Background: Patients on long-term opioid therapy with acute-on-chronic pain are medically and psychosocially complex, frequently hospitalized, and incur substantial health care costs (1–3). Despite their prevalence, hospitalists report limited success improving pain and struggle with the competing demands of alleviating pain and ensuring patient safety (4,5).
Methods: We conducted a national qualitative study within the Hospital Medicine Reengineering Network (HOMERuN) (6). Participants (n=30) were asked to complete a brief survey and participated in virtual focus groups led by trained moderators using guidelines developed based on the National Academy of Medicine’s 3C Framework for Pain and Unhealthy Substance Use: Minimum Core Competencies for Interprofessional Education and Practice (7).
Results: Participants averaged 12 years in clinical practice, worked predominantly in academic medical centers (84%), and represented all U.S. regions. Across institutions, Palliative Care (96%) and Acute Pain (88%) services were widely available, while Addiction Medicine (56%) and Chronic Pain (44%) were less available; outpatient specialty care showed a similar pattern of availability. Clinicians reported high comfort managing chronic pain (76%) but lower comfort caring for patients with both chronic pain and opioid use disorder (48%). Hospitalists described a substantial emotional and cognitive burden when caring for patients with acute-on-chronic pain. These encounters often required extensive preparation, including in-depth chart review, dedicated time to build rapport, and the need for boundary-setting. Participants noted that hospitalists largely shoulder the responsibility for inpatient pain management, with consultant input varying widely in quality and usefulness. Hospitalists reported that Addiction Medicine/Psychiatry could be helpful, but only when patients were open to engaging. As a result, hospitalists are often the ones setting expectations, selecting medications and doses, determining readiness for discharge, and arranging post-discharge care. Participants emphasized the need for system-level solutions rather than reliance on individual champions. The absence of national or institutional guidance leads to wide variation in care, creating frustration for both clinicians and patients. Promising approaches identified included multidisciplinary care plans and pathways, structured intensive outpatient programs, peer advocate involvement, and expanded access to buprenorphine.
Conclusions: Findings highlight the need for stronger support for hospitalists caring for patients on long-term opioid therapy who present with acute-on-chronic pain including the development of standardized, evidence-based guidelines. Health systems should elevate this issue and implement coordinated, multidisciplinary strategies to better meet the complex care needs of this population.