Dead in Bed: The Dangers of Opioids for Inpatients
Fifty years ago, the Rolling Stones sang of ‘Sister Morphine’ and the craving for the next shot of relief. The song has lost none of its relevancy — overprescribing and aggressive marketing of drugs such as Dilaudid, Demoral, OxyContin and Ritalin during the 1990s aggravated an already-serious dependency issue.
“The idea was to provide very potent, very effective pain relief,” said Kristin McMahon, chief claims officer, North American Specialty, Global Risk Solutions, Liberty Mutual Insurance.
“But the drugs were aimed at elderly patients living out their last days and intended only for a short duration — not for long-term pain relief over an extended period.”
Tackling the problem is no easy task; an estimated 42,000 drug overdose deaths involving opioids were recorded in 2016, five times 1999’s total. While the amount of opioids prescribed in the U.S. peaked eight years ago, it remains at high levels.
There are worrying signs that any progress in this area might be stalling. In March, the Centers for Disease Control and Prevention (CDC) reported that visits to emergency departments for suspected opioid overdoses rose 30 percent between July 2016 and September 2017.
Contributing to the opioid-related mortality toll is the so-called ‘Dead in Bed’ (DiB) phenomenon, which has garnered less public attention but is well-known within the medical community — particularly among anesthesiologists.
DiB accounts for an estimated 3,000 to 5,000 opioid-related deaths annually, typically of patients in hospital wards rather than intensive care.
Prescribed painkillers while recovering from surgery, many inpatients suffer respiratory failure in their sleep. Although the figure is low in relation to deaths from infections or surgical errors, it’s still a cause for concern. Wide variations across states in the number of cases suggest inconsistent prescribing policies among health care providers.
Health Risk Factors
Silvia Sacalis, vice president of clinical services for the pharmacy benefit company Healthesystems, said the risk factors relating to prescribing opioids for inpatients include several knowns and unknowns. Known risks include patients suffering anxiety, depression and pain disorders, and regular users of alcohol and/or tobacco which pre-dispose individuals to addictive behavior.
Unknown risk factors are more numerous.
“Post-surgery, the patient will often be unconscious and the system shuts down under anesthesia,” said Sacalis.
“Certain parts of the brain don’t receive information needed for them to be able to communicate what they’re experiencing.
“He or she might, say, have low blood pressure or an undiagnosed heart condition. As opioids typically slow the heart rate further, this puts the patient at risk of death.”
“Providers need to pay attention to these prescription standards of care, and risk managers within health care organizations are wise to monitor providers’ prescription patterns.” — Mike Midgley, vice president, healthcare risk engineering, Swiss Re Corporate Solutions
Other unknown risks include:
- Undiagnosed asthmatic conditions or breathing difficulties, which worsen respiratory depression.
- Undiagnosed liver or kidney conditions. These organs should metabolise and excrete the drug from the body, but instead they allow it to accumulate.
- Blockages in the intestine or stomach. Opioids slow metabolism and the way the stomach processes a drug, so any blockage can prove fatal.
“All these potential factors need to be discussed with patients and their medical history studied before an opioid is prescribed,” said Sacalis. “However, physicians are getting better at this.”
A November 2017 study from the Journal of the American College of Surgeons found that more vigilant prescribing guidelines could reduce the number of opioids prescribed post-operation by up to 40 percent without compromising patients’ pain management needs.
Imposing a Limit on Prescriptions
Mike Midgley, vice president, healthcare risk engineering at Swiss Re Corporate Solutions, said, “The Centers for Disease Control and Prevention recommends when opioids are used for acute pain, the prescribers should order no greater quantity than needed for the expected duration of pain severe enough to require the opioids. Three days or less will often be sufficient.
“So a prescription of, say, two weeks may in many instance fall outside the expected standard of care. This limit could potentially cause concerns for some patients who are accustomed to a prescription exceeding three days,” explained Midgley.
“Providers need to pay attention to these prescription standards of care, and risk managers within health care organizations are wise to monitor providers’ prescription patterns.”
The CDC guideline for prescribing opioids for chronic pain also encourages the use of prescription drug monitoring programs (PDMPs) to inform clinical practice.
“PDMPs in most states require providers to query a database of opioid prescription use for each patient prior to writing a prescription,” added Midgley.
Sacalis said more information sharing between each state’s PDMP would improve their efficacy.
Many insurers have also set goals to lower opioid use. Cigna, for example, announced in 2016 it was targeting a 25 percent cut over three years and recently reported it had already reached that goal. Last fall, the group also said it would withdraw cover for OxyContin, the branded version of the painkiller oxycodone, but not generic alternatives.
“Insurance companies we utilize that are primarily focused on physician exposures have established underwriting guidelines that don’t allow for refill of these types of drugs by their covered providers,” said Steve Kahl, senior managing director for Gallagher Healthcare Practice.
Working to Save Lives
Kahl said many health care risk managers are still trying to identify emerging liabilities, focusing on regulatory and legal requirements related to physician and pharmacy prescribing impacting their organizations.
“Risk managers are essentially addressing this issue on two fronts: firstly, the management and implementation of best practices for managing and monitoring controlled substances.
“Secondly, they are promoting strategies, tools and policy to minimize patient misuse, and exposures to the organization from patient misuse or harm caused by controlled substances.
McMahon said “the one case rivaling this is the $206 billion tobacco master settlement agreement of 1998, where each company’s contribution reflected their market share.
“We can also expect an opioid-related settlement in billions but deciding how it is divvied up among the market will prove more complicated.” &