Background:
Administering opiates safely in hospitalized patients with acute on chronic pain is challenging. There is limited data to guide pain management in this population due to high prevalence of opiate tolerance and variance in daily opiate exposure. There is a need to establish a safe and effective pain medicine regimen in the hospital that stratifies opiates based on daily exposure while optimizing adjunct pain medication options. Opiate tolerance leveling (OTL) has been trialed previously in the perioperative and post-surgical patients. We aimed to study OTL in the medical population and this is the first trial known to the best of our knowledge in non-surgical patients.
Methods:
An opiate tolerance leveling (OTL) order set was piloted on two medical units during February and March 2016 in a large academic health center. Patients on chronic daily opiates were leveled on admission from naïve to tolerant (OTL 1, OTL 2, or OTL 3) based on their daily opiate intake over 45 days prior to hospitalization. The order set provided mild to severe pain medication options for the nurse to choose from depending on the pain intensity assessment in addition to adjunct pain medications. Retrospective data analysis was completed on 48 patients. A 2-month period preceding this pilot served as a historical control for analysis. Descriptive statistics were used to analyze demographic data, discharge opioid regimen, naltrexone administration and addiction consultation recommendation. Pain Hospital Consumer Assessment of Health Care Providers and Systems (HCAHPS) scores in study and control population were analyzed using Chi square.
Results:
The trial included 48 patients, mean age was 49 years, 65% were females, the average length of stay was 7 days with 44% of the patients classified under OTL 1 category, 44% patients classified under OTL 2 category and 12% classified under OTL3 category. Addiction consultation was recommended in 27% of the sample, including OTL 2 patients with a psychiatric history and all OTL 3 patients. 23% of patients were discharged with increased dosages of opiate prescriptions when compared to their home regimen. Pain HCAHPS in trial patients was not statistically significant when compared to control population. Naloxone was not administered to any of the patients in the trial sample.
Conclusions:
This trial showed high incidence of opiate tolerance in OTL2 patients with psychiatric issues and in all OTL3 patients, supporting the need for an addiction specialist referral. Safety of the OTL order set was demonstrated by the lack of naloxone administration in the study population. This trial did not impact HCAHPS improvement supporting the need to further incorporate effective patient education strategies. Robust multi-center trials are needed to create a multimodal pain order set that is safe, effective and standardized for implementation in opiate tolerant patients.