AbstractBackgroundSpine surgery candidates are commonly treated with long-term opioid analgesia. However, chronic opioid analgesia is associated with poor pain control, psychological distress, decreased functional status and operative complications. Therefore, our medical centre piloted an outpatient biopsychosocial interdisciplinary opioid reduction program for spine surgery candidates on chronic opioid analgesia.MethodsOur case series reviews the outcomes of the first 5 interdisciplinary program completers. Data was collected on admission to the program, preoperatively at completion of the program, and 1 month postoperatively. We recorded changes in pain interference scores, physical functioning, and symptoms of depression and anxiety as captured by the Patient-Reported Outcome Measurement Information System (PROMIS-29) Profile.ResultsThe mean duration of the preoperative opioid reduction program was 6–7 weeks. The mean morphine equivalent daily dose (SD) decreased from 238.2 (226.9) mg on admission to 157.1 (161.0) mg preoperatively and 139.1 (84.0) mg one month postoperatively. Similarly, the mean pain interference score (SD) decreased from 72.4 (5.1) on admission to 66.5 (6.9) preoperatively and 67.7 (5.4) one month postoperatively. The preoperative opioid dose and pain interference scores decreased in all 5 patients, but one month postoperatively increased in one patient related to a surgical complication. Pre- and postoperative depression, anxiety and fatigue improved in all patients. Satisfaction with participation in social roles, sleep disturbances, and physical functioning improved in most patients.ConclusionsPre- and post-operative pain improved despite the opioid dose being tapered. These preliminary data suggest that a short-term outpatient preoperative interdisciplinary biopsychosocial opioid reduction program is safe, feasible, and improves patient-centred outcomes.ImplicationsOur preliminary data support the rationale for expansion of the opioid reduction program; opioid use and pain should be evaluated in all surgical candidates. These findings need to be replicated in larger studies.

Individuals who are on long-term opioid therapy (LTOT) for chronic noncancer pain are frequently admitted to the hospital with acute pain, exacerbations of chronic pain, or comorbidities. Consequently, hospitalists find themselves faced with complex treatment decisions in the context of uncertainty about the effectiveness of LTOT as well as concerns about risks of overdose, opioid use disorders, and adverse events. Our multidisciplinary team sought to synthesize guideline recommendations and primary literature relevant to assessing medical inpatients on LTOT, with the objective of assisting practitioners in balancing effective pain treatment and opioid risk reduction. We identified no primary studies or guidelines specific to assessing medical inpatients on LTOT. Recommendations from outpatient guidelines on LTOT and guidelines on pain management in acute-care settings include the following: evaluate both pain and functional status, differentiate acute from chronic pain, investigate the preadmission course of opioid therapy, obtain a psychosocial history, screen for mental health conditions, screen for substance use disorders, check state prescription drug monitoring databases, order urine drug immunoassays, detect use of sedative-hypnotics, and identify medical conditions associated with increased risk of overdose and adverse events. Although approaches to assessing medical inpatients on LTOT can be extrapolated from related guidelines, observational studies, and small studies in surgical populations, more work is needed to address these critical topics for inpatients on LTOT.

Vignette: An 88-year-old woman visiting from out of town, and out of network, presents to the emergency department with chest pain and rapidly progressing. Delays in the emergency department due to bed capacity lead the patient to be placed under the care of a hospitalist and emergency department physician while waiting for a floor bed. She develops increasing hemodynamic instability and is "upgraded" to an ICU bed with a presumptive diagnosis of septic shock. The ICU team is called. Dr Hackner: What are the challenges with regard to coordina tion of care among the intensivist and hospitalist teams? Dr Maldonado: From the medical standpoint, how much of the information was obtained directly from the emergency physician or from another emergency physician who may have gone off shift before any of the other doctors may have gotten involved? With each progressive handoff, there is potentially a tremendous loss of information. 1,2 Dr Greeno: I am centered on process in what I have been doing. From traveling around the country and visiting all kinds of hospitals, I have learned that there are all kinds of hospitals. Hospitals vary greatly. Most individuals at this roundtable discussion come from large hospitals in urban areas. 3,4 However, the majority of patients across the country are probably cared for in community hospitals that may have completely different types of staffing for the ICUs from closed units with adequate critical care staff to units in communities with absolutely no individuals with critical care training, certification, or boards. 5 Excerpts of the COMPACCS/ABT Report on ICU Physician Staffing 5 : The most common hospital type was private community.

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