Opioids: To Prescribe or Not to Prescribe

by Leslie Kumler

JONATHAN MILTON, 43, accidentally fell asleep on his floor while watching TV. He awoke the next morning and found he was barely able to get up because of a muscle spasm from his hip extending down his leg. At work later in the day, he tried to climb onto his forklift and fell.¹

“I was in so much pain — tears were coming out my eyes,” he said while waiting in the ER at St. Joseph’s University Medical Center in Paterson, NJ.¹

Millions of ER visits in the United States begin under similar circumstances  — due to injury or conditions that cause chronic pain, patients seek pain relief.

In the late 1990s and first decade of the 2000s, patients seeking pain relief were increasingly prescribed opioids.

Brief History of Opioids

Humans have sought pain relief through opioids for millennia, starting with the use of the opium poppy in about 3400 B.C. In 1527, laudanum was created by a Swiss-German alchemist, and it was commonly used to relieve pain in the 18th and 19th centuries. Morphine arrived on the scene in the first decade of the 1800s, quickly becoming a common therapy in the United States. It was even sold as a treatment for opium and alcohol addiction. At the turn of the 20th century, heroin was synthesized and Bayer marketed it as a cough suppressant without morphine’s addictive side effects.

In the early 1900s, the US government began to recognize the problem of opioid addiction with a series of laws. For example, the Harrison Narcotics Tax Act of 1914 restricted the sale of opioids and forbid doctors from prescribing to opioid addicts, and the passage of the Anti-Heroin Act in 1924 made manufacture, importation, or possession of heroin illegal.

By the 1990s, concerns about under-treatment of pain led to greater use of opioids. The pharmaceutical industry increased marketing efforts to health care providers and hospitals, encouraging greater adoption of opioids for both cancer pain/palliative care and chronic non-cancer pain.² Formulations such as extended-release oxycodone were marketed as non-addictive, just as heroin had been marketed 90 years earlier and morphine before that.

Epidemic Begins

By 2000, pain management was a hot topic, with organizations like the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) calling pain the “fifth vital sign” in their new standards.² Patient satisfaction surveys, which began to affect reimbursement, indicated that patients had a strong preference for opioids over other analgesics like acetaminophen and ibuprofen.³ These factors combined with lack of multi-modal pain care programs that incorporated non-pharmacologic approaches to pain management, difficulties accessing mental health resources for patients, and lack of coverage by insurance companies for non-pharmacologic options contributed to an increase in opioid prescriptions.⁴ In 2012, rates peaked at over 255 million prescriptions for opioids.⁵ Prescription rates have slowly dropped down to over 214 million prescriptions in 2016 as clinicians started implementing stricter protocols.

Over a similar period, 1999-2015, opioid overdose deaths increased significantly, with a sharp rise in synthetic opioid overdose deaths from 2013-2016. As opioid users moved to the cheaper and easier to obtain heroin substitute, overdose deaths from heroin also rose quickly beginning in 2010. In about 2013, the addition of fentanyl to illicit supplies began causing a large spike in overdose deaths. By 2016, the number of deaths involving prescription and illicit opioids was 5 times that of 1999. In the last few years, this has become known as the “Opioid Crisis.”

Source: Centers for Disease Control and Prevention (CDC)

Considerations Before Prescribing Opioids

Healthcare professionals are already working hard to decrease the number of opioid prescriptions they write, but there are some common guidelines that they can follow when deciding how to treat a patient in pain.

• Assess the patient’s pain history
• Assess the patient’s past medical history, including mental health and substance abuse/misuse/addiction history
• Assess the patient’s family and social history
• For women of childbearing potential, consider risks related to planned or unplanned pregnancy
• Check the Prescription Drug Monitoring Program (PDMP) for patient’s current or past use of opioids and other medications
• Do a physical exam and perform any testing as needed
• Consider non-opioid alternatives for treatment⁶

Know the factors that increase overdose risk:

• Higher than average daily dose
• Co-prescribing of benzodiazepines
• Existence of multiple prescribers
• Concurrent overlapping opioid prescriptions
• Use of long-acting opioids⁴

Factors that increase the likelihood the patient will develop opioid use disorder:

• Male
• History of illicit or prescription drug use, alcohol, or nicotine use
• Family history of substance use disorder
• DUI or incarceration
• Higher average daily dose or longer duration of opioid therapy
• Mental health disorder
• Higher rate of use of medical and psychiatric services
• Preadolescent sexual abuse⁴

If a clinician decides that an opioid is the best course of treatment, it is worth considering the following guidelines:

• Use the lowest possible effective dose
• Reassess the patient before increasing a dose to 50 MME or more per day
• Avoid doses of 90 MME or more if possible
• Discuss realistic treatment goals with the patient
• Educate the patient on known risks and benefits of opioid therapy both at the start of therapy and periodically during therapy
• At the outset, prescribe immediate-release opioids instead of extended-release/long-acting opioids
• Prescribe no higher quantity than needed for acute pain episodes – 3-4 days is usually sufficient
• Review PDMP data for the patient before beginning therapy and periodically throughout treatment (from each prescription to every 3 months)
• Use urine drug testing before and during treatment
• Avoid prescribing benzodiazepines at the same time as opioids
• Arrange evidence-based treatment for patients with opioid use disorder⁷

Reducing Opioid Use – A Multi-modal Approach

A number of hospitals and organizations have been working on programs to reduce the number of opioid prescriptions given out, especially in the ED. Here are some success stories:

• Dr. Mark Rosenburg and Dr. Alexis LaPietra started the Alternatives to Opiates (ALTO^SM) Program at St. Joseph’s University Medical Center in New Jersey. They identified 5 common conditions that could be effectively treated without opioids: acute low back pain, lumbar radiculopathy, renal colic, migraine, and extremity fracture/dislocation. Each condition has a treatment regimen that only uses opioids as a last resort. Various alternative therapies include non-opioid medications such as NSAIDs, gabapentin, topicals, trigger point injection, muscle relaxants, valium, Toradol (ketorolac), lidocaine, triptans, ultrasound-guided regional anesthesia, nitrous oxide, and more.⁸ The ALTO program has seen a 58% reduction in the St. Joseph ED’s opioid prescriptions. “We have to go back to times when things were a little more simple,” LaPietra says. “Those easy, at-home techniques — good patient education, really — they help a lot with some of that pain that patients have to deal with when they go home.”¹
• Ten hospitals spread throughout Colorado were part of a 6-month pilot project to reduce the use of prescription opioids. They managed to decrease use by 36% on average, significantly higher than their goal of 15%. This meant 35,000 fewer doses of opioids were handed out than the same period in the previous year. Safer alternatives such as lidocaine and ketamine were used instead. “It’s really a revolution in how we approach patients and approach pain,” said Dr. Don Stader, associate medical director at Swedish Medical Center, Englewood, CO. “And I think it’s a revolution in pain management that’s going to help us end the opioid epidemic.”⁹
• Harborview Medical Center in Seattle, WA is using a novel approach to pain management: virtual reality. During painful medical procedures, like burn debridement, patients are set up to use the immersive video game “SnowWorld,” developed under Dr. Hunter Hoffman, a research scientist in medical engineering at the University of Washington School of Medicine. Patients wear a headset and attempt to hit attacking penguins with snowballs. According to fMRI scans, pain is reduced by 30% or more. Burn patient Kevin Walsh says, “I have to admit, it did offer a distraction. I could tell they’re peeling off a bandage and I remember actually thinking in my head, ‘You know this should hurt a bit more,’ but I was focused on the game, so it didn’t. I was distracted.”¹⁰
• Doctors at Kaiser Permanente-Southern California, alarmed at the statistics for opioid prescriptions throughout the HMO, decided to make changes to reduce opioid prescriptions. In five years, they reduced the number of high-quantity prescriptions from 2,000 to nearly zero and reduced the pill count prescribed post-surgery from 60 to no more than 18. Using free seminar lunches and handing out swag like pharmaceutical companies do, they passed the message to colleagues. In addition to broadening urine testing for patients on opioids, they worked with their information technology department to change the e-record. “We’re … providing the choices to the doctors, with the ones we want them to prefer at the top: Tylenol, Motrin, physical therapy, meditation, exercise,” Joel Hyatt, then Kaiser’s quality-management director in Southern California said. “Down at the very bottom are opioids.”¹¹
• Kaiser Permanente in Colorado offers a $100, eight-week course that helps high-risk opioid patients manage their pain with a well-rounded approach. The integrated program uses the skills of a doctor, clinical pharmacist, two mental health therapists, a physical therapist, and a nurse who can meet with patients all at once or in groups. When 80 patients were tracked over a year-long period, ED visits were down 25%, inpatient admissions fell 40%, and opioid use significantly decreased. “We brought in all these specialists. We all know the up-to-date research of what’s most effective in helping to manage pain,” said Amanda Bye, a clinical psychologist in the program. “And that’s how the program got started.”¹²

Other approaches to pain management have included nerve blocks, physical therapy, yoga, acupuncture, hypnosis, meditation, medical marijuana, mental health treatment, and more.

One thing remains consistent throughout the alternative therapies: the need for patient education on pain management. “They say ‘only narcotics work for me, only narcotics work for me,’ ” said Claire Duncan, a clinical nurse coordinator in the ED at Swedish Medical Center. “Because they haven’t had the experience of that multifaceted care, they don’t expect that ibuprofen is going to work, or that ibuprofen plus Tylenol, plus a heating pad plus stretching measures — they don’t expect that to work.”⁹

Surgeons and anesthesiologists work with patients to manage post-operative pain expectations and treatment plans. For Dr. Clinton Devin, assistant professor of orthopedic surgery and neurosurgery at Vanderbilt Spine in Nashville, TN, this means asking patients to sign an agreement saying they expect to be finished with a course of opioids at 12 weeks after surgery.¹³

Physicians can also point to recent findings that opioids are not proven to stop pain any better than non-opioid analgesics. Dr. Erin Krebs, of the Minneapolis Veteran’s Administration Health Care System and the University of Minnesota, authored a study that came out in the Journal of the American Medical Association in early March. Over the course of 12 months, she studied 240 veterans with chronic back pain or pain from osteoarthritis of the knee or hip. Half received opioids and half received non-opioid alternatives like acetaminophen, naproxen, or topical lidocaine or meloxicam. Since patient expectations can play a role in how they feel, the patients and their doctors were informed about which group they were in. At the conclusion of the study, “‘there was really no difference between the groups in terms of pain interference with activities. And over time, the nonopioid group had less pain intensity and the opioid group had more side effects,’ such as constipation, fatigue, and nausea, Krebs says.”¹⁴

Although researchers are still studying the mechanism that causes it, hyperalgesia, the increase of pain sensitivity due to the use of opioids, may be one reason that some patients require higher and higher doses of prescription opioids or illicit opioids like heroin. Rather than developing a tolerance, or perhaps in addition to it, these patients become hypersensitized to pain.¹⁵ “This could be a major factor in the opioid crisis,” Caroline Arout, a scientist at the New York State Psychiatric Institute. “People have worsening pain, and so their dose is often increased because they are thought to be tolerant.”¹⁵ Including this information when educating patients may be crucial to helping prevent opioid use disorder.

Patients Are Equally Concerned About Opioid Misuse

Back in the St. Joseph’s ED, Jonathan Milton talks to Dr. Jessica Lim about the treatment for his muscle spasm and bruising from his subsequent fall. “Don’t give me [opioids],” says Milton, the forklift driver with a muscle spasm. “I’d rather just keep dealing with the Motrin or the Advil.”¹

Dr. Lim opted for a lidocaine patch for the affected side of Milton’s body and told him to take Motrin and Tylenol and stretch at home.¹

“We were considering giving you a muscle relaxer,” Lim explained to Milton, “and I know you don’t like that feeling. So we’re not going to give it to you. This is even more on you to do the work yourself at home, and I know a lot of patients don’t like hearing that.”¹

Like many patients who are coming to understand the risks that come with taking prescription opioids, Milton was happy to head home without them.

References

1. Wang, HL. ER reduces opioid use by more than half with dry needles, laughing gas. NPR. https://www.npr.org/sections/health-shots/2018/02/20/577139699/er-reduces-opioid-use-by-more-than-half-with-dry-needles-laughing-gas. Published February 20, 2018. Accessed April 2, 2018.

2. A brief history of opioids. The Atlantic. http://www.theatlantic.com/sponsored/purdue-health/a-brief-history-of-opioids/184/. Published January 7, 2015. Accessed April 2, 2018.

3. Gunderman, R. When physicians’ careers suffer because they refuse to prescribe narcotics. The Atlantic. http://www.theatlantic.com/sponsored/purdue-health/a-brief-history-of-opioids/184/. Published October 30, 2013. Accessed April 2, 2018.

4. A Primer on the Opioid Morbidity and Mortality Crisis: What Every Prescriber Should Know [CME Course]. American Medical Association.  https://cme.ama-assn.org/Courses.aspx. Published January 20, 2017. Accessed April 2, 2018.

5. Centers for Disease Control and Prevention. U.S. Prescribing Rate Maps. https://www.cdc.gov/drugoverdose/maps/rxrate-maps.html. Updated July 31, 2017. Accessed April 2, 2018.

6. Centers for Disease Control and Prevention. Common elements in guidelines for prescribing opioids for chronic pain. https://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-20160125-a.pdf. Published in 2015. Accessed April 2, 2018.

7. Centers for Disease Control and Prevention. Common elements in guidelines for prescribing opioids for chronic pain. https://www.cdc.gov/drugoverdose/pdf/common_elements_in_guidelines_for_prescribing_opioids-20160125-a.pdf. Published in 2015. Accessed April 2, 2018.

8. LaPietra, AM. Alternatives to opioids for pain management in the ED. Urgent Matters. https://smhs.gwu.edu/urgentmatters/content/alternatives-opioids-pain-management-ed. Published in 2016. Accessed April 2, 2018.

9. Daley, J. These 10 ERs sharply reduced opioid use and still eased pain. NPR. https://www.npr.org/sections/health-shots/2018/02/23/587666283/these-10-ers-sharply-reduced-opioid-use-and-still-eased-pain. Published February 23, 2018. Accessed April 2, 2018.

10. Hellerman, C. Finding alternatives to opioids. PBS. http://www.pbs.org/wgbh/nova/next/body/opioid-alternatives/. Published August 31, 2017. Accessed April 2, 2018.

11. Quinones, S. The California doctors who found a way to quit overprescribing opioids. The Atlantic. https://www.theatlantic.com/health/archive/2017/03/california-doctors-opioids/518931/. Published March 8, 2017. Accessed April 2, 2018.

12. Daley, J. Pain management program offers an alternative to opioids. NPR. https://www.npr.org/sections/health-shots/2017/12/29/567525861/pain-management-clinic-offers-an-alternative-to-opioids. Published December 29, 2017. Accessed April 2, 2018.

13. Pfaff, K. Surgeons explore non-opioid options for pain management. Orthopedics Today. https://www.healio.com/orthopedics/total-joint-reconstruction/news/print/orthopedics-today/%7B9da4e094-2f3d-451d-acbc-5a5f7d4d3e46%7D/surgeons-explore-non-opioid-options-for-pain-management. Published August 2014. Accessed April 2, 2018.

14. Smith, A. Opioids don’t beat other medications for chronic pain. NPR. https://www.npr.org/sections/health-shots/2018/03/06/590837914/opioids-dont-beat-other-medications-for-chronic-pain. Published March 6, 2018. Accessed April 2, 2018.

15. Dalton, C. When opioids make pain worse. NPR. https://www.npr.org/sections/health-shots/2018/03/03/586621236/when-opioids-make-pain-worse. Published March 3, 2018. Accessed April 2, 2018.