Percocet. Percocet, itself, has a higher street value then oxycodone. That may be completely false, but I think of it as a name brand that people want. | |
| Discharge: I think many providers, including myself, try to minimize the use of opiates when we can. I think we are all concerned every time we write, you know, our DEA #. Even when we have other providers ask us, you know, to prescribe opioids for their patients because they are out of the hospital or something like that, it is always a touchy subject. Because I think we all feel like our license is always at risk every time we are writing opioids. | |
| Discharge: I give them what they need but I want them to be seen in follow‐up. I encourage that by giving them a shortened course. I'm more skeptical. I've seen people misuse, have bad side effects, and overdose on opioids. I worry about that, so I tend to prescribe shorter courses and less. | |
| The use of opioids to improve efficiency | There is always the group of patients [for whom] we've done everything we can. We set up follow‐up. If giving you a few days of Percocet is going to help you leave the hospital comfortably and stay out of the hospital for appropriate reasons, then we give them a few days. It's horrible but... |
| I'll give 4 or 6 weeks' worth of opioid medication to the chronic abdominal pain patients, the ones who have ERCPs scheduled for every 4 or 6 weeks. You sort of end up managing their chronic pain. It's the people that we know. If you don't give them a month's worth of pain meds, they are going to come back in to the hospital. Because they always come in when they run out. | |
| I think physicians overprescribe opioids because we don't want people to bounce back to the hospital. We don't want them to have acute pain at home and have to go back to the ER to be readmitted. You don't want someone to be in pain. I think that sometimes people go overboard. I also think that sometimes physicians gauge like, oh, this person isn't a huge risk, and maybe give them more opioids than necessary. | |
Perceived Success, Satisfaction, and Comfort When Prescribing Opioids for Pain Management
Providing adequate pain control to their patients was of utmost importance to hospitalists and influenced opioid prescribing. Hospitalists felt confident in their ability to control acute pain using opioids, but notably perceived limited success in achieving adequate patient‐perceived pain control when treating acute exacerbations of chronic pain with opioids. A physician described his confidence in treating severe, acute pain:
If someone is dying of cancer, or if they have an acutely broken femur, I don't really care if they are actively in the 12‐Step Program or Narcotics Anonymous to stay sober. That pain is real and there is no effective pain medicine on earth except for opioids.
[I am uncomfortable treating] people that you classify with chronic pain syndrome. There is that terminology you use for people who have subjective pain, out of proportion to objective findings. In my experience it is a black hole. You never get an adequate level of pain control and you keep adding the doses up and they get habituated. An end point is very difficult to achieve. Not like with acute pain.
All of these things you do for patient satisfaction set up people, who aren't ever going to be without pain, to fail. They have pain all the time, and now you are asking them about their pain. Well, of course their pain is not controlled, because their pain is never going to be less than 5 out of 10, period. And no opioid is going to get them there, unless they are unconscious.
Professional Experiences Influenced Opioid Prescribing Practices
Physicians reported little opioid‐specific training during residency, and so opioid prescribing practices were shaped by the physicians' clinical experiences. Hospitalists reflected on negative, sentinel events that shaped their opioid prescribing practices in the inpatient setting or led them to adopt risk‐modifying behaviors when prescribing opioids at hospital discharge. Negative experiences varied and included a fatal overdose and suspected diversion of opioids for sale. A physician reflected on an avoidable in‐hospital overdose which left her more guarded when prescribing opioids:
It is both your cumulative experience and, sometimes, when you've had a negative experience, it really biases how you think. I've had an experience where my patient actually overdosed. She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died. We've all had experiences with opioids being abused. This just happened to be a very dramatic thing that happened right under my nose. It just makes me more guarded, in terms of my practice, and the lengths people will go through to do harm to themselves with opioids.
Hospitalists recognized that some of their patients had limited resources. They expressed suspicions that opioid prescriptions, in some cases, represented a form of currency for patients to supplement their income. A physician stated:
I think our population can divert quite a few meds. I think their financial situations can be really tenuous. Sometimes they sell pills to survive.
Physicians described past experiences with patients who were deceptive to get an opioid prescription, which left them much more reticent to prescribe the drugs. For example, a physician described how a patient altered her opioid prescription following hospital discharge:
I saw a patient who had her gallbladder removed. She asked for an opioid script until she could see her primary care physician, so I gave her a few days of opioids. I later found out she had forged my script and had changed it from 18 pills to 180 pills. She took it all over the state to try to fill. I got a call from the DEA [Drug Enforcement Administration] and had to write them a letter. I think she's in prison now.
These experiences inspired hospitalists to adopt strategies around opioid prescribing that would make it harder for a patient to misuse a prescription or to jeopardize their DEA license. A physician discussed her technique to prevent patients from selling their opioid prescriptions following discharge:
When I write the prescription, I put the name of the patient on the paper prescription with the patient's sticker on top. I don't want the patients to pull it off and sell the prescription, especially when it is my license.
Another physician described feeling reassured when she is able to verify a patient's opioid dose in a statewide prescription monitoring program:
Seeing they have filled opioids before supports your decision making. You just sort of cross your finger that this time my DEA number is not going to come up on the next drug bust!
The Use of Opioids to Improve Institutional Efficiency
Hospitalists felt institutional pressure to reduce hospital readmissions and to facilitate discharges. Pain was a common complaint among patients admitted to the hospital, and uncontrolled pain often prolonged a hospital stay. In these ways, physicians viewed opioid prescriptions as a tool to buffer against readmission or long hospital stays. A physician described his approach to more readily prescribed opioids when he felt it would prevent a patient from being rehospitalized:
If a patient tells you that they are in pain and they are receiving opioids in the hospital, and I have a strong sense that this is a person who comes back to the hospital easily and regularly if something is not right, I'm more likely to make sure that patient has adequate pain medicine for a reasonable duration of time to reduce the chance that they get readmitted just for pain alone.
Physicians used opioids as a tool to facilitate discharges and prevent readmissions; yet doing so sometimes left them feeling conflicted. On one hand, they felt pressured to maintain efficiency; on the other hand, they recognized it might not be in the patient's best interest to receive a higher than necessary quantity of opioids at discharge. A physician described his dilemma:
For the acute pain, I usually give them 15 to 20 [opioid pills]. For the chronics, maybe a little bit more like 30. A lot of them have told me they can just buy it off the street anyway. If we can help keep them out of the hospital, we are probably doing them a disservice [by prescribing more opioids], but we are also not clogging up our system.
Similarly, another hospitalist described opioid prescribing at discharge as a way to reduce hospital costs and prevent a readmission, despite feeling uncomfortable when a patient's diagnosis of pain was nebulous:
If the patient comes back and gets readmitted to the hospital when they don't have pain medicine, it's a $3,000.00, 2‐day stay in the hospital that was unnecessary. And when they have a prescription for a month of pain medicine, they stay out of the hospital. That is utterly pragmaticthere is no other way to do it and it's going to work. At other times, especially when a patient lacks a diagnosis which is known to cause pain, it can feel cheap and dirty.
DISCUSSION
To our knowledge, this is the first study to qualitatively explore the hospitalist perspective on opioid prescribing during hospitalization and at discharge. Hospitalists expressed discomfort and dissatisfaction when managing acute exacerbations of chronic pain with opioid medications. This stemmed from the discordance between the patients' expressed pain and the lack of objective clinical findings of pain, a perceived inability to adequately provide relief to patients with chronic pain, and a concern of contributing to future opioid dependence. Hospitalists identified negative professional experiences with opioid prescribing as a factor that influenced their opioid prescribing practices. Hospitalists also described using opioids as a tool to reduce readmissions and facilitate hospital discharges to contain healthcare costs. This sometimes left them feeling conflicted, especially when their patients lacked clear, pain‐related diagnoses.
Hospitalists were reluctant to increase patients' chronic opioid therapy doses, even when patients had acute exacerbations of chronic pain. Management of chronic pain presents a unique challenge to hospitalists. Existing clinical guidelines for chronic pain management are directed to the primary care physician.[36, 37] Acute exacerbations of chronic pain are commonly seen in hospitalized patients and should not be overlooked.[4] Management strategies that include in‐hospital, guideline‐based opioid dose adjustments are needed to address some of the concern hospitalists feel when managing chronic pain exacerbations. Involving the patient in the decision to temporarily increase their opioid dose may improve patient‐perceived pain control.[38] In addition, when possible, close communication between the hospitalist and the primary care physician may alleviate some of the uncertainty hospitalists feel when they prescribe an increased dose of chronic opioid therapy.[39, 40]
Opioid prescribing practices by hospitalists were influenced by past negative experiences. This principle, defined as negativity bias, refers to the notion that in most situations, negative events are more salient, potent, and dominant than positive events.[41, 42] Hospitalists recounted situations in which their patients overdosed on opioids in the hospital or forged an opioid prescription, which they perceived as jeopardizing their DEA licenses or reputations. They described concrete practice changes they made in an attempt to avoid these situations in the future. Whereas it is appropriate to critically assess practice behaviors that contribute to unanticipated patient outcomes, there may be unintended consequences when providers narrowly focus on the negative, including the undertreatment of pain. Focusing on successful outcomes associated with opioid prescribing, rather than negative outcomes, may lead to less restrictive and more thoughtful opioid prescribing practices. Furthermore, standardizing opioid prescribing to protect physicians from medicolegal consequences related to opioid diversion and fraud could lessen physicians' fears when prescribing opioids both during the hospitalization and at hospital discharge.
Hospitalists described prescribing opioids as a tool to improve efficiency in their practice, although at times it left them feeling conflicted. We interpreted this as a form of cognitive dissonance.[43] Hospitalists are acutely aware of the need to prevent costly hospital readmissions for their own success and longevity, which may lead them to become less judicious about how they prescribe opioids.[44, 45, 46] Our findings suggest a delicate balance between the potential benefits and drawbacks of using opioids to improve efficiency. Whereas it is important to provide pain relief to the patient, which can facilitate a discharge or delay time to next hospital admission, using opioids to smooth a difficult discharge may be detrimental to the patient. These findings highlight the competing pressures hospitalists face to deliver value‐based care[46, 47] while maintaining patient‐centered care.[48, 49]
This study has several limitations. First, qualitative data provide depth to the understanding of a behavior, but not breadth.[50, 51] Therefore, these results may not be generalizable to all hospitalists. We included a convenience sample of hospitalists who practiced in diverse settings including academic and private hospitals and the western and southern regions of the United States. The majority of the hospitalists interviewed had clinical experience less than 10 years. A national survey of hospitalists found the mean years of experience to be 6.9 years[16]; thus, the hospitalists we interviewed are likely representative of hospitalists nationally when considering clinical experience. Second, our interview guide was informed by prior literature and an a priori knowledge based on our experience as practicing hospitalist physicians. Interviews were conducted by 2 hospitalists who may have had similar experiences as those being described by the interviewees. Having shared experiences facilitated rapport and understating between the interviewers and participants; at the same time, however, shared experiences may have narrowed the focus of the interviews, eliminating themes that were already assumed. Lastly, hospitalists who chose to be interviewed may have participated because they felt strongly about the issues discussed and may not fully represent the population from which the sample was drawn.[15]
The development of evidence‐based strategies to promote optimal opioid prescribing for the management of acute exacerbations of chronic pain among hospitalized patients may benefit both hospital providers and patients who have a mutual goal for safe and effective pain relief. Methods to provide adequate pain relief to patients that allow hospitalists to maintain efficiency, while ensuring protection from medicolegal consequences related to opioid diversion or opioid overdose, are urgently needed.
Disclosures
This work was supported by the Denver Health Department of Medicine Small Grants Program, which was not involved in the design, conduct, or reporting of the study, or in the decision to submit the manuscript for publication. Dr. Binswanger was supported by the National Institute On Drug Abuse of the National Institutes of Health under award number R34DA035952. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they do not have any conflicts of interest.
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Pain is a frequent symptom among patients seen in the hospital.[1, 2, 3] Hospitalized patients often suffer before they come to the hospital and are commonly prescribed opioids in the months preceding their hospital stay.[4] Adequate pain control is important because uncontrolled pain is associated with higher levels of depression and anxiety among hospitalized patients.[5] In 2011, the Institute of Medicine called on healthcare providers to improve pain assessment and management in healthcare delivery.[6] Since then, pain management has become a key quality indicator for hospitals, and providers are encouraged to frequently assess and treat pain.[7, 8, 9, 10] Although the use of opioids for pain management among hospitalized patients is routine, the amount of opioids prescribed per patient varies widely between institutions.[11] In‐hospital guidelines for the optimal management of acute exacerbations of chronic pain are lacking.
Pain management also carries risks. Recently, the Centers for Disease Control and Prevention urged clinicians to prevent opioid overdoses by following best prescribing practices including screening patients for substance use disorders, mental health issues, and avoiding combinations of opioids and sedatives.[12, 13] These guidelines may be at odds with the priorities of current hospital care, which focus on patient‐perceived pain control rather than potential long‐term consequences of opioid use.[7, 8, 14] In light of the competing demands to provide adequate pain relief to hospitalized patients while optimally prescribing opioids, we sought to understand physicians' attitudes, beliefs, and experiences that inform opioid prescribing practices during hospitalization and at discharge.
METHODS
Study Design, Setting, and Participants
Between January 2015 and August 2015, we recruited a convenience sample via e‐mail solicitation from approximately 135 hospitalists practicing in Colorado and South Carolina.[15] Fifty‐three physicians responded. We conducted 25 in‐depth, semistructured interviews with physicians who represented the average hospitalist practicing in the United States in terms of years in practice and gender.[16] We enrolled physicians working in 4 distinct types of hospital settings, including 2 university hospitals, a safety‐net hospital, a Veterans Affairs hospital, and a private hospital. We used purposive sampling to achieve an even distribution with respect to gender and years in practice.[17] Interviews were either face‐to‐face (n = 16) or over the telephone (n = 9) and were performed outside of the physician's clinical shift. Informed consent was obtained from study participants, and the interview duration was approximately 1 hour. The study was approved by the Colorado Multiple Institutional Review Board.
Interview Guide Development and Content
Members of our multidisciplinary team (S.L.C., I.A.B., S.K.) developed an interview guide designed to explore hospitalists' attitudes and practices about opioid prescribing during hospitalization and at discharge (see Supporting Information, Appendix 1, in the online version of this article). Initial interview questions were developed with input from health sciences researchers (S.E.L., A.D.D., R.D.) and qualitative researchers (I.A.B., S.K.). During data collection, we occasionally edited or added questions to our guide to more fully explore new issues or information emerging from our interviews. Through open‐ended interviews, we sought to capture a qualitative narrative in which hospitalists would describe their attitudes and practices that may influence opioid prescribing within 3 major domains pertinent to clinical practice: patient factors,[18, 19, 20, 21, 22, 23] physician factors,[24, 25, 26, 27] and institutional factors.[27, 28, 29, 30, 31, 32] These domains were based on prior literature. All participants received a $25 gift card.
Data Analysis
Interview transcripts and a demographic survey were our primary data sources. Transcript files were entered into qualitative data analysis software (ATLAS.ti; Scientific Software Development GmbH, Berlin, Germany). We used a mixed inductive and deductive,[33] participatory, team‐based approach to explore patterns and themes related to attitudes and practices around opioid prescribing.[34, 35] A deductive or top‐down approach was used to link text to predefined codes and categories based on literature, prior knowledge, and our interview guide. An inductive or bottom‐up approach was used to identify new codes and categories that emerged from the data, including unanticipated information relevant to our research questions.
Team members included 2 hospitalists (S.L.C., A.D.D.), 2 research assistants with experience in qualitative methods (S.E.L., R.D.), an addiction medicine physician and researcher (I.A.B.), and a medical anthropologist (S.K.). S.L.C. performed initial coding using an a priori template that reflected the primary areas of interest in the study. The codes were categorized as patient, physician, and institutional factors. Using this template as a guide, 3 other team members (S.E.L., A.D.D., R.D.) independently coded 3 transcripts by assigning predefined codes to text and assigning new codes to emergent findings. Using this subset of 4 transcripts, the team reached a consensus on initial codes to be applied to the remaining transcripts. In weekly meetings, team members discussed and modified the codebook based on inconsistencies noted among team members to refine the coding scheme and to ensure consensus. Through group consensus, codes were condensed into a list of categories, subcategories, and emergent themes (ie, themes that did not originate from summarized answers to specific interview questions). The team identified emergent themes represented across all major domains (Table 1). Three of the most prevalent themes representing physicians' personal opioid prescribing practices are reported here. The study team determined that thematic saturation was reached after 25 interviews, as additional interview data created little change to the codebook and no new patterns or themes emerged.
|
| Perceived success, satisfaction, comfort, and the use of opioids for pain management* |
| Professional experiences influenced opioid prescribing practices* |
| The use of opioids to improve efficiency* |
| Skepticism between other physician subspecialty types and opioid prescribing practices |
| Unintended consequences of patient‐perceived pain control metrics and opioid prescribing |
| Lack of trust with patients when reported pain level was not supported with objective data |
| Resident burnout contributed to a lack of empathy and undertreatment of pain |
| Limited perceived risk of personal opioid prescribing practices and patient overdose with short‐acting opioids |
| Unreal expectations by patients to have complete pain eradication contributes to overprescribing |
| Recognition that patient profiling impacts personal opioid‐prescribing practices |
RESULTS
Of the 25 hospitalist participants who were all trained in internal medicine, 16 (64%) were women. The majority were non‐Hispanic white (21 [84%]). Nine physicians (36%) completed residency within the past 5 years, 12 (48%) completed residency within the past 5 to 10 years, and 4 (16%) completed residency >10 years ago. Sixteen (64%) hospitalists practiced medicine in Colorado, where 8 (32%) worked in a safety‐net hospital, 5 (20%) worked in a university hospital, and 3 (12%) worked in a Veterans Affairs hospital. Nine hospitalists (36%) practiced in South Carolina, where 2 (8%) worked in a university hospital and 7 (28%) worked in a private hospital (Table 2).
| Female, no. (%) | 16 (64) |
| Race/ethnicity, no. (%) | |
| White, non‐Hispanic | 21 (84) |
| Asian, non‐Hispanic | 4 (16) |
| Years postresidency, no. (%) | |
| <5 | 9 (36) |
| 510 | 12 (48) |
| >10 | 4 (16) |
| State of practice, no. (%) | |
| Colorado | 16 (64) |
| South Carolina | 9 (36) |
| Private hospital, no. (%) | 7 (28) |
| Academic institution, no. (%) | |
| Safety‐net hospital | 8 (32) |
| Veteran Affairs hospital | 3 (12) |
| University hospital | 7 (28) |
Emergent themes described here include: (1) hospitalists' perceived success, satisfaction, and comfort when prescribing opioids for their patients' pain management; (2) the influence of physicians' professional sentinel experiences on opioid prescribing practices; and (3) opioid prescribing as a tool to improve efficiency in the hospital. Additional quotations to support emergent themes are listed in Table 3.
| Theme | Illustrative Quote |
|---|---|
| |
| Perceived success, satisfaction, comfort, and the use of opioids for pain management | Acute pain: I'm more comfortable treating acute pain. With chronic pain, it depends on the circumstance. There are certain people who have objective reasons to have chronic pain, for instance they have severe degenerate disc disease, for example. With chronic painlet me just say, getting their pain under control is quite challenging. Acute pain is much more straight forward to treat. |
| Chronic pain; If I am treating an exacerbation of someone's chronic pain, it makes me a little less comfortable as far as sending people out on large doses of opioids because of the whole addiction thought behind it. And you don't want to start or feed people's addiction. Or, you know, lead them to it, in the future, requiring increased doses of opioids. | |
| Chronic pain: I have a hard time feeling like I'm very successful with people who have chronic noncancer pain who come in for an exacerbation. Unless I can figure out clear reasons for that exacerbation, I feel I rarely succeed in having the patient, the providers, and the caregivers be happy. It is an unrewarding situation all around. | |
| Chronic pain: I'm less comfortable treating chronic pain because we don't know the patients as well, I think, in the hospital, and you just worry about people abusing the system to get their needs met while they are in the hospital. We don't have much objective data in terms of assessing pain, and you know, they are on chronic narcotics, you don't really know what to believe, I guess. | |
| Professional experiences that influenced opioid prescribing practices | In the hospital: I had 1 horrible experience. I had a young woman who came in with chronic abdominal pain. She told me how much opioids she took. It was before there was a statewide database and I couldn't verify her doses. I gave her what she told me she was taking. I hadn't put a pulse ox on her which I always do now because it makes me feel better. Later the nurse called and said she wasn't responsive. I put her on Pulse Ox and she was sating 30% and blue. A code was called and we brought her back. That was in my mind for ever, I almost killed a 23 year old. |
| In the hospital: I think past experiences inform what I do now. I mean it's not that I've murdered anybody, but there was a time when I took over a patient and didn't realize that, while she had terrible pain from her restless leg syndrome, she also had severe pulmonary hypertension. I gave her 5 mg of oxycodone. She ended up somnolent with hypercarbic respiratory failure. I think that is something that will always stick in my head. | |
| Discharge: When discussing what type of opioids prescribed at dischargeI worry about, not just deliberate diversion, but for the patient being robbed, for the type of opioid I might choose. So I might do oxycodone instead of Percocet. Percocet, itself, has a higher street value then oxycodone. That may be completely false, but I think of it as a name brand that people want. | |
| Discharge: I think many providers, including myself, try to minimize the use of opiates when we can. I think we are all concerned every time we write, you know, our DEA #. Even when we have other providers ask us, you know, to prescribe opioids for their patients because they are out of the hospital or something like that, it is always a touchy subject. Because I think we all feel like our license is always at risk every time we are writing opioids. | |
| Discharge: I give them what they need but I want them to be seen in follow‐up. I encourage that by giving them a shortened course. I'm more skeptical. I've seen people misuse, have bad side effects, and overdose on opioids. I worry about that, so I tend to prescribe shorter courses and less. | |
| The use of opioids to improve efficiency | There is always the group of patients [for whom] we've done everything we can. We set up follow‐up. If giving you a few days of Percocet is going to help you leave the hospital comfortably and stay out of the hospital for appropriate reasons, then we give them a few days. It's horrible but... |
| I'll give 4 or 6 weeks' worth of opioid medication to the chronic abdominal pain patients, the ones who have ERCPs scheduled for every 4 or 6 weeks. You sort of end up managing their chronic pain. It's the people that we know. If you don't give them a month's worth of pain meds, they are going to come back in to the hospital. Because they always come in when they run out. | |
| I think physicians overprescribe opioids because we don't want people to bounce back to the hospital. We don't want them to have acute pain at home and have to go back to the ER to be readmitted. You don't want someone to be in pain. I think that sometimes people go overboard. I also think that sometimes physicians gauge like, oh, this person isn't a huge risk, and maybe give them more opioids than necessary. | |
Perceived Success, Satisfaction, and Comfort When Prescribing Opioids for Pain Management
Providing adequate pain control to their patients was of utmost importance to hospitalists and influenced opioid prescribing. Hospitalists felt confident in their ability to control acute pain using opioids, but notably perceived limited success in achieving adequate patient‐perceived pain control when treating acute exacerbations of chronic pain with opioids. A physician described his confidence in treating severe, acute pain:
If someone is dying of cancer, or if they have an acutely broken femur, I don't really care if they are actively in the 12‐Step Program or Narcotics Anonymous to stay sober. That pain is real and there is no effective pain medicine on earth except for opioids.
[I am uncomfortable treating] people that you classify with chronic pain syndrome. There is that terminology you use for people who have subjective pain, out of proportion to objective findings. In my experience it is a black hole. You never get an adequate level of pain control and you keep adding the doses up and they get habituated. An end point is very difficult to achieve. Not like with acute pain.
All of these things you do for patient satisfaction set up people, who aren't ever going to be without pain, to fail. They have pain all the time, and now you are asking them about their pain. Well, of course their pain is not controlled, because their pain is never going to be less than 5 out of 10, period. And no opioid is going to get them there, unless they are unconscious.
Professional Experiences Influenced Opioid Prescribing Practices
Physicians reported little opioid‐specific training during residency, and so opioid prescribing practices were shaped by the physicians' clinical experiences. Hospitalists reflected on negative, sentinel events that shaped their opioid prescribing practices in the inpatient setting or led them to adopt risk‐modifying behaviors when prescribing opioids at hospital discharge. Negative experiences varied and included a fatal overdose and suspected diversion of opioids for sale. A physician reflected on an avoidable in‐hospital overdose which left her more guarded when prescribing opioids:
It is both your cumulative experience and, sometimes, when you've had a negative experience, it really biases how you think. I've had an experience where my patient actually overdosed. She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died. We've all had experiences with opioids being abused. This just happened to be a very dramatic thing that happened right under my nose. It just makes me more guarded, in terms of my practice, and the lengths people will go through to do harm to themselves with opioids.
Hospitalists recognized that some of their patients had limited resources. They expressed suspicions that opioid prescriptions, in some cases, represented a form of currency for patients to supplement their income. A physician stated:
I think our population can divert quite a few meds. I think their financial situations can be really tenuous. Sometimes they sell pills to survive.
Physicians described past experiences with patients who were deceptive to get an opioid prescription, which left them much more reticent to prescribe the drugs. For example, a physician described how a patient altered her opioid prescription following hospital discharge:
I saw a patient who had her gallbladder removed. She asked for an opioid script until she could see her primary care physician, so I gave her a few days of opioids. I later found out she had forged my script and had changed it from 18 pills to 180 pills. She took it all over the state to try to fill. I got a call from the DEA [Drug Enforcement Administration] and had to write them a letter. I think she's in prison now.
These experiences inspired hospitalists to adopt strategies around opioid prescribing that would make it harder for a patient to misuse a prescription or to jeopardize their DEA license. A physician discussed her technique to prevent patients from selling their opioid prescriptions following discharge:
When I write the prescription, I put the name of the patient on the paper prescription with the patient's sticker on top. I don't want the patients to pull it off and sell the prescription, especially when it is my license.
Another physician described feeling reassured when she is able to verify a patient's opioid dose in a statewide prescription monitoring program:
Seeing they have filled opioids before supports your decision making. You just sort of cross your finger that this time my DEA number is not going to come up on the next drug bust!
The Use of Opioids to Improve Institutional Efficiency
Hospitalists felt institutional pressure to reduce hospital readmissions and to facilitate discharges. Pain was a common complaint among patients admitted to the hospital, and uncontrolled pain often prolonged a hospital stay. In these ways, physicians viewed opioid prescriptions as a tool to buffer against readmission or long hospital stays. A physician described his approach to more readily prescribed opioids when he felt it would prevent a patient from being rehospitalized:
If a patient tells you that they are in pain and they are receiving opioids in the hospital, and I have a strong sense that this is a person who comes back to the hospital easily and regularly if something is not right, I'm more likely to make sure that patient has adequate pain medicine for a reasonable duration of time to reduce the chance that they get readmitted just for pain alone.
Physicians used opioids as a tool to facilitate discharges and prevent readmissions; yet doing so sometimes left them feeling conflicted. On one hand, they felt pressured to maintain efficiency; on the other hand, they recognized it might not be in the patient's best interest to receive a higher than necessary quantity of opioids at discharge. A physician described his dilemma:
For the acute pain, I usually give them 15 to 20 [opioid pills]. For the chronics, maybe a little bit more like 30. A lot of them have told me they can just buy it off the street anyway. If we can help keep them out of the hospital, we are probably doing them a disservice [by prescribing more opioids], but we are also not clogging up our system.
Similarly, another hospitalist described opioid prescribing at discharge as a way to reduce hospital costs and prevent a readmission, despite feeling uncomfortable when a patient's diagnosis of pain was nebulous:
If the patient comes back and gets readmitted to the hospital when they don't have pain medicine, it's a $3,000.00, 2‐day stay in the hospital that was unnecessary. And when they have a prescription for a month of pain medicine, they stay out of the hospital. That is utterly pragmaticthere is no other way to do it and it's going to work. At other times, especially when a patient lacks a diagnosis which is known to cause pain, it can feel cheap and dirty.
DISCUSSION
To our knowledge, this is the first study to qualitatively explore the hospitalist perspective on opioid prescribing during hospitalization and at discharge. Hospitalists expressed discomfort and dissatisfaction when managing acute exacerbations of chronic pain with opioid medications. This stemmed from the discordance between the patients' expressed pain and the lack of objective clinical findings of pain, a perceived inability to adequately provide relief to patients with chronic pain, and a concern of contributing to future opioid dependence. Hospitalists identified negative professional experiences with opioid prescribing as a factor that influenced their opioid prescribing practices. Hospitalists also described using opioids as a tool to reduce readmissions and facilitate hospital discharges to contain healthcare costs. This sometimes left them feeling conflicted, especially when their patients lacked clear, pain‐related diagnoses.
Hospitalists were reluctant to increase patients' chronic opioid therapy doses, even when patients had acute exacerbations of chronic pain. Management of chronic pain presents a unique challenge to hospitalists. Existing clinical guidelines for chronic pain management are directed to the primary care physician.[36, 37] Acute exacerbations of chronic pain are commonly seen in hospitalized patients and should not be overlooked.[4] Management strategies that include in‐hospital, guideline‐based opioid dose adjustments are needed to address some of the concern hospitalists feel when managing chronic pain exacerbations. Involving the patient in the decision to temporarily increase their opioid dose may improve patient‐perceived pain control.[38] In addition, when possible, close communication between the hospitalist and the primary care physician may alleviate some of the uncertainty hospitalists feel when they prescribe an increased dose of chronic opioid therapy.[39, 40]
Opioid prescribing practices by hospitalists were influenced by past negative experiences. This principle, defined as negativity bias, refers to the notion that in most situations, negative events are more salient, potent, and dominant than positive events.[41, 42] Hospitalists recounted situations in which their patients overdosed on opioids in the hospital or forged an opioid prescription, which they perceived as jeopardizing their DEA licenses or reputations. They described concrete practice changes they made in an attempt to avoid these situations in the future. Whereas it is appropriate to critically assess practice behaviors that contribute to unanticipated patient outcomes, there may be unintended consequences when providers narrowly focus on the negative, including the undertreatment of pain. Focusing on successful outcomes associated with opioid prescribing, rather than negative outcomes, may lead to less restrictive and more thoughtful opioid prescribing practices. Furthermore, standardizing opioid prescribing to protect physicians from medicolegal consequences related to opioid diversion and fraud could lessen physicians' fears when prescribing opioids both during the hospitalization and at hospital discharge.
Hospitalists described prescribing opioids as a tool to improve efficiency in their practice, although at times it left them feeling conflicted. We interpreted this as a form of cognitive dissonance.[43] Hospitalists are acutely aware of the need to prevent costly hospital readmissions for their own success and longevity, which may lead them to become less judicious about how they prescribe opioids.[44, 45, 46] Our findings suggest a delicate balance between the potential benefits and drawbacks of using opioids to improve efficiency. Whereas it is important to provide pain relief to the patient, which can facilitate a discharge or delay time to next hospital admission, using opioids to smooth a difficult discharge may be detrimental to the patient. These findings highlight the competing pressures hospitalists face to deliver value‐based care[46, 47] while maintaining patient‐centered care.[48, 49]
This study has several limitations. First, qualitative data provide depth to the understanding of a behavior, but not breadth.[50, 51] Therefore, these results may not be generalizable to all hospitalists. We included a convenience sample of hospitalists who practiced in diverse settings including academic and private hospitals and the western and southern regions of the United States. The majority of the hospitalists interviewed had clinical experience less than 10 years. A national survey of hospitalists found the mean years of experience to be 6.9 years[16]; thus, the hospitalists we interviewed are likely representative of hospitalists nationally when considering clinical experience. Second, our interview guide was informed by prior literature and an a priori knowledge based on our experience as practicing hospitalist physicians. Interviews were conducted by 2 hospitalists who may have had similar experiences as those being described by the interviewees. Having shared experiences facilitated rapport and understating between the interviewers and participants; at the same time, however, shared experiences may have narrowed the focus of the interviews, eliminating themes that were already assumed. Lastly, hospitalists who chose to be interviewed may have participated because they felt strongly about the issues discussed and may not fully represent the population from which the sample was drawn.[15]
The development of evidence‐based strategies to promote optimal opioid prescribing for the management of acute exacerbations of chronic pain among hospitalized patients may benefit both hospital providers and patients who have a mutual goal for safe and effective pain relief. Methods to provide adequate pain relief to patients that allow hospitalists to maintain efficiency, while ensuring protection from medicolegal consequences related to opioid diversion or opioid overdose, are urgently needed.
Disclosures
This work was supported by the Denver Health Department of Medicine Small Grants Program, which was not involved in the design, conduct, or reporting of the study, or in the decision to submit the manuscript for publication. Dr. Binswanger was supported by the National Institute On Drug Abuse of the National Institutes of Health under award number R34DA035952. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they do not have any conflicts of interest.
Pain is a frequent symptom among patients seen in the hospital.[1, 2, 3] Hospitalized patients often suffer before they come to the hospital and are commonly prescribed opioids in the months preceding their hospital stay.[4] Adequate pain control is important because uncontrolled pain is associated with higher levels of depression and anxiety among hospitalized patients.[5] In 2011, the Institute of Medicine called on healthcare providers to improve pain assessment and management in healthcare delivery.[6] Since then, pain management has become a key quality indicator for hospitals, and providers are encouraged to frequently assess and treat pain.[7, 8, 9, 10] Although the use of opioids for pain management among hospitalized patients is routine, the amount of opioids prescribed per patient varies widely between institutions.[11] In‐hospital guidelines for the optimal management of acute exacerbations of chronic pain are lacking.
Pain management also carries risks. Recently, the Centers for Disease Control and Prevention urged clinicians to prevent opioid overdoses by following best prescribing practices including screening patients for substance use disorders, mental health issues, and avoiding combinations of opioids and sedatives.[12, 13] These guidelines may be at odds with the priorities of current hospital care, which focus on patient‐perceived pain control rather than potential long‐term consequences of opioid use.[7, 8, 14] In light of the competing demands to provide adequate pain relief to hospitalized patients while optimally prescribing opioids, we sought to understand physicians' attitudes, beliefs, and experiences that inform opioid prescribing practices during hospitalization and at discharge.
METHODS
Study Design, Setting, and Participants
Between January 2015 and August 2015, we recruited a convenience sample via e‐mail solicitation from approximately 135 hospitalists practicing in Colorado and South Carolina.[15] Fifty‐three physicians responded. We conducted 25 in‐depth, semistructured interviews with physicians who represented the average hospitalist practicing in the United States in terms of years in practice and gender.[16] We enrolled physicians working in 4 distinct types of hospital settings, including 2 university hospitals, a safety‐net hospital, a Veterans Affairs hospital, and a private hospital. We used purposive sampling to achieve an even distribution with respect to gender and years in practice.[17] Interviews were either face‐to‐face (n = 16) or over the telephone (n = 9) and were performed outside of the physician's clinical shift. Informed consent was obtained from study participants, and the interview duration was approximately 1 hour. The study was approved by the Colorado Multiple Institutional Review Board.
Interview Guide Development and Content
Members of our multidisciplinary team (S.L.C., I.A.B., S.K.) developed an interview guide designed to explore hospitalists' attitudes and practices about opioid prescribing during hospitalization and at discharge (see Supporting Information, Appendix 1, in the online version of this article). Initial interview questions were developed with input from health sciences researchers (S.E.L., A.D.D., R.D.) and qualitative researchers (I.A.B., S.K.). During data collection, we occasionally edited or added questions to our guide to more fully explore new issues or information emerging from our interviews. Through open‐ended interviews, we sought to capture a qualitative narrative in which hospitalists would describe their attitudes and practices that may influence opioid prescribing within 3 major domains pertinent to clinical practice: patient factors,[18, 19, 20, 21, 22, 23] physician factors,[24, 25, 26, 27] and institutional factors.[27, 28, 29, 30, 31, 32] These domains were based on prior literature. All participants received a $25 gift card.
Data Analysis
Interview transcripts and a demographic survey were our primary data sources. Transcript files were entered into qualitative data analysis software (ATLAS.ti; Scientific Software Development GmbH, Berlin, Germany). We used a mixed inductive and deductive,[33] participatory, team‐based approach to explore patterns and themes related to attitudes and practices around opioid prescribing.[34, 35] A deductive or top‐down approach was used to link text to predefined codes and categories based on literature, prior knowledge, and our interview guide. An inductive or bottom‐up approach was used to identify new codes and categories that emerged from the data, including unanticipated information relevant to our research questions.
Team members included 2 hospitalists (S.L.C., A.D.D.), 2 research assistants with experience in qualitative methods (S.E.L., R.D.), an addiction medicine physician and researcher (I.A.B.), and a medical anthropologist (S.K.). S.L.C. performed initial coding using an a priori template that reflected the primary areas of interest in the study. The codes were categorized as patient, physician, and institutional factors. Using this template as a guide, 3 other team members (S.E.L., A.D.D., R.D.) independently coded 3 transcripts by assigning predefined codes to text and assigning new codes to emergent findings. Using this subset of 4 transcripts, the team reached a consensus on initial codes to be applied to the remaining transcripts. In weekly meetings, team members discussed and modified the codebook based on inconsistencies noted among team members to refine the coding scheme and to ensure consensus. Through group consensus, codes were condensed into a list of categories, subcategories, and emergent themes (ie, themes that did not originate from summarized answers to specific interview questions). The team identified emergent themes represented across all major domains (Table 1). Three of the most prevalent themes representing physicians' personal opioid prescribing practices are reported here. The study team determined that thematic saturation was reached after 25 interviews, as additional interview data created little change to the codebook and no new patterns or themes emerged.
|
| Perceived success, satisfaction, comfort, and the use of opioids for pain management* |
| Professional experiences influenced opioid prescribing practices* |
| The use of opioids to improve efficiency* |
| Skepticism between other physician subspecialty types and opioid prescribing practices |
| Unintended consequences of patient‐perceived pain control metrics and opioid prescribing |
| Lack of trust with patients when reported pain level was not supported with objective data |
| Resident burnout contributed to a lack of empathy and undertreatment of pain |
| Limited perceived risk of personal opioid prescribing practices and patient overdose with short‐acting opioids |
| Unreal expectations by patients to have complete pain eradication contributes to overprescribing |
| Recognition that patient profiling impacts personal opioid‐prescribing practices |
RESULTS
Of the 25 hospitalist participants who were all trained in internal medicine, 16 (64%) were women. The majority were non‐Hispanic white (21 [84%]). Nine physicians (36%) completed residency within the past 5 years, 12 (48%) completed residency within the past 5 to 10 years, and 4 (16%) completed residency >10 years ago. Sixteen (64%) hospitalists practiced medicine in Colorado, where 8 (32%) worked in a safety‐net hospital, 5 (20%) worked in a university hospital, and 3 (12%) worked in a Veterans Affairs hospital. Nine hospitalists (36%) practiced in South Carolina, where 2 (8%) worked in a university hospital and 7 (28%) worked in a private hospital (Table 2).
| Female, no. (%) | 16 (64) |
| Race/ethnicity, no. (%) | |
| White, non‐Hispanic | 21 (84) |
| Asian, non‐Hispanic | 4 (16) |
| Years postresidency, no. (%) | |
| <5 | 9 (36) |
| 510 | 12 (48) |
| >10 | 4 (16) |
| State of practice, no. (%) | |
| Colorado | 16 (64) |
| South Carolina | 9 (36) |
| Private hospital, no. (%) | 7 (28) |
| Academic institution, no. (%) | |
| Safety‐net hospital | 8 (32) |
| Veteran Affairs hospital | 3 (12) |
| University hospital | 7 (28) |
Emergent themes described here include: (1) hospitalists' perceived success, satisfaction, and comfort when prescribing opioids for their patients' pain management; (2) the influence of physicians' professional sentinel experiences on opioid prescribing practices; and (3) opioid prescribing as a tool to improve efficiency in the hospital. Additional quotations to support emergent themes are listed in Table 3.
| Theme | Illustrative Quote |
|---|---|
| |
| Perceived success, satisfaction, comfort, and the use of opioids for pain management | Acute pain: I'm more comfortable treating acute pain. With chronic pain, it depends on the circumstance. There are certain people who have objective reasons to have chronic pain, for instance they have severe degenerate disc disease, for example. With chronic painlet me just say, getting their pain under control is quite challenging. Acute pain is much more straight forward to treat. |
| Chronic pain; If I am treating an exacerbation of someone's chronic pain, it makes me a little less comfortable as far as sending people out on large doses of opioids because of the whole addiction thought behind it. And you don't want to start or feed people's addiction. Or, you know, lead them to it, in the future, requiring increased doses of opioids. | |
| Chronic pain: I have a hard time feeling like I'm very successful with people who have chronic noncancer pain who come in for an exacerbation. Unless I can figure out clear reasons for that exacerbation, I feel I rarely succeed in having the patient, the providers, and the caregivers be happy. It is an unrewarding situation all around. | |
| Chronic pain: I'm less comfortable treating chronic pain because we don't know the patients as well, I think, in the hospital, and you just worry about people abusing the system to get their needs met while they are in the hospital. We don't have much objective data in terms of assessing pain, and you know, they are on chronic narcotics, you don't really know what to believe, I guess. | |
| Professional experiences that influenced opioid prescribing practices | In the hospital: I had 1 horrible experience. I had a young woman who came in with chronic abdominal pain. She told me how much opioids she took. It was before there was a statewide database and I couldn't verify her doses. I gave her what she told me she was taking. I hadn't put a pulse ox on her which I always do now because it makes me feel better. Later the nurse called and said she wasn't responsive. I put her on Pulse Ox and she was sating 30% and blue. A code was called and we brought her back. That was in my mind for ever, I almost killed a 23 year old. |
| In the hospital: I think past experiences inform what I do now. I mean it's not that I've murdered anybody, but there was a time when I took over a patient and didn't realize that, while she had terrible pain from her restless leg syndrome, she also had severe pulmonary hypertension. I gave her 5 mg of oxycodone. She ended up somnolent with hypercarbic respiratory failure. I think that is something that will always stick in my head. | |
| Discharge: When discussing what type of opioids prescribed at dischargeI worry about, not just deliberate diversion, but for the patient being robbed, for the type of opioid I might choose. So I might do oxycodone instead of Percocet. Percocet, itself, has a higher street value then oxycodone. That may be completely false, but I think of it as a name brand that people want. | |
| Discharge: I think many providers, including myself, try to minimize the use of opiates when we can. I think we are all concerned every time we write, you know, our DEA #. Even when we have other providers ask us, you know, to prescribe opioids for their patients because they are out of the hospital or something like that, it is always a touchy subject. Because I think we all feel like our license is always at risk every time we are writing opioids. | |
| Discharge: I give them what they need but I want them to be seen in follow‐up. I encourage that by giving them a shortened course. I'm more skeptical. I've seen people misuse, have bad side effects, and overdose on opioids. I worry about that, so I tend to prescribe shorter courses and less. | |
| The use of opioids to improve efficiency | There is always the group of patients [for whom] we've done everything we can. We set up follow‐up. If giving you a few days of Percocet is going to help you leave the hospital comfortably and stay out of the hospital for appropriate reasons, then we give them a few days. It's horrible but... |
| I'll give 4 or 6 weeks' worth of opioid medication to the chronic abdominal pain patients, the ones who have ERCPs scheduled for every 4 or 6 weeks. You sort of end up managing their chronic pain. It's the people that we know. If you don't give them a month's worth of pain meds, they are going to come back in to the hospital. Because they always come in when they run out. | |
| I think physicians overprescribe opioids because we don't want people to bounce back to the hospital. We don't want them to have acute pain at home and have to go back to the ER to be readmitted. You don't want someone to be in pain. I think that sometimes people go overboard. I also think that sometimes physicians gauge like, oh, this person isn't a huge risk, and maybe give them more opioids than necessary. | |
Perceived Success, Satisfaction, and Comfort When Prescribing Opioids for Pain Management
Providing adequate pain control to their patients was of utmost importance to hospitalists and influenced opioid prescribing. Hospitalists felt confident in their ability to control acute pain using opioids, but notably perceived limited success in achieving adequate patient‐perceived pain control when treating acute exacerbations of chronic pain with opioids. A physician described his confidence in treating severe, acute pain:
If someone is dying of cancer, or if they have an acutely broken femur, I don't really care if they are actively in the 12‐Step Program or Narcotics Anonymous to stay sober. That pain is real and there is no effective pain medicine on earth except for opioids.
[I am uncomfortable treating] people that you classify with chronic pain syndrome. There is that terminology you use for people who have subjective pain, out of proportion to objective findings. In my experience it is a black hole. You never get an adequate level of pain control and you keep adding the doses up and they get habituated. An end point is very difficult to achieve. Not like with acute pain.
All of these things you do for patient satisfaction set up people, who aren't ever going to be without pain, to fail. They have pain all the time, and now you are asking them about their pain. Well, of course their pain is not controlled, because their pain is never going to be less than 5 out of 10, period. And no opioid is going to get them there, unless they are unconscious.
Professional Experiences Influenced Opioid Prescribing Practices
Physicians reported little opioid‐specific training during residency, and so opioid prescribing practices were shaped by the physicians' clinical experiences. Hospitalists reflected on negative, sentinel events that shaped their opioid prescribing practices in the inpatient setting or led them to adopt risk‐modifying behaviors when prescribing opioids at hospital discharge. Negative experiences varied and included a fatal overdose and suspected diversion of opioids for sale. A physician reflected on an avoidable in‐hospital overdose which left her more guarded when prescribing opioids:
It is both your cumulative experience and, sometimes, when you've had a negative experience, it really biases how you think. I've had an experience where my patient actually overdosed. She crushed up the oxycodone we were giving her in the hospital and shot it up through her central line and died. We've all had experiences with opioids being abused. This just happened to be a very dramatic thing that happened right under my nose. It just makes me more guarded, in terms of my practice, and the lengths people will go through to do harm to themselves with opioids.
Hospitalists recognized that some of their patients had limited resources. They expressed suspicions that opioid prescriptions, in some cases, represented a form of currency for patients to supplement their income. A physician stated:
I think our population can divert quite a few meds. I think their financial situations can be really tenuous. Sometimes they sell pills to survive.
Physicians described past experiences with patients who were deceptive to get an opioid prescription, which left them much more reticent to prescribe the drugs. For example, a physician described how a patient altered her opioid prescription following hospital discharge:
I saw a patient who had her gallbladder removed. She asked for an opioid script until she could see her primary care physician, so I gave her a few days of opioids. I later found out she had forged my script and had changed it from 18 pills to 180 pills. She took it all over the state to try to fill. I got a call from the DEA [Drug Enforcement Administration] and had to write them a letter. I think she's in prison now.
These experiences inspired hospitalists to adopt strategies around opioid prescribing that would make it harder for a patient to misuse a prescription or to jeopardize their DEA license. A physician discussed her technique to prevent patients from selling their opioid prescriptions following discharge:
When I write the prescription, I put the name of the patient on the paper prescription with the patient's sticker on top. I don't want the patients to pull it off and sell the prescription, especially when it is my license.
Another physician described feeling reassured when she is able to verify a patient's opioid dose in a statewide prescription monitoring program:
Seeing they have filled opioids before supports your decision making. You just sort of cross your finger that this time my DEA number is not going to come up on the next drug bust!
The Use of Opioids to Improve Institutional Efficiency
Hospitalists felt institutional pressure to reduce hospital readmissions and to facilitate discharges. Pain was a common complaint among patients admitted to the hospital, and uncontrolled pain often prolonged a hospital stay. In these ways, physicians viewed opioid prescriptions as a tool to buffer against readmission or long hospital stays. A physician described his approach to more readily prescribed opioids when he felt it would prevent a patient from being rehospitalized:
If a patient tells you that they are in pain and they are receiving opioids in the hospital, and I have a strong sense that this is a person who comes back to the hospital easily and regularly if something is not right, I'm more likely to make sure that patient has adequate pain medicine for a reasonable duration of time to reduce the chance that they get readmitted just for pain alone.
Physicians used opioids as a tool to facilitate discharges and prevent readmissions; yet doing so sometimes left them feeling conflicted. On one hand, they felt pressured to maintain efficiency; on the other hand, they recognized it might not be in the patient's best interest to receive a higher than necessary quantity of opioids at discharge. A physician described his dilemma:
For the acute pain, I usually give them 15 to 20 [opioid pills]. For the chronics, maybe a little bit more like 30. A lot of them have told me they can just buy it off the street anyway. If we can help keep them out of the hospital, we are probably doing them a disservice [by prescribing more opioids], but we are also not clogging up our system.
Similarly, another hospitalist described opioid prescribing at discharge as a way to reduce hospital costs and prevent a readmission, despite feeling uncomfortable when a patient's diagnosis of pain was nebulous:
If the patient comes back and gets readmitted to the hospital when they don't have pain medicine, it's a $3,000.00, 2‐day stay in the hospital that was unnecessary. And when they have a prescription for a month of pain medicine, they stay out of the hospital. That is utterly pragmaticthere is no other way to do it and it's going to work. At other times, especially when a patient lacks a diagnosis which is known to cause pain, it can feel cheap and dirty.
DISCUSSION
To our knowledge, this is the first study to qualitatively explore the hospitalist perspective on opioid prescribing during hospitalization and at discharge. Hospitalists expressed discomfort and dissatisfaction when managing acute exacerbations of chronic pain with opioid medications. This stemmed from the discordance between the patients' expressed pain and the lack of objective clinical findings of pain, a perceived inability to adequately provide relief to patients with chronic pain, and a concern of contributing to future opioid dependence. Hospitalists identified negative professional experiences with opioid prescribing as a factor that influenced their opioid prescribing practices. Hospitalists also described using opioids as a tool to reduce readmissions and facilitate hospital discharges to contain healthcare costs. This sometimes left them feeling conflicted, especially when their patients lacked clear, pain‐related diagnoses.
Hospitalists were reluctant to increase patients' chronic opioid therapy doses, even when patients had acute exacerbations of chronic pain. Management of chronic pain presents a unique challenge to hospitalists. Existing clinical guidelines for chronic pain management are directed to the primary care physician.[36, 37] Acute exacerbations of chronic pain are commonly seen in hospitalized patients and should not be overlooked.[4] Management strategies that include in‐hospital, guideline‐based opioid dose adjustments are needed to address some of the concern hospitalists feel when managing chronic pain exacerbations. Involving the patient in the decision to temporarily increase their opioid dose may improve patient‐perceived pain control.[38] In addition, when possible, close communication between the hospitalist and the primary care physician may alleviate some of the uncertainty hospitalists feel when they prescribe an increased dose of chronic opioid therapy.[39, 40]
Opioid prescribing practices by hospitalists were influenced by past negative experiences. This principle, defined as negativity bias, refers to the notion that in most situations, negative events are more salient, potent, and dominant than positive events.[41, 42] Hospitalists recounted situations in which their patients overdosed on opioids in the hospital or forged an opioid prescription, which they perceived as jeopardizing their DEA licenses or reputations. They described concrete practice changes they made in an attempt to avoid these situations in the future. Whereas it is appropriate to critically assess practice behaviors that contribute to unanticipated patient outcomes, there may be unintended consequences when providers narrowly focus on the negative, including the undertreatment of pain. Focusing on successful outcomes associated with opioid prescribing, rather than negative outcomes, may lead to less restrictive and more thoughtful opioid prescribing practices. Furthermore, standardizing opioid prescribing to protect physicians from medicolegal consequences related to opioid diversion and fraud could lessen physicians' fears when prescribing opioids both during the hospitalization and at hospital discharge.
Hospitalists described prescribing opioids as a tool to improve efficiency in their practice, although at times it left them feeling conflicted. We interpreted this as a form of cognitive dissonance.[43] Hospitalists are acutely aware of the need to prevent costly hospital readmissions for their own success and longevity, which may lead them to become less judicious about how they prescribe opioids.[44, 45, 46] Our findings suggest a delicate balance between the potential benefits and drawbacks of using opioids to improve efficiency. Whereas it is important to provide pain relief to the patient, which can facilitate a discharge or delay time to next hospital admission, using opioids to smooth a difficult discharge may be detrimental to the patient. These findings highlight the competing pressures hospitalists face to deliver value‐based care[46, 47] while maintaining patient‐centered care.[48, 49]
This study has several limitations. First, qualitative data provide depth to the understanding of a behavior, but not breadth.[50, 51] Therefore, these results may not be generalizable to all hospitalists. We included a convenience sample of hospitalists who practiced in diverse settings including academic and private hospitals and the western and southern regions of the United States. The majority of the hospitalists interviewed had clinical experience less than 10 years. A national survey of hospitalists found the mean years of experience to be 6.9 years[16]; thus, the hospitalists we interviewed are likely representative of hospitalists nationally when considering clinical experience. Second, our interview guide was informed by prior literature and an a priori knowledge based on our experience as practicing hospitalist physicians. Interviews were conducted by 2 hospitalists who may have had similar experiences as those being described by the interviewees. Having shared experiences facilitated rapport and understating between the interviewers and participants; at the same time, however, shared experiences may have narrowed the focus of the interviews, eliminating themes that were already assumed. Lastly, hospitalists who chose to be interviewed may have participated because they felt strongly about the issues discussed and may not fully represent the population from which the sample was drawn.[15]
The development of evidence‐based strategies to promote optimal opioid prescribing for the management of acute exacerbations of chronic pain among hospitalized patients may benefit both hospital providers and patients who have a mutual goal for safe and effective pain relief. Methods to provide adequate pain relief to patients that allow hospitalists to maintain efficiency, while ensuring protection from medicolegal consequences related to opioid diversion or opioid overdose, are urgently needed.
Disclosures
This work was supported by the Denver Health Department of Medicine Small Grants Program, which was not involved in the design, conduct, or reporting of the study, or in the decision to submit the manuscript for publication. Dr. Binswanger was supported by the National Institute On Drug Abuse of the National Institutes of Health under award number R34DA035952. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The authors declare that they do not have any conflicts of interest.
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- , . Achieving the right balance in oversight of physician opioid prescribing for pain: the role of state medical boards. J Law Med Ethics. 2003;31(1):21–40.
- , , , , . Regulating opioid prescribing through prescription monitoring programs: balancing drug diversion and treatment of pain. Pain Med. 2004;5(3):309–324.
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- US Drug Enforcement Administration, Department of Justice. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Fed Regist. 2014;79(163):49661–49682.
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- , , , , . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307–310.
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- , , , . Emotion, attention, and the ‘negativity bias’, studied through event‐related potentials. Int J Psychophysiol. 2001;41(1):75–85.
- , . Cognitive Dissonance: Progress on a Pivotal Theory in Social Psychology. Washington, DC: American Psychological Association; 1999.
- , , , , . Identifying hospital organizational strategies to reduce readmissions. Am J Med Qual. 2013;28(4):278–285.
- , , , , . Avoiding readmissions‐support systems required after discharge to continue rapid recovery? J Arthroplasty. 2015;30(4):527–530.
- , , , , . Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786–793.
- , , . A framework for the frontline: how hospitalists can improve healthcare value. J Hosp Med. 2016;11(4):297–302.
- , , , . Hospitalist staffing and patient satisfaction in the national Medicare population. J Hosp Med. 2013;8(3):126–131.
- , . Improving patient satisfaction: timely feedback to specific physicians is essential for success. J Hosp Med. 2015;10(8):555–556.
- , . Users' guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence‐Based Medicine Working Group. JAMA. 2000;284(4):478–482.
- , . Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence‐Based Medicine Working Group. JAMA. 2000;284(3):357–362.
- , , , , , . The prevalence of pain in hospitalized patients and resolution over six months. Pain. 1992;50(1):15–28.
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- , , , , , . Prevalence and characteristics of hospitalized adults on chronic opioid therapy. J Hosp Med. 2014;9(2):82–87.
- , , , . Characteristics of pain in hospitalized medical patients, surgical patients, and outpatients attending a pain management centre. Br J Anaesth. 2013;110(6):1017–1023.
- Institute of Medicine (US) Committee on Advancing Pain Research, Care, and Education. Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: National Academy of Sciences; 2011.
- , , , . Patient perception of pain care in hospitals in the United States. J Pain Res. 2009;2:157–164.
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- , , . Impact of patient satisfaction ratings on physicians and clinical care. Patient Prefer Adherence. 2014;8:437–446.
- , , , , . Opioid utilization and opioid‐related adverse events in non‐surgical patients in U.S. hospitals. J Hosp Med. 2014;9(2):73–81.
- Centers for Disease Control and Prevention. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10–13.
- Centers for Disease Control and Prevention. Vital signs: overdoses of prescription opioid pain relievers and other drugs among women—United States, 1999–2010. MMWR Morb Mortal Wkly Rep. 2013;62(26):537–542.
- , , , , . Patient perception of pain care in the United States: a 5‐year comparative analysis of hospital consumer assessment of health care providers and systems. Pain Physician. 2014;17(5):369–377.
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- , , , , . What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug‐related behaviors? A structured evidence‐based review. Pain Med. 2008;9(4):444–459.
- , , , , , . Controlled substance abuse and illicit drug use in chronic pain patients: an evaluation of multiple variables. Pain Physician. 2006;9(3):215–225.
- , , , et al. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res. 2006;6:46.
- , , , , . Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers? Pain Med. 2007;8(8):647–656.
- , , , et al. Prescription long‐term opioid use in HIV‐infected patients. Clin J Pain. 2012;28(1):39–46.
- , , , et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003;4(3):277–294.
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- , , , , . Exploring beliefs and practice of opioid prescribing for persistent non‐cancer pain by general practitioners. Eur J Pain. 2007;11(1):93–98.
- , , , , . Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. J Opioid Manag. 2014;10(6):375–382.
- , , , . Influences of attitudes on family physicians' willingness to prescribe long‐acting opioid analgesics for patients with chronic nonmalignant pain. Clin Ther. 2007;29(suppl):2589–2602.
- . Failure of enforcement controlled substance laws in health policy for prescribing opiate medications: a painful assessment of morbidity and mortality. Am J Ther. 2006;13(6):527–533.
- , . Achieving the right balance in oversight of physician opioid prescribing for pain: the role of state medical boards. J Law Med Ethics. 2003;31(1):21–40.
- , , , , . Regulating opioid prescribing through prescription monitoring programs: balancing drug diversion and treatment of pain. Pain Med. 2004;5(3):309–324.
- . The other side of trust in health care: prescribing drugs with the potential for abuse. Bioethics. 2007;21(1):51–60.
- US Drug Enforcement Administration, Department of Justice. Schedules of controlled substances: rescheduling of hydrocodone combination products from schedule III to schedule II. Fed Regist. 2014;79(163):49661–49682.
- , . Demonstrating rigor using thematic analysis: a hybrid approach of inductive and deductive coding and theme development. Int J Qual Methods. 2008;5(1):80–92.
- , . Analyzing Qualitative Data: Systematic Approaches. Thousand Oaks, CA: Sage; 2009.
- . Qualitative Research and Evaluation Methods, Third Edition. Thousand Oaks, CA: Sage; 2002.
- , , , et al. Pharmacological management of chronic neuropathic pain—consensus statement and guidelines from the Canadian Pain Society. Pain Res Manag. 2007;12(1):13–21.
- , , , et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–130.
- , , , . Communication interventions make a difference in conversations between physicians and patients: a systematic review of the evidence. Med Care. 2007;45(4):340–349.
- , , , . Promoting effective transitions of care at hospital discharge: a review of key issues for hospitalists. J Hosp Med. 2007;2(5):314–323.
- , , , , . We need to talk: primary care provider communication at discharge in the era of a shared electronic medical record. J Hosp Med. 2015;10(5):307–310.
- , , , . Negative information weighs more heavily on the brain: the negativity bias in evaluative categorizations. J Pers Soc Psychol. 1998;75(4):887–900.
- , , , . Emotion, attention, and the ‘negativity bias’, studied through event‐related potentials. Int J Psychophysiol. 2001;41(1):75–85.
- , . Cognitive Dissonance: Progress on a Pivotal Theory in Social Psychology. Washington, DC: American Psychological Association; 1999.
- , , , , . Identifying hospital organizational strategies to reduce readmissions. Am J Med Qual. 2013;28(4):278–285.
- , , , , . Avoiding readmissions‐support systems required after discharge to continue rapid recovery? J Arthroplasty. 2015;30(4):527–530.
- , , , , . Effect of hospitalist workload on the quality and efficiency of care. JAMA Intern Med. 2014;174(5):786–793.
- , , . A framework for the frontline: how hospitalists can improve healthcare value. J Hosp Med. 2016;11(4):297–302.
- , , , . Hospitalist staffing and patient satisfaction in the national Medicare population. J Hosp Med. 2013;8(3):126–131.
- , . Improving patient satisfaction: timely feedback to specific physicians is essential for success. J Hosp Med. 2015;10(8):555–556.
- , . Users' guides to the medical literature: XXIII. Qualitative research in health care B. What are the results and how do they help me care for my patients? Evidence‐Based Medicine Working Group. JAMA. 2000;284(4):478–482.
- , . Users' guides to the medical literature: XXIII. Qualitative research in health care A. Are the results of the study valid? Evidence‐Based Medicine Working Group. JAMA. 2000;284(3):357–362.
Let ’em cry … or not
A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”
You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?
Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.
Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.
Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.
The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.
The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?
Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.
One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”
You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?
Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.
Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.
Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.
The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.
The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?
Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.
One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
A young couple already has decided to bring their as-yet-unborn child to your group. Now they are interviewing each member in hopes of finding a primary care physician who will best fit their expectations. Their second question for you is, “How do you feel about letting a baby cry itself to sleep?”
You sense that their question is a Rorschach test and a sneaky attempt to peer into what makes you tick. But let’s pretend for a moment that you are seized by a brain cramp and fail to do the obvious by turning the question around and asking them about how they feel about sleep training. Instead, you shoot from the hip. How would you respond?
Would you tell them that allowing a child to cry himself to sleep is neither dangerous nor cruel? Nor does it commit the child to a life of insecurity and emotional imbalance. In your opinion, if done correctly, it is usually the quickest and least painful way to help a child develop healthy sleep habits.
Or would you tell them that their child’s cry means that he needs something, and it is their responsibility to meet that need? That you believe letting a child cry himself to sleep is cruel and that it is better to let a child develop the skill of falling to sleep naturally at his own pace.
Because you neglected to first determine where these parents are coming from, regardless of which end of the spectrum you favor, your candid, nuance-free answer is likely to be a problem for somebody. If you revealed that you are a let-’em-cry proponent, the parents who were looking for a sensitive, child-centered pediatrician will quickly cross you off their list. However, if the parents choose you because you presented yourself as a let-nature-take-its-time pediatrician, they may have narrowed their options when their baby fails to settle in easily.
The challenge of how best to advise parents about infant sleep problems is a prime example of when practicing primary care medicine becomes an art. The answer to the let-’em-cry … or not dilemma is saturated with emotion and pretty much devoid of supporting scientific data. My gut, my personality, and 40 years of experience tell me that, more often than not, letting children cry themselves to sleep is the better approach. However, experience also has told me to keep my mouth shut when the topic of infant sleep is painted in the black-and-white question of let ‘em cry … or not.
The best approach is to learn as much as possible about the baby’s parents. Do they have similar or widely differing tolerances for a crying infant? I won’t really learn this until the parenting game has begun. Will I be able to convince these parents that, while it may be their responsibility to meet their crying child’s needs, one of those needs is the need to fall asleep? Or will I be wasting my time by trying to change their instincts?
Regardless of your own bias, your advice must be tailored to each individual family’s strengths and vulnerabilities, including the child’s temperament and the parents’ emotional resilience and tolerance for crying. Just as when we are counseling a mother who is nearing the end of her struggle with breastfeeding, a pediatrician must be prepared to become a chameleon and leave his or her bias behind.
One of the best strategies for avoiding that treacherous let-’em-cry … or not fork in the road is to promote good sleep habits from the beginning. When a baby is gaining weight, I encourage mothers to shorten feedings so that the baby finishes most feedings sated and drowsy but not fully asleep. I urge parents who find that a pacifier helps to use it only when the child is in his crib and to create a dim light, minimal-stimulation environment from around 7 p.m. to 7 a.m. By encouraging families to adopt these and other sleep-friendly practices early, I can often avoid revealing the ugly truth that, at my core, I am really a let-’em-cry guy.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.”
MRSA prevalence in asymptomatic athletes comparable to dialysis, HIV patients
The prevalence of methicillin-resistant Staphylococcus aureus colonization among asymptomatic athletes is more than three times higher than the rate reported for the community population overall, a systematic review and meta-analysis showed.
Investigators searched PubMed and EMBASE looking for studies on MRSA colonization among the athletic community. They did not include studies involving individuals who previously were infected or had active MRSA infections. The database search yielded 382 studies, and of those, 15 were included in the meta-analysis, reported Dr. Styliani Karanika of Rhode Island Hospital’s infectious diseases division at Brown University, Providence, R.I. (Clin Infect Dis. 2016 April 18. doi: 10.1093/cid/ciw240).
By conducting a statistical analysis among 1,495 screened asymptomatic athletic team members (athletes and staff), Dr. Karanika and colleagues were able to see how the prevalence of MRSA colonization differed among athletes by level of playing experience and sport. The investigators found that the 6% prevalence of MRSA colonization among asymptomatic athletes was comparable to the prevalence among patients on dialysis (6%) and those with HIV (6.9%). Among college athletes, the 13% prevalence of MRSA was almost twice the rate found among patients in intensive care units (7%).
When it came to individual sports, the highest prevalence was found in wrestling (22%), followed by football (8%) and basketball (8%). The risk for subsequent MRSA skin and soft tissue infection among colonized athletes was more than seven times higher than the risk of MRSA skin and soft tissue infection among noncolonized athletes within a 3-month follow-up period upon documented MRSA colonization. Decolonization treatment was effective in reducing the risk of infection in colonized individuals.
“Our findings highlight the importance of controlling the spread of MRSA in the athletic setting, particularly among collegiate athletes,” Dr. Karanika said in an interview.
Dr. Karanika noted that athletes are more susceptible to MRSA because of the frequency of skin abrasions, close contact, shared equipment and training facilities, and poor hygiene practices that can result from the intense demands and time restrictions. Because the prevalence of MRSA colonization is high among this group, coaches, athletes, and athletic trainers should be aware of the early symptoms of a MRSA skin and soft tissue infection, and they should be educated about proper hygiene and prevention and control protocols to halt the spread of MRSA.
Though researchers found decolonization to be effective at reducing the risk of subsequent infection, they believe more research is needed to determine the durability and feasibility of decolonization regimens. Until these protocols are established, they said, strategies including implementing MRSA surveillance in athletes, environmental surveys, and regularly occurring physical examinations of athletes over the course of the season might help break the cycle of MRSA colonization-infection-transmission in athletic settings.
The investigators declared no conflicts of interest.
The prevalence of methicillin-resistant Staphylococcus aureus colonization among asymptomatic athletes is more than three times higher than the rate reported for the community population overall, a systematic review and meta-analysis showed.
Investigators searched PubMed and EMBASE looking for studies on MRSA colonization among the athletic community. They did not include studies involving individuals who previously were infected or had active MRSA infections. The database search yielded 382 studies, and of those, 15 were included in the meta-analysis, reported Dr. Styliani Karanika of Rhode Island Hospital’s infectious diseases division at Brown University, Providence, R.I. (Clin Infect Dis. 2016 April 18. doi: 10.1093/cid/ciw240).
By conducting a statistical analysis among 1,495 screened asymptomatic athletic team members (athletes and staff), Dr. Karanika and colleagues were able to see how the prevalence of MRSA colonization differed among athletes by level of playing experience and sport. The investigators found that the 6% prevalence of MRSA colonization among asymptomatic athletes was comparable to the prevalence among patients on dialysis (6%) and those with HIV (6.9%). Among college athletes, the 13% prevalence of MRSA was almost twice the rate found among patients in intensive care units (7%).
When it came to individual sports, the highest prevalence was found in wrestling (22%), followed by football (8%) and basketball (8%). The risk for subsequent MRSA skin and soft tissue infection among colonized athletes was more than seven times higher than the risk of MRSA skin and soft tissue infection among noncolonized athletes within a 3-month follow-up period upon documented MRSA colonization. Decolonization treatment was effective in reducing the risk of infection in colonized individuals.
“Our findings highlight the importance of controlling the spread of MRSA in the athletic setting, particularly among collegiate athletes,” Dr. Karanika said in an interview.
Dr. Karanika noted that athletes are more susceptible to MRSA because of the frequency of skin abrasions, close contact, shared equipment and training facilities, and poor hygiene practices that can result from the intense demands and time restrictions. Because the prevalence of MRSA colonization is high among this group, coaches, athletes, and athletic trainers should be aware of the early symptoms of a MRSA skin and soft tissue infection, and they should be educated about proper hygiene and prevention and control protocols to halt the spread of MRSA.
Though researchers found decolonization to be effective at reducing the risk of subsequent infection, they believe more research is needed to determine the durability and feasibility of decolonization regimens. Until these protocols are established, they said, strategies including implementing MRSA surveillance in athletes, environmental surveys, and regularly occurring physical examinations of athletes over the course of the season might help break the cycle of MRSA colonization-infection-transmission in athletic settings.
The investigators declared no conflicts of interest.
The prevalence of methicillin-resistant Staphylococcus aureus colonization among asymptomatic athletes is more than three times higher than the rate reported for the community population overall, a systematic review and meta-analysis showed.
Investigators searched PubMed and EMBASE looking for studies on MRSA colonization among the athletic community. They did not include studies involving individuals who previously were infected or had active MRSA infections. The database search yielded 382 studies, and of those, 15 were included in the meta-analysis, reported Dr. Styliani Karanika of Rhode Island Hospital’s infectious diseases division at Brown University, Providence, R.I. (Clin Infect Dis. 2016 April 18. doi: 10.1093/cid/ciw240).
By conducting a statistical analysis among 1,495 screened asymptomatic athletic team members (athletes and staff), Dr. Karanika and colleagues were able to see how the prevalence of MRSA colonization differed among athletes by level of playing experience and sport. The investigators found that the 6% prevalence of MRSA colonization among asymptomatic athletes was comparable to the prevalence among patients on dialysis (6%) and those with HIV (6.9%). Among college athletes, the 13% prevalence of MRSA was almost twice the rate found among patients in intensive care units (7%).
When it came to individual sports, the highest prevalence was found in wrestling (22%), followed by football (8%) and basketball (8%). The risk for subsequent MRSA skin and soft tissue infection among colonized athletes was more than seven times higher than the risk of MRSA skin and soft tissue infection among noncolonized athletes within a 3-month follow-up period upon documented MRSA colonization. Decolonization treatment was effective in reducing the risk of infection in colonized individuals.
“Our findings highlight the importance of controlling the spread of MRSA in the athletic setting, particularly among collegiate athletes,” Dr. Karanika said in an interview.
Dr. Karanika noted that athletes are more susceptible to MRSA because of the frequency of skin abrasions, close contact, shared equipment and training facilities, and poor hygiene practices that can result from the intense demands and time restrictions. Because the prevalence of MRSA colonization is high among this group, coaches, athletes, and athletic trainers should be aware of the early symptoms of a MRSA skin and soft tissue infection, and they should be educated about proper hygiene and prevention and control protocols to halt the spread of MRSA.
Though researchers found decolonization to be effective at reducing the risk of subsequent infection, they believe more research is needed to determine the durability and feasibility of decolonization regimens. Until these protocols are established, they said, strategies including implementing MRSA surveillance in athletes, environmental surveys, and regularly occurring physical examinations of athletes over the course of the season might help break the cycle of MRSA colonization-infection-transmission in athletic settings.
The investigators declared no conflicts of interest.
FROM CLINICAL INFECTIOUS DISEASES
Key clinical point: The prevalence of methicillin-resistant Staphylococcus aureus colonization among asymptomatic athletes is comparable to that among individuals with chronic illnesses.
Major finding: The prevalence of MRSA colonization was 8% among U.S. athletes and 13% among U.S. collegiate athletes. The prevalence of MRSA in the total athletic population was comparable to MRSA in patients with illnesses such as kidney disease and HIV.
Data source: A PubMed and EMBASE search yielded 382 studies and was narrowed to 15 analyses.
Disclosures: The investigators declared no conflicts of interest.
Phone coaching adds limited benefits in knee osteoarthritis
Adding telephone coaching to a home-based physiotherapist-prescribed activity program does not increase the pain and function benefits of such a program alone in knee osteoarthritis, a randomized controlled trial shows.
Kim L. Bennell, Ph.D., and her associates recruited volunteers who were aged 50 years and older, had knee pain rated at 4 or higher on an 11-point scale, and were classified as sedentary. One group participated in both coaching and the home-based physiotherapy program; the other participated in the home-based physiotherapy program alone.
Overall,142 (85%), 136 (81%), and 128 (76%) participants completed 6-, 12-, and 18-month measurements. In the 6-month outcomes, no significance differences were found between the two groups in average pain (mean difference, 0.4 units) or in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function (1.8 units). In addition, there was no change between group differences observed at either 12 or 18 months. At 6 months, however, both groups showed large significant and clinically important improvements from baseline in the primary outcomes of pain and function, reported Dr. Bennell of the Centre for Health, Exercise and Sports Medicine at the University of Melbourne.
Reseachers also examined secondary outcomes and found there was no significant difference for change in numeric rating scale walking pain, WOMAC pain, or quality-of-life scores at any time.
“Improving exercise adherence was an aim of our coaching intervention given that adherence is positively linked to clinical outcomes in knee OA,” the reseachers concluded. “Our study provides novel information about the effects of telephone coaching alongside a physiotherapy prescribed physical activity and exercise program and extends the limited research in telephone coaching for OA.”
Read the full study in Arthritis Care & Research (doi: 10.1002/acr.22915).
Adding telephone coaching to a home-based physiotherapist-prescribed activity program does not increase the pain and function benefits of such a program alone in knee osteoarthritis, a randomized controlled trial shows.
Kim L. Bennell, Ph.D., and her associates recruited volunteers who were aged 50 years and older, had knee pain rated at 4 or higher on an 11-point scale, and were classified as sedentary. One group participated in both coaching and the home-based physiotherapy program; the other participated in the home-based physiotherapy program alone.
Overall,142 (85%), 136 (81%), and 128 (76%) participants completed 6-, 12-, and 18-month measurements. In the 6-month outcomes, no significance differences were found between the two groups in average pain (mean difference, 0.4 units) or in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function (1.8 units). In addition, there was no change between group differences observed at either 12 or 18 months. At 6 months, however, both groups showed large significant and clinically important improvements from baseline in the primary outcomes of pain and function, reported Dr. Bennell of the Centre for Health, Exercise and Sports Medicine at the University of Melbourne.
Reseachers also examined secondary outcomes and found there was no significant difference for change in numeric rating scale walking pain, WOMAC pain, or quality-of-life scores at any time.
“Improving exercise adherence was an aim of our coaching intervention given that adherence is positively linked to clinical outcomes in knee OA,” the reseachers concluded. “Our study provides novel information about the effects of telephone coaching alongside a physiotherapy prescribed physical activity and exercise program and extends the limited research in telephone coaching for OA.”
Read the full study in Arthritis Care & Research (doi: 10.1002/acr.22915).
Adding telephone coaching to a home-based physiotherapist-prescribed activity program does not increase the pain and function benefits of such a program alone in knee osteoarthritis, a randomized controlled trial shows.
Kim L. Bennell, Ph.D., and her associates recruited volunteers who were aged 50 years and older, had knee pain rated at 4 or higher on an 11-point scale, and were classified as sedentary. One group participated in both coaching and the home-based physiotherapy program; the other participated in the home-based physiotherapy program alone.
Overall,142 (85%), 136 (81%), and 128 (76%) participants completed 6-, 12-, and 18-month measurements. In the 6-month outcomes, no significance differences were found between the two groups in average pain (mean difference, 0.4 units) or in Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) function (1.8 units). In addition, there was no change between group differences observed at either 12 or 18 months. At 6 months, however, both groups showed large significant and clinically important improvements from baseline in the primary outcomes of pain and function, reported Dr. Bennell of the Centre for Health, Exercise and Sports Medicine at the University of Melbourne.
Reseachers also examined secondary outcomes and found there was no significant difference for change in numeric rating scale walking pain, WOMAC pain, or quality-of-life scores at any time.
“Improving exercise adherence was an aim of our coaching intervention given that adherence is positively linked to clinical outcomes in knee OA,” the reseachers concluded. “Our study provides novel information about the effects of telephone coaching alongside a physiotherapy prescribed physical activity and exercise program and extends the limited research in telephone coaching for OA.”
Read the full study in Arthritis Care & Research (doi: 10.1002/acr.22915).
FROM ARTHRITIS CARE & RESEARCH
Strong gender difference for stroke in diabetes patients with restless legs syndrome
CHICAGO – Stroke risk in diabetic women with restless legs syndrome (RLS) is triple that of diabetic men with the sensorimotor disease, Zoe Heis reported at the annual meeting of the American College of Cardiology.
The mechanism underlying this marked gender discrepancy in risk requires further investigation, as does the highly practical question of whether improved diabetic control can reduce the stroke risk, said Ms. Heis of the Center for Integrative Research on Cardiovascular Aging at Aurora Health Care in Milwaukee.
She presented a retrospective cohort study of 385 patients diagnosed with RLS during 2011-2013 at a community sleep center using the International RLS Study Group criteria. Along with 770 propensity-matched controls, they were followed until mid-2015. At baseline, 40% of the RLS patients had diabetes and 70% had hypertension, as did 32% and 63% of controls, respectively.
Stroke occurred in 7.5% of the RLS group and 4.2% of matched controls. The presence of diabetes more than doubled the stroke risk in both groups.
The risk of stroke was 18.2% in diabetic women with RLS and 7% in diabetic men with RLS. In a multivariate analysis that controlled for potential confounding factors, this translated to a threefold increased stroke risk.
Diabetes was associated with a doubling of stroke risk in subjects without RLS, but the risk was similar in men and women, according to Ms. Heis.
In addition to diabetes and female gender, the other major predictor of increased stroke risk in patients with RLS was, not surprisingly, hypertension. It was associated with a 13-fold increased likelihood of stroke, she noted.
RLS was initially linked to increased risk of coronary heart disease in a report from the Nurses’ Health Study (Circulation. 2012 Oct 2;126[14]:1689-94). In 2015, another research group linked more severe RLS to an increased risk of stroke. Ms. Heis and her coinvestigators carried out the current study to test their hypothesis that, since diabetes is a condition that accelerates cardiovascular disease, the endocrine disorder would boost stroke risk more in subjects with RLS than in those without it.
Ms. Heis reported having no financial conflicts regarding her study, which was conducted free of commercial support.
CHICAGO – Stroke risk in diabetic women with restless legs syndrome (RLS) is triple that of diabetic men with the sensorimotor disease, Zoe Heis reported at the annual meeting of the American College of Cardiology.
The mechanism underlying this marked gender discrepancy in risk requires further investigation, as does the highly practical question of whether improved diabetic control can reduce the stroke risk, said Ms. Heis of the Center for Integrative Research on Cardiovascular Aging at Aurora Health Care in Milwaukee.
She presented a retrospective cohort study of 385 patients diagnosed with RLS during 2011-2013 at a community sleep center using the International RLS Study Group criteria. Along with 770 propensity-matched controls, they were followed until mid-2015. At baseline, 40% of the RLS patients had diabetes and 70% had hypertension, as did 32% and 63% of controls, respectively.
Stroke occurred in 7.5% of the RLS group and 4.2% of matched controls. The presence of diabetes more than doubled the stroke risk in both groups.
The risk of stroke was 18.2% in diabetic women with RLS and 7% in diabetic men with RLS. In a multivariate analysis that controlled for potential confounding factors, this translated to a threefold increased stroke risk.
Diabetes was associated with a doubling of stroke risk in subjects without RLS, but the risk was similar in men and women, according to Ms. Heis.
In addition to diabetes and female gender, the other major predictor of increased stroke risk in patients with RLS was, not surprisingly, hypertension. It was associated with a 13-fold increased likelihood of stroke, she noted.
RLS was initially linked to increased risk of coronary heart disease in a report from the Nurses’ Health Study (Circulation. 2012 Oct 2;126[14]:1689-94). In 2015, another research group linked more severe RLS to an increased risk of stroke. Ms. Heis and her coinvestigators carried out the current study to test their hypothesis that, since diabetes is a condition that accelerates cardiovascular disease, the endocrine disorder would boost stroke risk more in subjects with RLS than in those without it.
Ms. Heis reported having no financial conflicts regarding her study, which was conducted free of commercial support.
CHICAGO – Stroke risk in diabetic women with restless legs syndrome (RLS) is triple that of diabetic men with the sensorimotor disease, Zoe Heis reported at the annual meeting of the American College of Cardiology.
The mechanism underlying this marked gender discrepancy in risk requires further investigation, as does the highly practical question of whether improved diabetic control can reduce the stroke risk, said Ms. Heis of the Center for Integrative Research on Cardiovascular Aging at Aurora Health Care in Milwaukee.
She presented a retrospective cohort study of 385 patients diagnosed with RLS during 2011-2013 at a community sleep center using the International RLS Study Group criteria. Along with 770 propensity-matched controls, they were followed until mid-2015. At baseline, 40% of the RLS patients had diabetes and 70% had hypertension, as did 32% and 63% of controls, respectively.
Stroke occurred in 7.5% of the RLS group and 4.2% of matched controls. The presence of diabetes more than doubled the stroke risk in both groups.
The risk of stroke was 18.2% in diabetic women with RLS and 7% in diabetic men with RLS. In a multivariate analysis that controlled for potential confounding factors, this translated to a threefold increased stroke risk.
Diabetes was associated with a doubling of stroke risk in subjects without RLS, but the risk was similar in men and women, according to Ms. Heis.
In addition to diabetes and female gender, the other major predictor of increased stroke risk in patients with RLS was, not surprisingly, hypertension. It was associated with a 13-fold increased likelihood of stroke, she noted.
RLS was initially linked to increased risk of coronary heart disease in a report from the Nurses’ Health Study (Circulation. 2012 Oct 2;126[14]:1689-94). In 2015, another research group linked more severe RLS to an increased risk of stroke. Ms. Heis and her coinvestigators carried out the current study to test their hypothesis that, since diabetes is a condition that accelerates cardiovascular disease, the endocrine disorder would boost stroke risk more in subjects with RLS than in those without it.
Ms. Heis reported having no financial conflicts regarding her study, which was conducted free of commercial support.
AT ACC 16
Key clinical point: Diabetic women who have restless legs syndrome face a sharply elevated risk of stroke.
Major finding: Stroke occurred in 18.2% of diabetic women with restless legs syndrome, compared with 7% of men.
Data source: This retrospective cohort study included 385 patients with restless legs syndrome and 770 propensity-matched controls.
Disclosures: This study was conducted free of commercial support. The presenter reported having no financial conflicts.