Pain management in the midst of an opioid epidemic: How to keep patients (and their families) safe

On average, 91 people in the United States die every day due to painkiller overdoses according to the CDC, and providers prescribe many of those pain pills legally. One in five patients who receive 10-day opioid prescriptions after surgery becomes addicted.

Back pain and spine surgery patients comprise a large percentage of the opioid prescriptions. According to a study published in The Spine Journal, 50 percent of patients who used opioids before surgery were still using them one year later; 17.5 percent of the opioid naïve patients were still using opioids one year after surgery.

Jerry L. Epps, MD, senior vice president and CMO of University Health Systems as well as chairman emeritus in the department of anesthesiology at Knoxville-based University of Tennessee Medical Center; and Jim Silliman, MD, president and CEO of GeneAlign, Pinpoint Clinical and Pinpoint Partners gave a presentation titled "Managing Pain in the Midst of an Opioid Epidemic" at the Becker's Hospital Review 8th Annual Meeting in Chicago.

"We are in the midst of a national epidemic," said Dr. Epps. "If you look at the number of opioids we as physicians prescribe, we are prescribing enough for every American adult to have a bottle of opioid pills at any point in time."

A 2016 study published in PLOS found for C-sections, 83 percent of patients took less than half of their pills. The study also found 71 percent of thoracic surgery patients took less than half of their prescribed opioids. In some cases, patients give extra pills to friends or family members; in other cases acquaintances steal those pills. "Not only are these prescriptions leading to long-term use in our patients, but they're also leading to long-term use in their family members, and that's one of the scariest parts of this issue to me," said Dr. Epps.

Opioid addiction and adverse events are harmful to the healthcare system, as they increase hospital stays, costs and readmission rates. "Physicians did not realize when we gave narcotics we were putting our patients at risk for long-term opioid addiction. Now that is quite clear, and it's been clear for the past five years," said Dr. Epps. "What can we do as physicians to help avert that problem?"

Employing a multimodal pain strategy to reduce opioid consumption and pharmacogenetics tests to identify the proper narcotic for each patient is a start. GeneAlign offers a lab test designed to identify genes associated with metabolism, response and interactions from more than 180 prescribed medications. Physicians could reduce opioid use by receiving good guidance instead of prescribing three different narcotics and seeing which one is most effective.

As a former orthopedic surgeon, Dr. Silliman prescribed painkillers for surgical patients; however, now with a background in pharmacogenetics he has seen how patients' behavioral, social and genetic makeup affect how they will react to opioids. He suggested taking a precision medicine approach, examining the patient's genetics and performing urine drug testing before surgery to avoid giving opioids to someone at risk of addiction.

"If you treat everyone the same, you aren't going to get the same results," said Dr. Silliman. "There are an unbelievable number of studies that come out every day based on the genetics of this and looking at how people respond to various medications."

PET scans show how the brain changes anatomically after patients take narcotics for one year, and there is scientific literature examining how opioids are metabolized and interact with other drugs including antidepressants and sleep aids. The tests exist to identify patients who will respond poorly to different types of drugs, but health systems often look at the line item costs for another lab study and reject it without understanding how it could improve care and reduce costs for the overall episode.

"There isn't a line item cost for managing this problem. The costs are all downstream. The pharmacy department looks at the cost of adding new drugs and wants to resist that; labs look at the cost of adding new labs and want to resist that," said Dr. Silliman. "We have to invest in this and everyone has to get involved. The physician office and rehabilitation center aren't the place to fix this. Recidivism rates from people getting addicted to these drugs are so high that most of the time we just give up and give them a long acting drug that we can control so they don't end up with needles and heroine."

There has been some pushback on pharmacogenetics related to opioid addiction. However, Dr. Silliman said the science behind understanding what enzymes help metabolize drugs is strong; what's lacking is the data.

To combat opioid over-prescription and addiction, physicians and anesthesiologists are working together in a multidisciplinary team to standardize pain management. Dr. Epps described how his team created pain pathways for inexperienced clinicians with a multimodal approach including the non-narcotic local anesthetic Exparel administered at the surgical site. Additional pain drugs can include NSAIDS, IV ketamine, IV acetaminophen, gabapentinoids and dexamethasone. The nursing staff especially pays attention to the new pain instructions to deal with opioid addicted patients.

"More of our nurses are becoming younger and younger, so we had to give them much more guidance on the management of patients with opioid addiction issues," said Dr. Epps. He also established patient activated care teams so nurses that had concerns could summon an expert evaluate the patient.

Opioid addicted patients are different because they will often report their pain is at the top of the pain scale, so instead of focusing on patient-reported pain, the clinicians examine the patient's function. He also developed a tool to standardize the amount of narcotics patients receive. "We have a pain flow sheet summarizing every narcotic the patient receives and converts that to morphine milligram equivalents," said Dr. Epps, which paints a full picture of the painkillers a patient receives.

Educating physicians, nurses and patients about opioid addiction and exploring alternatives for pain management is critical to combating the opioid epidemic and reducing opioid-related deaths in the United States.

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