By Mark A. York (February 27, 2018)
(MASS TORT NEXUS MEDIA) The speech of a medical specialty society president at a medical conference doesn’t usually get attention outside the conference center, sometimes a few trade publications might report something. On November 11, 1996, however, something different happened. Standing before a room of medical prescribers, James N. Campbell, MD, president of the American Pain Society (APS), announced a new initiative. “Vital signs are taken seriously,” he said. “If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. It was the kickoff for the APS’s new campaign to convince doctors they should treat “pain as the 5th vital sign.”
And the initiative got instant traction, with the Veterans Health Administration and the Joint Commission on Accreditation of Healthcare Organizations (now the Joint Commission) adopting the slogan and calling on US physicians to manage patients’ pain. But just as quickly, some researchers say, the campaign got off track. Where leaders said, “Manage pain,” doctors and patients seemed to hear “Prescribe opioids.”
Today, governmental and professional groups are frantically trying to hit the rewind button. The American Medical Association has previously issued a “call to action” on opioid over-prescribing, as well as former President Barack Obama, who requested $1.1 billion to address opioid and heroin abuse. Then the Centers for Disease Control and Prevention (CDC) issued new guidelines calling for reduced use of opioids in chronic pain.
Among orthopedists, the calls for action carry particular urgency. By some measures, orthopedists are the third highest prescribers of opioid medications among medical specialties. “In the United States, the current expectation of opioid use as the primary treatment for acute and chronic pain has created an opioid epidemic,” the American Academy of Orthopaedic Surgeons (AAOS) said in a statement .
A look at the statistics explains this tone of urgency. In the decade following Dr. Campbell’s speech, sales of prescription opioids in the United States quadrupled. And rates of overdose, death rates, and substance abuse treatment admissions spiraled in tandem. In 2013, almost 2 million Americans 12 years of age or older either abused prescription opioids or were hooked on them. Also that year, more than 16,000 people in the United States died of an overdose related to opioid pain relievers. The drugs killed more people than heroin and cocaine combined, more than suicide, and more than car crashes.
The prevalence of pain remained undiminished during this period.
“There’s a fear that we’re going to get in trouble if we don’t control pain appropriately,” says Loree K. Kalliainen, MD, MA, who specializes in wrist and peripheral nerve surgery at the University of North Carolina in Chapel Hill. “But we’re creating people who are habituated to these medications, which is tragic, and we’re not using things that actually do work instead of or in addition” to opioids.
For example, whereas doctors were dramatically increasing their opioid prescriptions, they did not prescribe more nonopioid analgesics, such as nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
Why the Focus on Opioids for Pain Management?
Why did the emphasis on pain management in the 1990s result in a focus on opioid prescriptions? One reason may have been aggressive marketing efforts by opioid drug makers. For example, from 1996 to 2001, Purdue Pharma held more than 40 pain management conferences for healthcare providers to promote the use of its new OxyContin® extended-release formula of oxycodone. Sales surged from $45 million in 1996 to $1.1 billion a year in 2000—an increase of well over 2000%.
“We were told way back in the ’90s that these drugs were safe, that they wouldn’t hurt people, and that it was imperative to control pain,” Dr. Kalliainen recalls. Then, in 2007, Purdue admitted it had misled doctors into thinking OxyContin was less easily abused than other drugs in its class. It agreed to pay $600 million in fines and other fees to the Justice Department. Something else has changed in the culture as well, says Dr. Kalliainen. Patients seem to be in as much emotional pain as physical pain. “I’ve been in practice for 16 years now, and there’s been a huge increase in free-floating anxiety in patients,” she says.
US physicians often that find writing a prescription for an opioid is the most convenient way to respond to their patients’ demands, Dr. Kallianen says. As a resident in the 1990s, she remembers being told by the attending physician to write prescriptions for 60 or 70 opioid tablets for nearly every surgery patient. “You started a whole generation of physicians who are out there saying, ‘Write them for 60 [tablets] so they don’t call in.'”
One reason the practice has persisted is that surgeons often don’t know what effect their prescriptions are having, says Dr. Kalliainen. “We don’t see somebody dying of an overdose or becoming addicted. We don’t know if somebody is coming in and stealing their medications from their medicine cabinet and then having a problem. All the negative effects are away from our direct vision. So we’re not taking as much responsibility.” But research shows that once they have received opioid drugs, many patients can’t stop using them. One study found that 8.2% of patients who took opioids for the first time after total knee arthroplasty were still using them 6 months later, despite weak evidence that the drugs are effective for chronic pain management.
Among people already abusing drugs, some studies suggest that the opioids serve as a bridge between other substances and heroin.] Even when patients don’t abuse the opioids themselves, the drugs prescribed to them may end up in the hands of people who do. Surveys of people who abuse opioids show that as many as 23.8% obtained the drugs from clinicians, and 53% obtained them from friends or relatives, most of whom obtained them from clinicians.
“It’s not like these are stolen off the truck,” says Brent J. Morris, MD, a shoulder and elbow surgeon at the Shoulder Center of Kentucky in Lexington, who has published extensively on opioid prescribing patterns. “Certainly, physicians play a role in this.”
Strategies for Minimizing Treatment Addiction
So how can orthopedic surgeons avoid contributing to the epidemic?
In its October statement, the AAOS recommended nine strategies. In brief, it said orthopedic surgeons should:
- Set strict policies about how opioids are used in their practices, perhaps limiting prescriptions to the amount they think a patient will actually use after surgery;
- Identify patients at risk of abusing opioids, perhaps using an assessment tool, such as the Opioid Risk Tool (ORT) for narcotic abuse.
- Rehearse empathetic conversations with patients who are in pain or requesting opioids;
- Establish relationships with hospitals, employers, patient groups, state medical and pharmacy boards, law enforcement, pharmacy benefit manager, insurers, and others with whom they can collaborate on reducing opioid abuse;
- Use state databases to check patients’ other opioid prescriptions and coordinate with other healthcare providers who can provide alternative pain management strategies;
- Inform themselves and staff about opioid uses and misuses;
- Add improved opioid practices to their practice’s quality metrics;
- Recognize that patients with terminal conditions and other appropriate indications should have access to opioids; and
- Spread the word that opioids are not the best way to manage pain in most circumstances.
Reducing opioid prescriptions may not only reduce abuse but also improve outcomes, says Dr. Morris. Patients who use opioids before surgery have worse outcomes than patients who don’t, he and his colleagues found in a study of total shoulder arthroplasty. And other researchers have found that patients who continue using opioids for 1 month or more after surgery have more psychological distress, less effective coping strategies, more symptoms, and more disability than patients who do not use opioids.
The information has changed what Dr. Morris says to his patients. “I still do shoulder surgery in patients who are on opioids before surgery, but now I counsel them. I say, ‘We now have data that says you will do very well, but you are not going to do as well as patients who are not using opioids.’ That sets the stage for postoperative liberation from the opioids after surgery. And we have an appropriate schedule for opioid tapering.”
Dr. Morris also relies on screening tools aimed at identifying high-risk patients. “When a patient has an ankle fracture or shoulder arthritis, we may not be aware of all the other things going on that that may be contributing to their response to pain, whether it’s pain catastrophizing, depression, anxiety, or things going on socially for them,” he says. Frequently, patients with chronic pain ask Dr. Morris for opioid medications. It’s hard to say no, he acknowledges. “Certainly, it makes for a challenging discussion if the patient is already on opioids for that arthritic problem,” he says. He responds to this situation by discussing it with the patient’s primary care doctor and the patient, quoting from the literature about the way outcomes can be affected, warning about the long-term risks of opioid use, and referring patients to pain management specialists.
Pain Management Is Still Educated Guesswork
But for postoperative pain management, Morris still writes plenty of prescriptions for opioids. And he acknowledges that all his research has not helped much in figuring out how much of the drugs to prescribe for postoperative pain management. That’s still a matter of educated guesswork, he says, because patients vary tremendously in their response to pain.
Many other orthopedists are struggling with the same question. After reviewing charts in her department at Regions Hospital in St Paul, Minnesota, Dr. Kalliainen found a huge range in the quantity of opioids prescribed for pain management after the same procedures.
Bothered by this, she calculated the average amount of opioids physicians in the department were prescribing for each procedure and listed them on a card. The other side of the card lists alternatives to opioids, such as nerve block, NSAIDs, ice, and elevation. She printed the card on pink paper, laminated it, and distributed it throughout the department. Then she once again surveyed charts. “About half the number of pills was being used, and peoples’ pain was better controlled,” she says.
And Dr. Kallianen has other evidence that patients can survive with fewer opioids. Currently on sabbatical in New Zealand, Kalliainen has noticed far less reliance on opioids in surgery departments there. “Patients are maybe a little bit sturdier,” she says. “They’re not asking for these medications. They understand that with surgery, there will be some discomfort.” New Zealand is not an outlier. The United States uses more opioids than any other country, including virtually all of the hydrocodone and 81% of the oxycodone in the world. One study comparing the United States with The Netherlands found that 85% of patients with hip fractures treated in the United States were prescribed opioids after discharge, compared with none of the Dutch patients.
The American Pain Society is now working to put the genie back in the bottle. In a press release last February, it announced new guidelines for pain management, calling on physicians to avoid relying on any one single class of medication to treat postoperative pain.
Disclosure: This article contains excerpts from Medscape media releases and other sources – Mass Tort Nexus asserts no rights or ownership to media contents within this article.