Every day, 115 Americans die after overdosing on an opioid. The rate of opioid-related deaths increased nearly threefold between 2002 and 2015, and heroin-related overdose deaths increased more than six times over during that same time period. These statistics highlight an imperative to reevaluate the use of opioids in pain management and how opioids factor into the patient experience.
Opioids prescribed for legitimate pain management reasons are often a gateway to unintentional abuse, statistics show. Eighty percent of heroin users began their drug abuse using a prescribed opioid, SAMHSA says. Between 21 and 29 percent of people prescribed an opioid for chronic pain end up misusing their drugs.
These facts have started to influence providers’ use of opioids in pain management. Because so many patients are progressing from opioid use for pain management to misuse and potential drug addiction, some advocates have called for more controlled opioid prescribing.
But the opioid epidemic is a complex challenge that goes beyond reducing prescribing rates. Pain management is essential to a positive patient experience, and providers are faced with competing priorities to alleviate patient pain while preventing potential addiction.
Adequate acute pain management is a critical aspect of the overall patient experience within the four walls of the hospital, especially among patients recovering from surgery.
“I'm an anesthesiologist by training, so I do both anesthesia and pain management,” said Arianna Dessilier, MD, who practices at Tufts Medical Center.
“I can tell you that patients immediately after surgery will remember the degree of pain or how poorly the pain was controlled, but they will not remember who the nurse was, how nice the nurse was, or if the surgeon stopped by afterwards.”
Providers face an imperative to mediate patient pain following a complicated medical procedure. This is not only the humane thing to do, Dessilier said, but is also essential for making sure the patient walks away from the care encounter satisfied.
Reconciling the opioid epidemic, pain management, and patient satisfaction becomes even more complicated for providers treating patients with chronic pain.
Eleven percent of adults experience chronic pain, which can quickly become quality of life issue. Pain impacts the patient experience throughout their daily routines, and may limit participation in work, school, or social activities.
But patients who are on long-term opioid treatment plans run a higher risk of becoming dependent on an opioid, leading to addiction to the drug or to heroin, wrote Nora D. Volkow, MD, and A. Thomas McLellan, PhD, in a 2016 New England Journal of Medicine article.
“Opioid analgesics are widely diverted and improperly used, and the widespread use of the drugs has resulted in a national epidemic of opioid overdose deaths and addictions,” the researchers wrote.
The risks of opioid dependence has called into question the use of opioid-based treatments for chronic pain
Healthcare professionals are currently observing friction between priorities for patient quality of life, positive patient experiences, and judicious opioid management. To reconcile conflicting agendas, healthcare professionals must understand the alternatives to opioid pain treatment, how to discuss alternatives with patients, and how to manage patients who still need an opioid medication.
Exploring non-opioid pain management solutions
Across the country, new prescribing guidelines are aiming to reduce the use of opioids. Reduced opioid use should lead to less drug abuse, policymakers have reasoned.
Nationally, the Centers for Disease Control (CDC) has advised providers to prescribe opioids only when necessary, to prescribe the lowest dosage necessary, and to regularly monitor patients for emerging drug dependency.
Providers are also turning to non-opioid pain management options when appropriate.
The decision to use or not to use an opioid treatment for pain patients needs to balance empathy with clinical evidence and expertise, said Dessilier.
“I have to believe every patient when they talk about their pain,” she said. “We have certain signs that would tell us if the condition that the patient describes is real or not. Someone that had a few back surgeries will almost certainly have pain.”
Some warning signs include doctor shopping — the practice of visiting multiple providers in search of a narcotic prescription — and asking for high-potency pain medications.
Dessilier also looks at current scans and tests, the level of engagement patients have with their physical therapy, and other indicators of patient activation in care.
Patients with a history of addiction, alcohol abuse, nicotine addiction, and some mental health issues also tend to be excellent candidates for alternative pain management solutions.
For Nicholas B. Frisch, MD, a Michigan-based orthopedic surgeon, not using opioids for most of his knee and hip replacement patients is the default standard of care.
The increasing popularity of value-based payment models in orthopedic surgery has pushed Frish to alter his pain management protocols. Those changes have also aligned with efforts to combat the opioid epidemic.
“The biggest shift has been realizing that you don’t need to use opioids to manage pain effectively.”
“The concept of multimodal pain control is basically what has allowed us to perform more of these surgeries in an outpatient setting while getting quality outcomes for our patients with pain control,” Frisch added.
Frisch’s multimodal pain control system begins prior to surgery when he gives patients a series of medications that target their pain pathways. Once in surgery, Frisch and the surgical team use a variety of different pain management tools, including periarticular injections around the site they’re working on and non-opioid-based IV medications, such as Tylenol and Decadron.
Following surgery, Frisch proactively gives patients non-opioid medications, such as Tylenol, NSAIDs, and gabapentinoids.
The idea is that non-opioid solutions will address pain before patients need an opioid. If the patient breaks through typical pain thresholds, Frisch and his team prescribe a low-dose opioid treatment.
Frisch and Dessilier both noted that special considerations go into pain management protocols for surgery patients who also use opioids for chronic pain.
“If we have patients who have been on opioids before, and we know they’re going to have surgery and will probably need opioids for a little longer, we try to introduce other adjuvants and other medications to help with that regimen,” Dessilier said. “We work on different mechanisms to improve this pain without the need to increase opioids, because they may not be beneficial.”
Of course, asking a patient who has previously used an opioid for pain management to use a different therapy may not yield a positive response, Dessilier acknowledged, so empathetic patient education is key.
For Frisch, care coordination plays an important role in avoiding opioid use. If a fibromyalgia patient is receiving a hip replacement, he discusses pain management with the pain doctor and the primary care physician.
“We work together to come up with a reasonable program for the patient before surgery, during their inpatient stay, and after surgery,” Frisch explained. “I always follow up with their pain management and primary care doctors to get the patient in a week before surgery to make adjustments. We try to avoid the potential for self-treatment.”
In these cases, Frisch recommends weaning the patient off the opioid prior to the surgery. This must be a frank conversation, Frisch said, with the providers explaining the purpose of discontinuing the medication.
Frisch also recommends consulting the anesthesiologist because patients using chronic opioid medications may react to typical anesthesia protocols differently.
Reconciling reduced use of opioids, patient satisfaction
Pain management needs to be a holistic experience. If a provider is treating the whole person, and not just their pain, opioids may be less necessary.
“Even though you are doing these piecemeal interventions, you need to know that pain medicine is not just about doing interventions,” said Mario De Pinto, medical director of the University of California San Francisco's pain management center. “It’s about taking care of a patient - taking care of his or her problems as a human being.”
Frisch shared similar sentiments. In his role as a knee and hip surgeon, Frisch tells his patients that the joint replacement may reduce their everyday pain and quality of life, eliminating the need for opioids.
“The most important thing is being candid with the patient and having an open discussion about their causes of pain, how it’s evolved over time, how their treatment has been managed and how that’s evolved over time,” Frisch explained.
“Chronic pain may not just be from one area. It’s oftentimes due to several different things. They might come in and have knee or hip pain, but that’s just one part of it.”
This means providers need to engage in more meaningful conversations about patient pain and the benefits and risks of long-term opioid use.
“That’s not always easy, but I’ve found that once that discussion is over most patients don’t want to be on chronic pain medication,” Frisch noted. “That’s not always the case because some have been on opioids for years and it’s become a part of a lifestyle. But once you break it down to this level, they begin to wonder what life will be like when they aren’t on pain medication.”
Dessilier says she educates her patients about the different approaches to pain management. Using only one type of intervention usually isn’t effective.
“I try to educate patients on what their condition is and what are the options of treatment,” she advised. “I usually try to give more than one option of treatment if appropriate; most of the time it’s appropriate. I truly believe in communicating with the patient, spending time listening to the patient, and educating the patient on what their condition is and what the options of treatment is.”
Caring for patients when opioids are the best option
Each of these providers still sometimes uses opioids in some cases, even if they understand the risks in doing so. There isn’t necessarily anything wrong in that, De Pinto said, so long as prescribing is judicious.
“Over the course of the past 30 years, we have gone from a widespread, indiscriminate opioid prescription to a diminished prescription to opioid phobia,” De Pinto said.
“We have switched swinging the pendulum from one way to the other a little bit too much in my opinion.”
“The best possible option that we have for putting a halt to the opioid epidemic is for primary care providers, pain providers, patients, and family to discuss together a more rational and appropriate way to deal with these medications,” he continued.
While healthcare professionals should not constantly turn to their prescription pad, the fundamental issue with the opioid epidemic is not the act of prescribing, De Pinto asserted. Instead, it’s with clinicians who prescribe opioids with insufficient patient education.
“If we use all the tools that we have available these days – including prescription medication monitoring programs, urine drug screening tests, counting pills, and establishing a collaborative and trustworthy relationship with patients and family – we will be able to put an end to the opioid epidemic,” De Pinto asserted.
As legislation and regulation work to streamline opioid prescribing, many initiatives ask providers to learn more about opioid prescribing, patient use, and alternative treatments.
For example, the new Michigan Automated Prescribing System (MAPS), for which Frisch had to register, offers significant provider education.
“In the past, it has been very difficult to see what patients are taking and how much they are taking,” he said. “These rules that are coming about as part of this legislation are going to be a positive shift for providers to be more educated when they are prescribing for patients who need more aggressive pain management.”
If they do prescribe a narcotic, providers and pharmacists need to be aware of the warning signs that the patient may be becoming addicted. Running out of pills early, losing medications, or saying they have been stolen, are some telltale behaviors for patients who are getting hooked on opioids.
Frisch added that doctor shopping — being the fourth or fifth referral for pain patient — is a warning sign. Patients with an obsessive knowledge of their pain medications or who ask for extremely high-dose pain medications, such as long-lasting hydrocodone, is another red flag.
Finally, Frisch looks at the patient’s prior treatment protocol to assess whether the pain should have been alleviated. Again, pain is a symptom of a larger medical condition. After he has treated that condition, Frisch pays careful attention to patients who are still asking for opioids.
“What is the cause of their pain?” he questioned. “If we can alleviate the cause of their pain and still there is opioid consumption, that is a red flag. If I get a call from someone who has gotten an injection and they are in physical therapy and they ask for more pain narcotics, that is a red flag.”
When Frisch notices a patient is becoming addicted to a prescribed opioid treatment, he has to have a frank conversation. These discussions are not necessarily easy, but a come with the territory of being a doctor.
Medical professionals need to be open and candid with patients during these conversations. Although each case is unique, providers can usually expect that patients will avoid the conversation and offer excuses for their medication dependency. Maintaining strong relationships with patients during pain management will help providers address these issues and determine if they are legitimate.
Providers must be resolute in their position, explain to patients the risks of their growing addiction or opioid dependency, and offer viable solutions to the problem. Treatments for opioid addiction will vary depending on addiction severity and patient life circumstances.
For patients who do have dependencies that must be addressed, medication-assisted treatment (MAT) can be an important option. MAT uses a series of less harmful medications that help ease the patient out of an opioid addiction.
Providers also refer patients to opioid tapering programs or behavior health centers to address narcotic dependence.
They key to confronting the opioid crisis is to understand that opioids do play a role in patient care. Some patient pain thresholds do call for narcotic treatment, and studies indicate that opioid use in pain management can improve patient satisfaction.
Instead, efforts to quell the opioid crisis need to be embedded in education. Providers need to understand which alternative pain management solutions will be effective, thus reducing the use of opioids. Patients need to understand the risks involved in opioid use and how to responsibly take these drugs.
“We know that we have an opioid crisis,” De Pinto concluded. “We know that there is a problem. Why don’t we work together to better understand opioid prescribing? It is imperative upon us to find out how to do comprehensive pain management.”
This article was originally published on April 17, 2018.