In the 2014, nearly 260 million painkiller prescriptions were issued in the United States, and the steady annual increase in issuance has been called into question as opioid-related deaths have surged. The CDC reported earlier this year opioid-related overdoses increased by 200 percent since 2000. Most of the people who overdosed were 25 to 44 years old, or older than 55 years old, and lived in the Midwestern, Northeastern and Southern states.
“These findings indicate that the opioid overdose epidemic is worsening. There is a need for continued action to prevent opioid abuse, dependence and death, improve treatment capacity for opioid use disorders, and reduce the supply of illicit opioids, particularly heroin and illicit fentanyl,” wrote CDC authors in the Morbidity and Mortality Weekly Report, published on Jan. 1, 2016.
“I do not think anyone in the country can pinpoint what led to this increase in prescriptions, but obviously, as we look back, (the United States) obviously consumes more than any other (country) in the world,” said Dr. Asokumar Buvanendran, an Anesthesiologist and professor at Rush University Department of Anesthesia and Vice Chair of the Pain Committee at American Society of Anesthesiologist (ASA). With more patients taking opioids, the probability of more addicts also increases. After prescriptions runs out, patients turn to the street for illegally sold drugs or to their primary care providers for a prescription refill. Increased awareness of this phenomenon resulted in several changes, including:
- The FDA announced in March 2016 it would add a boxed warning to immediate-release opioid painkillers, in addition to the extended-release drugs that were given the warning in 2013.
- The CDC offered recommendations to clinicians in mid-March that suggest limiting opioid treatment to three days.
- Massachusetts Gov. Charlie Baker spearheaded a law that passed in March 2016 mandating patient screening, monitoring programs and substance-abuse assessments, in addition to other measures, to limit and identify opioid abuse.
The “first, do no harm” principle of healthcare is being challenged and opioids are in question. Those in favor of opioids argue the drug has offered patients pain relief for decades and can be relied on, is accessible and is easy to administer. Those against using opioids as the central component of a pain management system argue the constipation, drowsiness, nausea, vomiting and slower recovery do enough harm to find a better solution.
“In light of the current opioid epidemic and its status as a public health issue, it is clear physicians need to further evaluate and scrutinize their current screening methods for selecting pain management systems — the development of the CDC guidelines, and others, are a direct response to that,” said Roger Massengale, general manager of Halyard Health acute pain, adding, “Now, individual states are creating prescribing practice guidelines, such as best practices for managing opioids in the emergency department and throughout the hospital where prescriptions are written, to curb the amount of opioids prescribed to patients. This effort goes beyond traditional screenings conducted by an individual clinician and provides broader, standardized guidelines to address the epidemic head on.”
Opioids in Recovery
Chronic pain has been the focus of these discussions. Yet, how postoperative pain is managed does not seem to be affected. Instead of external pressures molding practices, surgical teams seem to be slowly evolving themselves. Early recovery programs have been promoting multi-modal analgesic management approaches for decades, and, in addition to improving overall outcomes, the programs inadvertently reduce the potential for opioid abuse.
Buvanendran has been part of studies evaluating the impact of multi-modal approaches, and says it should be a baseline for pain management; opioids can be used as a pain rescue, but the foundation of the approach should be non-opioid.
Although nerve-blocks, pain pumps and other non-narcotic approaches have their own side effects, Massengale says the safety data is comprehensive. “Unfortunately, some clinicians are not aware of the full extent of the near-term and long-term detrimental effects of prescribing opioids,” he said referring to side effects such as higher costs associated with longer length of stay, nausea, vomiting, constipation and grogginess, but also addiction.
Because opioids have been the crutch of pain management for decades, Buvanendran says even with supporting evidence, change is slow. “Doing clinical studies itself is hard, but to change clinical practices based on clinical studies is a harder component to affect, because to change people’s inherent culture… is harder.”
This slow-to-change culture in medicine could be confronted with patient demand for non-opioid treatment. Programs, like the CDC’s Vital Signs initiative, are encouraging more patient education toward the risk of opioids, and drug diversion programs are making patients aware of how dangerous leftover or unmonitored drugs can be to addicts. Patients are also being pressured to ask their doctors if narcotics are necessary for their pain.
Although the consumer mindset has not been completely reversed toward taking pain medication, Mayo Clinic did a study in 2015 that showed 72 percent of patients would prefer a non-narcotic pain medication for postoperative pain over a narcotic. Historically, patient preference has led to a gradual shift in practice, but as the Affordable Care Act puts patient satisfaction on a pedestal, more questions from patients about pain management could make this shift faster, especially as opioids remain challenged.
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