How do we manage pain in the era of the opioid crisis?

“6 in 10 Kids Got Opioids After Tonsil Surgery, Study Says.”

So screams the headline from The Daily Beast.

“In the midst of the opioid crisis, doctors sent many kids home with oxycodone and hydrocodone,” it goes on to say. Another example of scaremongering and sensational headlines, or is this something we should still be concerned about?

Well, according to the actual article, there was no greater risks of complications in the patients who received opioids versus those who did not. The study analyzes a large cohort of children from a private insurance database who underwent tonsillectomy and adenoidectomy (T&A) procedures. They reviewed opioid prescriptions filled or refilled and incidence of admission within seven days. In this retrospective review of over 15,000 patients, there was no increased complication rate as measured by the authors. There was no way to determine pain, nausea, vomiting, or any other measure of postoperative well-being.

The Daily Beast article goes on to ask: “What about Ice cream?” While the traditional post-tonsillectomy treatment of ice cream is great for some patients, it is definitely not for all. A tonsillectomy procedure is an extremely painful surgery, although certain techniques can decrease postoperative pain and are used by some surgeons for some patients, they are not indicated for all.

There are a couple of other recent articles that show that a few days’ worth of opioids are all that is required after minor surgery in both children and adults. Wonderful!

Improving prescribing patterns can make a huge difference in decreasing unnecessary opioids floating around people’s homes and medicine cabinets. There is still a great deal of variability in prescription patterns not just after surgery, but for a multitude of conditions. This is a rich area for further research and education of all prescribers (NPs, dentists, and PAs). Calls for returning to no opioids are disingenuous and do a disservice to our patients. We must treat pain appropriately, and we need to look for better analgesics, better techniques, and ways to optimize nonpharmacologic techniques. Addiction does not occur just because there are extra pills lying around. Addiction is a disease.

Opioid prescriptions have been steadily decreasing over the past two years, and the number of opioid-related overdose deaths are finally starting to decrease too. While opioid use disorder and addiction are real problems, inadequate pain management should not be ignored. The push for opioid-free anesthesia and surgery is laudable but shouldn’t replace common sense and careful review of the literature.

Limiting physician’s prescriptions to patients won’t solve the opioid crisis, training, and providing high-quality mental health professionals will.

Addiction is a disease.

Unfortunately, limiting opioid prescriptions that has not stopped the continuing crisis. The increase in overdose death in the past eight years is due to heroin and synthetic opioids. The number one culprit now is fentanyl. Knock-off fentanyl manufactured in China, cut with who knows what additives, added to heroin and other street drugs. Further limiting prescription drugs is not going to have any impact on these deaths.

The days of the liberal use of opioids for the treatment of chronic pain and after minor trauma or surgery are appropriately gone. But the need for good pain management after painful conditions and in select chronic pain patients remains.

Lawmakers, with few exceptions, are not physicians. By April 2018, 28 states have some sort of limits on opioid prescriptions most focusing on the total number of days an opioid may be prescribed, others limiting the total dose in morphine milligram equivalents (MME). They range from a 14-day limit to a three-day limit. There is some science behind these seemingly random limits. The CDC has found that the incidence of long-term opioid use increases after a three or five-day supply of these medications, and again after 31 days.

There are multiple other risk factors, but unfortunately dealing with those can be more complicated, costly, and difficult to implement.

Addiction is a disease, artificially limiting or restricting medications for legitimate medical reasons is not the solution. Non – physicians (lawmakers) practicing medicine and creating barriers for patients to receive needed and appropriate treatment is not helpful. Focusing on the risk factors for addiction, and the misuse of opioids is a more important approach.

The CDC has studied the epidemic extensively and has a list of recommendations:

• Report non-fatal and fatal opioid overdoses more quickly, identify hot spots and rapidly respond with targeted resources;
• Identify risk factors for fatal overdoses;
• Increase comprehensive toxicology testing and support to medical examiners and coroners;
• Share data with key stakeholders also working on prevention activities;
• Share data to improve multi-state surveillance and response to the epidemic;
• Enhance prescription drug monitoring programs;
• Implement and evaluate strategies to improve safe opioid prescribing practices;
• Share CDC’s Rx Awareness communication campaign to increase awareness and knowledge among consumers about the risks of prescription opioids.

Prescription Drug Monitoring Programs (PDMP) are of critical importance to these efforts. Allowing states to share information can really help decrease the ability of patients to “doctor shop” or obtain opioids from physicians in different states. California uses the Controlled Substance Utilization Review and Evaluation System (CURES). While not perfect, it is fairly easy to use and reliable. But where I practice, we have patients from Nevada, Oregon, Hawaii, Arizona, and other states. We cannot access their PDMPs.

Addiction is a disease. Chronic pain patients did not cause this epidemic and should not be punished by having their opioids stopped. Improving and increasing mental health services, increasing access to care for pain patients and others, funding research to develop better medications and treatments, mandating payment by insurance companies for the use of nonpharmacologic techniques, such as cognitive-behavioral therapy, and continuing education could help combat this destructive and fatal epidemic. Physicians who suspect their patients of misusing their opioids need to have options to treat/prevent/report these patients before escalation occurs.

Thoughtful legislation can help us combat this crisis without hurting our ability to appropriately treat our patients. Laws should help physicians and other healthcare providers, diagnosis and treat this disease, not add obstacles to appropriate patient care.

Rita Agarwal is a pediatric anesthesiologist.

TAGS: Daily Beast, tonsillectomy and adenoidectomy (T&A) procedures,, opioid, nonpharmacologic techniques,

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