At an educational dinner event hosted by HealthTrust, three physician speakers reflected on the challenges of reversing longstanding pain management practices, as well as some practical and thought-provoking alternatives to unrestrained prescribing of opioid medications. David R. Reagan, M.D., Ph.D., chief medical officer of the Tennessee Department of Health, provided the public health perspective on the current opioid epidemic. HealthTrust physician advisors Valerie Norton, M.D., FACEP, medical director of emergency services at Scripps Health in San Diego, California, and Jeffrey T. Hodrick, M.D., orthopedic surgeon at Southern Joint Replacement Institute (SJRI) in Nashville, Tennessee, then shared their boots-on-the-ground viewpoints on mitigating the crisis.
Two recent studies cited by Dr. Reagan are sufficient in sounding the alarm. The first, courtesy of the Centers for Disease Control and Prevention (CDC), demonstrates that patients can become dependent earlier than once thought—among the opioid-naïve on narcotics for only five days, 10 percent are still on opioids a year later and after 30 days nearly one-third remain users. The second study, looking at opioid consumption 90 to 180 days postoperatively, finds narcotics are equally risky for those undergoing minor surgical procedures (15-fold risk of chronic use) as major ones (16-fold increase) when compared to a control group using non-narcotic alternatives for pain control.
In Tennessee, there are multiple positive signals on the drug war front. Dispensing of opioids fell by 32 percent between 2012 to 2016, pain clinics are 48 percent fewer in number, and doctor-shopping has dropped by two-thirds. But there are still a whole lot of opioids floating around the state—roughly the weight of 107 adult elephants, by Dr. Reagan’s calculation. And overdose deaths were up in 2016, to 1,631, with opioids being implicated in 73 percent of those cases—the highest percentage ever in Tennessee.
Prescription opioids serve as gateway drugs to illicit ones (notably fentanyl and heroin) identified as the ultimate culprits, says Dr. Reagan. Deadly street cocktails are being churned out at the rate of 10,000 pills every hour. Substance abuse disorders have hit adults ages 25 to 55 particularly hard and, while they may well blame themselves, it is technically their body’s dopamine reward system that is hijacking their ability to make good decisions.
People abusing opioids might get 30 days of treatment, if they’re lucky, but research indicates five-year programs are far more successful, Dr. Reagan reports. While there is as yet no reliable genetic test for susceptibility to substance abuse, what is known is that regular users commonly get their first dose via diversion from the medicine cabinet of a friend or family member. The first overdose, he notes, is especially hazardous.
His advice to physicians? Don’t prescribe for more than five days or write more than two scripts, and first give Tylenol and ibuprofen a try. Develop a working relationship with local pharmacies and watch for some of the red flags of patient abuse risk—including problem drinking, smoking, mood disorders, childhood history of abuse or family history of addiction. When e-prescribing is available everywhere, he adds, it will be a “game changer.”
Prevention is the Focus at Scripps
At Scripps Health, Dr. Norton is highly engaged in a perioperative opioid stewardship program (recipient of the 2017 HealthTrust Innovation Grant) that acknowledges the reality that patients prescribed opioids in lieu of non-narcotic alternatives face more surgical complications and longer lengths of stay—and cost the average, 250-bed hospital about $2.5 million more per year. Prevention is her focus, and it helps that there is a long list of options for managing pain that include ice, massage, deep breathing, hypnosis, yoga and distractions.
“The U.S. consumes 99 percent of world’s hydrocodone and 80 percent of its oxycodone, so what are they doing in Europe?” she rhetorically asks. Easy first steps might include physicians requesting “partial fills” of opioid prescriptions, soon to be allowed by California law. Patients could also be reminded that any unconsumed pills—contrary to popular belief—can safely be flushed down the toilet.
It’ll take a good deal of physician re-training—Dr. Norton herself was taught to prescribe a standard 20 pain pills, although research indicates the average patient only takes six of them. Some of that education can’t happen until Scripps establishes prescribing standards for different disease states (recently issued CDC guidelines, aimed at primary care physicians, focus broadly on long-term chronic pain). “I think there is hope,” she says. “This is the most important thing I will do in my career.”
Dr. Norton says hospital administrators can help by letting clinicians know they are supported in their efforts to lower opioid use, and that their job will not be on the line by doing so, especially if outcomes are good and patients aren’t returning in agony for pain relief. Patient satisfaction, with or without a formal scoring mechanism to make the connection, is closely associated with patient comfort. But there are counter measures that physicians can take to improve the care experience without resorting to narcotics, Dr. Norton contends—including introducing themselves, apologizing for waits and talking to the patient’s family. Those tactics should also help make patients more well-disposed toward their doctor before the topic of pain management gets broached.
SJRI Approach Addressing Diversion Risk
Orthopedists are the third highest opioid prescribers among surgeons, which is both a concern and an opportunity for the Southern Joint Replacement Institute, notes Dr. Hodrick. Joint replacement patients today start walking shortly after surgery and are discharged only a day or two after surgery. One of the challenges in prescribing them fewer (if any) narcotics is the time it takes to explain the rationale in a language they can understand. But, he adds, “They appreciate it when you do.” The hesitation is doing so in the face of judgment by patient satisfaction rankings by Yelp and Healthgrades.
Dr. Hodrick is also a strong proponent of changing the clinical obsession with pain—it’s often measured with a numeric score, highlighted on computerized hospital whiteboards, which patients can easily “game” for more opioids. He’s interested in setting up a functional pain scoring system that instead measures the ability of patients to perform activities of daily living. This might logically include yardsticks like normal bowel movements, given that constipation is one of biggest concerns of SJRI patients as well as a chief side effect of opioids.
Diversion is the big opioid-related issue for SJRI (it participated in a local take-back event at Nashville’s TriStar Centennial Medical Center in October), which has shifted its educational focus to ways of managing pain without narcotics. When opioids are prescribed, it’s for no more than six weeks and includes tapering to reduced doses. Since pain medications are often dispensed for convenience, he adds, “the ability to e-prescribe would be helpful and we’re working on that.”
Using less opioids following orthopedic surgery is primarily a matter of setting expectations, says Dr. Hodrick, and much of it can happen during preoperative joint classes and by more aggressively treating inflammation. At SJRI, doctors also manage pain with aromatherapy and massage (thanks to their OB-GYN colleagues), believe TV sets might be useful in teaching meditation, and are experimenting with various perioperative drug cocktails. They are additionally interested in figuring out how to start taking back narcotics at their office once patients hit the six-week mark.
“The Hawthorne effect is real,” he stresses. “Just by thinking about it you will start prescribing narcotics less.” That may well be the biggest lesson of them all.