Pain Management for Opioid Tolerant Patients

Over the past 15 years, opioid use to treat pain has increased dramatically. Between 1999 and 2008, for example, prescription opioid overdose death rates, treatment admission rates, and prescription opioid sales increased 400% (US Centers for Disease Control and Prevention, 2011). As a result, more than 2% of inpatient stays are opioid-related, and more than 15% of inpatients arrive at the hospital already receiving high doses of opioids, even if these drugs are not a direct cause of their admission (Owens et al., 2014).
Despite increases in opioid use among inpatients, the care of hospitalized patients with chronic pain remains insufficient, and is an ongoing source of human suffering and expanded hospital resource utilization (Cole, 2002; Torrance et al., 2010; Herzig et al., 2014). While patients report neither decreased pain levels nor improved satisfaction (Bell, 1997; Bot et al., 2014; Brown et al., 2014), they are increasingly overmedicated, becoming both tolerant and dependent on very high doses of opioids. This cohort is at higher risk for under-managed pain, resulting in significant suffering, prolonged hospital stays, and higher risk for readmission (Apfelbaum et al., 2003; Herzig et al., 2014; Pavon et al., 2014; Wilson et al., 2015). Severe chronic pain and high opioid use increases the incidence of opioid-related adverse events including untimely death (Torrance et al., 2010; Kessler et al., 2013; Anderegg et al., 2014; Herzig et al., 2014; Tayne et al., 2014).. Patients who are opioid-tolerant at the time of admission have longer lengths of stay, higher readmission rates, lower patient satisfaction, and higher rates of adverse events compared to patients who are not opioid-tolerant (Gulur et al., 2014). Our review of inpatient data from University of California-Irvine Health (HS#2014-1493) showed that 1 in 6 admissions is opioid-tolerant. Further, the readmission rate of these patients was 2 to 3 times higher than for patients who are not opioid-tolerant at admission. It is extremely apparent that this population will benefit from targeted intervention, however the existing literature and clinical practice is extremely limited in this regard.

Here, we propose a highly scalable intervention backed by a rigorous research design and aimed at effectively managing pain in opioid-tolerant patients. Specifically, we will conduct a prospective randomized-controlled trial to test a novel clinical care, pain management pathway for patients who are opioid-tolerant at admission. This intervention pathway integrates pain specialists into the clinical care team upon admission, and the patients and their outpatient care providers will have ongoing tele-support and outpatient access as needed, for 30 days post discharge. The control group will receive current standard-of-care, ie, an optional pain management consult at the discretion of the admitting team.