Organizers and Facilitators: Morgan Esperance, Rebecca Jaffe, Keri Holmes-Maybank, Amanda Ramsdell, Katherine Welter, Dana Clifton, Jillian Zavodnick, Melissa Bregger, Susan Calcaterra, Catherine Callister, Yuri Shindo, Erin Bredenberg, Noel Ivey, and Elizabeth Pope-Collins.

Background

Patients on long-term opioid therapy (LTOT) admitted with acute-on-chronic pain are medically and psychosocially complex, frequently hospitalized, and incur substantial health care costs. Despite their prevalence, hospitalists report limited success and frustration managing this patient population.

This summary describes hospitalist experiences caring for patients with acute-on-chronic pain, outlines key barriers and facilitators to effective inpatient management, and presents strategies to enhance hospital-based care for this population.

Hospitalist Experiences Managing Patients with Acute-on-Chronic Pain

Hospitalists describe caring for patients with acute-on-chronic pain as emotionally and cognitively demanding. Many clinicians anticipate longer daily visits and potential conflict.

• Considerable time is required to build rapport and understand why a patient is presenting to the hospital now.
• Hospitalists prepare by reviewing the electronic medical record to understand prior admissions, baseline opioid needs, and previous management strategies.
• Hospitalists are aware of the need to avoid anchoring bias and remain alert to new causes of pain.
• Persistent uncertainty exists regarding which consultants to involve, alongside variable engagement and often inadequate support from specialty services.
• Primary responsibility for directing the pain management plan frequently falls to hospitalists.
• Significant challenges arise in minimizing or tapering opioids when efforts generate conflict or when doses are subsequently escalated by other providers.
• Clinical success is commonly defined not by pain scores at discharge, but by a patient’s ability to cope and function outside the hospital.

"Really investing in the story of the patient — recognizing that their hospitalization is just a blip in their entire chronic pain story — takes time, and we need buy-in from them on any plan."

Barriers and Facilitators to Effective Care

Hospitalists report inconsistency in available supports, fragmented systems, and lack of clear national guidance. Despite these challenges, relationship-building and interprofessional collaboration remain bright spots.



• Consultant involvement varies, and recommendations are often nonspecific, requiring hospitalists to independently trial management strategies.
• Care remains siloed, with few unified, patient-centered plans extending across the continuum of care.
• National expert consensus and standardized guidelines are lacking, leading to reliance on local expertise.
• Therapeutic relationships grounded in empathy and clear expectation-setting support improved patient outcomes.
• Leadership models have shifted from anesthesia-led to addiction medicine–led approaches, reflecting a more integrated biopsychosocial framework.
• Interprofessional care models that include nursing, physical therapy, and pharmacy enhance coordination and continuity of care.

"There are all of these different specialists that can consult for these patients, but the hospitalist is often the one setting expectations, choosing doses of medicine — there really doesn't seem to be another service that takes that piece on."

Strategies to Improve Hospital-Based Care

Hospitalists emphasize the importance of coordinated, longitudinal structural solutions rather than isolated inpatient fixes.

• Implementing patient-centered care plans within the electronic health record may promote consistent management but requires clear ownership, regular updating, and clinical authority to avoid increasing patient distress or patient-provider conflict.
• Adopting patient-engagement innovations, such as virtual reality–based distraction tools and mobile care carts, may offer additional avenues to improve the inpatient experience.
• Expanding the use of peer advocates may represent an underutilized strategy for supporting patients with complex pain, drawing on established models from addiction medicine.
• Standardizing care through institutional or hospital medicine group–level guidelines may reduce practice variation, minimize conflict, and improve outcomes.
• Empowering generalists to lead de-siloing efforts may strengthen coordination among inpatient, outpatient, and specialty teams.

"We don't do a good job of supporting this population. There are a lot of opportunities to do things better."

Conclusion



Hospitalists describe caring for patients with acute-on-chronic pain on long-term opioid therapy as highly-complex, emotionally demanding work that is often carried out without consistent guidance or support. Improving care will require coordinated, longitudinal approaches, including standardized guidelines, shared care plans, and strong interprofessional collaboration. With appropriate institutional investment, hospitalists are well-positioned to lead these efforts.

New Publication

A new perspective article from the HOMERuN HEARS working group underscores the need for strategic adaptation to sustain health equity initiatives amid increasingly challenging political and institutional environments. Recent federal policies have created widespread uncertainty, placing clinicians in ethically fraught situations that risk moral injury. To navigate this shifting landscape, the authors review key policies that directly affected health care between January and April 2025 and outline three essential strategies: (1) prioritizing self-care and mutual support; (2) engaging in proactive education and collaborative advocacy; and (3) sustaining the work through individual clinical practices, teaching, and creative funding partnerships that protect research and community engagement.

Wang SXY, Eniasivam A, Sterken D, Johl K, Auerbach A, Hur J, Jenkins A, Maw AN; HOMERuN HEARS Work Group, HOMERuN Collaborative. Navigating Uncertainty: Sustaining Health Equity in a Shifting Landscape. J Gen Intern Med. 2025.

Our next HOMERuN meeting will be on February 6, 2026.

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