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11 Articles in Volume 16, Issue #7
A Perspective on Tapentadol Therapy
Acupuncture to Treat Brachial Plexopathy and CRPS
Behavioral Medicine: How to Incorporate Into Pain Management
EpiPens and Opioids: Common Ground
Fibromyalgia and Coexisting Chronic Pain Syndromes
Life-Saving Naloxone: Review of Currently Approved Products
Medical Foods Hold Promise In Chronic Pain Patients
Moving Beyond Pain Scales: Building Better Assessment Tools for Today’s Pain Practitioner
Moving Toward an (Almost) Opioid-Free Emergency Department
No Perfect Medicine—What You Need to Know About NSAIDs and Opioids
Prescribing Opioids: How New Policies Are Affecting Medical Specialties

Prescribing Opioids: How New Policies Are Affecting Medical Specialties

Learn how emergency room physicians, dentists, rheumatologists, and orthopedic surgeons are dealing with new regulations and guidelines for pain management.

The opioid abuse epidemic continues to dominate the news as celebrities die from overdoses, and federal and state agencies try to stem the tide of addiction and abuse. The Centers for Disease Control and Prevention (CDC) has issued new guidelines1; the Food and Drug Administration (FDA) has announced new safety labels2; President Obama signed the Comprehensive Addiction Recovery Act (CARA) aimed at addressing the pressing concerns of heroin and prescription drug abuse3; and, the National Governors Association has promised to create a set of protocols for dispensing opioids. Along with these developments, medical facilities and professional organizations are adopting new policies and procedures to help address the crisis.

When considering which doctors are most likely to be affected by these changes, the most obvious physicians are pain management specialists and oncologists, who routinely treat severe or unrelenting pain. However, pain management is an essential part of many other practices as well, including emergency room medicine, rheumatology, orthopedics, and even dentistry. While pain may not be their primary focus, these specialists are likely to encounter it as a common complaint every day, with opioids often included in their treatment toolkits. 

How are these medical professionals, whose patients experience varying levels of both acute and chronic pain, adapting to new guidelines and the pressures to reduce opioid use while still keeping patients’ pain at bay?

Emergency Medicine

Few specialists encounter more kinds of pain than emergency department (ED) physicians. ED doctors see it all, whether it’s a gunshot wound, a kidney stone, an auto accident, or an acute exacerbation of a chronic pain condition. Whether or not to prescribe opioids is a decision they face daily.

The American College of Emergency Physicians (ACEP) noted that the “primary goal of emergency care is to alleviate pain quickly, safely, effectively, and compassionately.” While opioids remain vital analgesic tools in this effort, heightened awareness of the dangers they pose, along with the new CDC guidelines, mean ED doctors face difficult decisions. “You want to provide pain relief, but you don’t want to start someone on the trajectory towards disaster,” said Lewis S. Nelson, MD, professor and chair of emergency medicine at Rutgers New Jersey Medical School, and a Core Expert Group member of the CDC guidelines task force.

The most challenging situation for ED doctors is the patient who arrives in the emergency room with an acute exacerbation of chronic pain. These patients suffer from a variety of conditions, including herniated discs, osteoarthritis, and migraines. (See related story.)

The goal with managing chronic pain in the ED is to return the patient’s pain level to baseline, not remove it altogether or fix the underlying cause, said Christopher Hogrefe, MD, assistant professor of emergency medicine and orthopedic surgery at Northwestern University Feinberg School of Medicine.

Many patients who take opioids regularly for their chronic pain are often asked to sign patient-provider agreements (PPAs), stating that they will consult their long-term pain management provider instead of heading immediately to the ED for pain relief. When such patients do request care at an ED, “we would attempt to contact the primary provider, who often expresses their dissatisfaction that the patient did not call them first,” said Dr. Nelson. “On occasion, in concert with the primary provider, we may medicate the patient in the ED with close follow-up by the primary.”

Whatever brings a patient to the emergency room, doctors are becoming increasingly cautious about using opioids. Dr. Hogrefe tells his medical residents that prescribing opioids in these cases is like fishing with dynamite: “You catch a lot of fish, but you also make a lot of mess in the process.”

Over time, opioids may even worsen pain, defeating their own purpose and triggering a vicious cycle. Even a small dose may lead to “tolerance and hyperalgesia, which leads to increasing the dosage, which leads to more tolerance and more hyperalgesia,” then on to dependence and, too often, addiction, said Dr. Nelson.

There are few decisions that Dr. Nelson takes more seriously than whether or not to prescribe an opioid. While he encounters many cases in the ED in which opioids are clearly the best option, he thinks long and hard about situations where the patient is in pain, but not enough to warrant such powerful and potentially addictive medications.

“I conduct a risk analysis every time I consider an opioid. I’d rather [the patient] experience a slightly higher pain score than take the 3% or 4% risk that” the patient may become dependent, he said.

When it comes to reducing reliance on opioids, another challenge physicians face is the patient satisfaction survey, which can affect both the individual doctor and hospital reimbursement. Surveys often ask patients to rate how well their pain was treated, which puts pressure on the physician to eliminate it quickly—something only opioids can do. “There are all these perverse incentives to overmedicate patients,” says Dr. Nelson.

Increased awareness of how surveys may encourage opioid prescribing has led some institutions to rephrase or eliminate questions related to pain. When opioids are prescribed, doctors are making a greater effort to inform their patients about the proper use of these medications, the risks they pose, and the right way to dispose of any leftover pills.

Drug Seekers and the ED

Drug seekers are a common problem in emergency rooms. “I think anyone who’s worked in the ED has encountered drug seeking” behavior, said Dr. Hogrefe.

ED physicians and others who suspect a patient is trying to satisfy a drug habit can turn to their state-run prescription drug monitoring program (PDMP). The PDMP shows when individual patients filled their prescriptions and if they have multiple opioid prescriptions on file. While the PDMP is a valuable tool, updates have a lag time of several days.

New systems have recently been developed that provide additional information in real time. The Emergency Department Information Exchange (EDIE) gathers registration data from participating emergency departments, allowing clinicians to see which patients are frequent visitors to the ED, and which may have special needs. It then sends alerts to physicians who can review previous visit information and better determine how to help the patient—whether that means denying the patient an opioid prescription and referring them to a treatment program, or providing the patient some other form of care.

Both systems have their limitations. Although EDIE information tends to be more up to date than the PDMP, not all facilities use the EDIE system, and the EDIE tracks only emergency department data, while the PDMP tracks opioid prescriptions regardless of specialty. When used together, the 2 databases “can provide tremendous insight and information to ensure the best possible care for patients without putting them in a position that could potentially harm them,” said Dr. Hogrefe.

Dentistry

Almost any dental procedure, from a routine cleaning to an extensive surgical procedure, can cause pain and may require some form of analgesic. While multiple medications are available to treat the pain, dentists often turn to opioids first. In fact, dentists are among the leading prescribers of opioids.4

A study recently published in JAMA found that dentists performing surgical tooth extractions—one of the most common dental procedures—routinely prescribe opioids post-procedure.5 According to the study, “a large fraction of patients are prescribed opiates following tooth extraction despite the fact that there’s some data that suggests that nonopioid alternatives may be as, or even more, effective in treating post-extraction pain,” said Brian Bateman, MD, MSc, associate professor of anesthesia at Harvard Medical School, Cambridge.

Dr. Bateman noted that the research reflects “tremendous variability” in the amount of opioids prescribed. “There was about a 3-fold difference between the 10th and 90th percentiles with respect to the amount of the opioid dispensed. And, at the high end, patients are being dispensed very large amounts of opioid,” he said.

Sometimes prescription practices are a matter of habit. A doctor can easily fall into a routine of prescribing opioids after certain procedures, said Daniel Becker, DDS, associate director of education, General Dental Practice Residency at Miami Valley Hospital. He urges dentists to be more cautious and to consider other options, such as acetaminophen (APAP) and ibuprofen, or other nonsteroidal anti-inflammatory drugs (NSAIDs), which work better than opioids for dental pain.

Martha Nowycky, PhD, professor of pharmacology, physiology, and neuroscience at the New Jersey Medical School agreed. “Almost all dental pain has an inflammatory component,” she said. “NSAIDs are far preferred to opioids because they act on [inflammation], which is the cause of the pain. Opioids should only be considered as a last resort.” In addition to NSAIDs, Dr. Nowycky recommends that dentists consider acetaminophen, local anesthetics, and other options that pose no risk of dependency.

While dentists are concerned about the known risks of opioids, they often encounter patient resistance when they try to prescribe NSAIDs, or APAP, instead. Patients commonly complain that the alternatives are ineffective—although this may result from patients discontinuing the drugs as soon as the pain subsides. The key to successful relief using NSAIDs and APAP is to administer them before the anesthetic has worn off and then instruct the patient to continue taking them even after the pain subsides. Tell patients that this really works “if you take it the way I’m telling you to,” said Dr. Becker.

“The risks of prescribing opioids, particularly in large amounts, is twofold,” said Dr. Bateman. First, “you are exposing patients to a potentially addictive substance, and it could be that, in the context of receiving opioids for a small procedure like tooth extraction, patients experience the kind of euphoric effects of opioids that could potentially lead them to misusing” these medications.

The second risk arises from leftover medication. Dr. Bateman’s research found that the median number of 5 mg tablets of hydrocodone prescribed is 24. “For pain that’s expected to be relatively mild and short-lived,” Dr. Bateman cautioned, “this is a tremendous amount of medication to be dispensing.” Leftover pills can be misused or diverted by family members or others who have easy access to the medicine cabinet, making overprescribing a serious threat to public health.

Fortunately, the situation seems to be improving. “There has been a rise in the medical and dental professions’ appreciation of the dangers associated with [opioids] in recent years,” said Dr. Bateman. But, he cautioned, “We don’t have nationwide data to tell us whether this has resulted in more careful prescribing by dentists yet.”

Rheumatology

Rheumatologists treat over a hundred diseases that affect the musculoskeletal system, including systemic autoimmune diseases such as rheumatoid arthritis (RA), psoriatic arthritis, and lupus, that cause joint swelling, stiffness, and pain. Indeed, pain is the symptom that most often drives patients to their rheumatologist’s office.

RA is the most common type of autoimmune disease treated by rheumatologists. This chronic inflammatory disorder not only damages joints, but also can affect many other systems in the body. The pain it causes can be severe.

To control pain and prevent joint damage, rheumatologists focus on attacking the underlying disease process with a variety of disease-modifying drugs (DMARDs), like methotrexate, and biologics, such as etanercept (Enbrel). The American College of Rheumatology (ACR) recommendations advocate that the first priority is remission or reducing disease activity.6 Although the ACR has not yet issued a position paper or guidelines specific to opioids, the organization recognizes that an aggressive treatment approach not only helps prevent further joint damage, but is also the best way to reduce pain.

DMARDs can take several weeks to work, and painful flare-ups are a common occurrence in RA. NSAIDs and glucocorticoids are the usual first-line agents for reducing inflammation and pain, but when they don’t provide sufficient relief, some rheumatologists turn to opioids. According to a recent study, more than a third of RA patients “use opioids in some form, and in more than a 10th, use is chronic.”7 When there are no better options, using opioids for a limited time and at the lowest possible dose can help patients cope with the pain until the flare abates, or the DMARD treatment begins to work.

In light of the new CDC guidelines,1 and the increased awareness of opioids’ dangers, however, rheumatologists say they have become more cautious about turning to these drugs even for a flare-up of pain. “If we’re going to put someone on an opioid, it’s as a last resort, and we look at it very seriously,” said Scott Zashin, MD, clinical professor of rheumatology at the University of Texas Southwest Medical School.

Osteoarthritis (OA) is the most common type of arthritis and often represents a large segment of a rheumatologist’s patient population. OA affects 30 million Americans, most of them over the age of 45. To reduce pain, rheumatologists have often prescribed opioids, but now increasingly rely on NSAIDs and APAP, physical therapy, physical braces, and nutritional supplements, such as chondroitin and glucosamine, or hyaluronic injections, to lubricate the joints.  

When cyclo-oxygenase (COX)-2 inhibitors were introduced to the market and promoted as less likely to cause gastrointestinal upset and peptic ulceration than nonselective NSAIDs, these agents quickly became leaders in first-line pain therapy for OA. But most were withdrawn in 2004 due to serious side effects (only celecoxib [Celebrex] remains on the market), and many physicians turned to opioids instead, adding to the number of OA patients taking them for chronic pain. The use of opioids in an aging population is another concern. Reliance on opioids is associated with an increased risk of falls/fractures in elderly patients with OA.8

Given the added challenges that come with these agents, “I rarely prescribe opioids” for any patients, said Anisha Dua, MD, assistant professor of rheumatology at the University of Chicago Medical Center. “The highest level I’ll go up to is tramadol, which is a partial opioid” and use it for only 1 week. If an opioid is needed, Dr. Dua said, she is more likely to refer the patient to a pain specialist, or a primary care physician who has expertise in medication management, and can monitor the patient for adverse events.

Some rheumatologists are also giving more serious consideration to nonconventional treatments to better address pain. While there is no evidence that natural remedies reduce damage from RA, they can sometimes provide pain relief and, when used alongside conventional treatments, can improve patients’ quality of life. For example, along with DMARDs, Dr. Zashin has prescribed supplements made from tart cherry extract or turmeric to help reduce inflammation in some of his patients with RA. He also suggests acupuncture to patients with OA and others who he believes may benefit from a chance to reduce pain.

Another important factor in treating RA, OA, and other chronic musculoskeletal diseases is setting realistic pain management goals. Lucy Chen, MD, PhD, director of the Massachusetts General Hospital Center for Translational Pain Research, believes that patients need help managing their expectations and learning how to cope with pain, using nonopioid and sometimes nonpharmaceutical treatments. They may never be “pain-free,” she says, but the pain can be “reduced to a level they can tolerate,” markedly improving their quality of life.

Orthopedic Surgery

Orthopedic surgeons are the third highest prescriber group of opioids in the US, exceeded only by primary care physicians and internists.9 A study published last year in Pain Research and Management found that opioid use “is most prevalent within orthopedic and neurosurgery patients.”10

Orthopedic surgeries often involve significant trauma to surrounding tissues, causing severe pain and a need for strong analgesics. While opioids remain an essential pain relieving option, surgeons increasingly recognize the risks, and are making greater efforts to prescribe opioids less often.

A recent position statement by the American Academy of Orthopedic Surgeons (AAOS) supports these efforts: “The AAOS believes that a comprehensive opioid program is necessary to decrease opioid use, misuse, and abuse in the United States.” It calls for more effective education programs for physicians, patients, and caregivers; better patient monitoring; more funding for research to find effective alternative pain management and coping strategies; and support for better opioid abuse treatment programs.11

Dr. Hogrefe, an orthopedic surgeon, said he is not “vehemently opposed to [opioid] use, but I am judicious with prescribing them.” While he does not prescribe opioids for chronic conditions, Dr. Hogrefe said they can be appropriate for some conditions, such as “acute fractures, traumatic compartment syndrome…or post-surgical” pain. And when he does prescribe opioids, Dr. Hogrefe does so “for a short term [perhaps a couple of weeks at most] and in modest amounts.” He makes sure to counsel patients on their proper use, and “there is always a conversation about exercising caution regarding the concomitant use of opioids with acetaminophen [to avoid liver toxicity], as opioids often do contain acetaminophen, as well.”

Alternative Approaches to Postoperative Pain

Although opioids are likely to remain a mainstay of post-operative pain relief, albeit administered with greater care and oversight, some orthopedic surgeons are reexamining the cause of pain in their search for better ways to treat it.

David Ring, MD, PhD, associate dean of comprehensive care and professor of orthopedic surgery at the Dell Medical School at the University of Texas/Austin, urges doctors to first distinguish between pain and nociception, the physiology of actual or potential tissue damage. He suggests that individuals with the same injury may have different pain experiences—a difference he believes can be attributed to psychological and social stressors.12-14

“Stress, distress, and coping strategies” all affect how much pain we experience, said Dr. Ring. He believes that the mindset is as important as conventional analgesics for relieving pain. “I never think of pain relief as being something in a bottle, a shot, or even surgery. It’s not that those things don’t work, but the number one pain reliever is peace of mind, so I try to make sure I maximize their hope, minimize their despair, and get them on the right track.”

Increasing self-efficacy and reducing depression and anxiety, according to Dr. Ring, does more to treat pain than most medications, including opioids. Pain reduction “is much more of a mind-body thing,” he said. “It’s not a nociception treated with a pharmaceutical. We need to be more comprehensive” than that.

Another way to reduce postoperative pain, say Dr. Ring and others, is to better prepare patients for it. Before surgery, he recommends asking the patient about previous experiences with surgery. This makes them aware they will experience some pain, but also reminds them they will get through it—and demonstrates the surgeon’s concern. “They really just need to know that you care about their pain” and that there is a pain management plan in place,” Dr. Ring said.

Though not all surgeons take such a personal approach, many are open to exploring new ways to treat pain, including trying comprehensive approaches to pain relief using a variety of tools.

Dr. Hogrefe said he employs a multifaceted approach in his sports medicine practice that includes recommending “a good diet, a good exercise regimen, perhaps group or cognitive behavioral therapy, and sometimes certain types of medications or medical devices.” Other tools, like applying ice and elevation, NSAIDs, APAP, and muscle relaxants (for spasms) are also included as first-line therapies. “If you pick from that group, you increase the likelihood of success,” Dr. Hogrefe said.

When opioids are prescribed after a procedure, Dr. Chen urges surgeons to pay special attention to their discharge instructions. She said doctors should make sure that any opioid prescription is written for the lowest dose and for no more than 2 weeks “to reduce the most severe symptoms.” Patients should also be taught how to use the drugs and be informed of their risks. “This is very important,” said Dr. Chen. “Patients who do not understand what to expect and just want the pain to go away immediately may use opioids irresponsibly.”

Last updated on: June 19, 2017
Continue Reading:
Moving Toward an (Almost) Opioid-Free Emergency Department

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1 comment.

By drstephenrodrigues on 10/07/2016
It has taken me 33 years to figure out that the fundamentals of health care and how doctors fight disease was broken 60 years ago. The authors of Medicare left out the first four fundamentals which could mitigate and almost eliminate many of the top 10 causes of death. Everyone knows that the policies and procedures embedded in Medicare rule everything that we do. The authors left out 1. education, 2. prevention, meaning teaching 3. assistance and 4. Physical Medicine and Rehabilitation. These are all the principles which will help fight diseases before the seed into the body. The #4 PM&R category of treatments are the only options to treat physical pain and misery!! This is Myofascial Pain and Dysfunctions. BUT, MF pain and the idea of Trigger Points have corrupted all of the critical facts needed to understand this pain pathology. Most all of the definitions and constructs are mixed up with poor imagery and mythologies. Muscles full of microscars drive pain signals. Muscles full of microscars drive muscle tissues to falter and fail. Muscles full of microscars drive secondary and tertiary findings. Muscles full of microscars make up all of the various TrP theories. TrPs do not drive all of the pain signals. The muscle system diseases are where the multitude of office based very odd and complex problems are sourced and located. Going back into the archives of PM&R and PT therapeutics before Medicare started to be so stringently enforced, physicians knew for certain that physical pain and misery was easily and effectively treated with physical therapy. This simple cause-effect, problem-solution is so easily overlooked because most all of it is invisible. Physical pain and dysfunction are treated with PM&R+PT. So while everyone is busy following Medicare policies and procedures we forgot to look, talk and touch our patients. Muscles can only heal from the inside by the natural forces from within. Medications or surgery cannot reach this pathology of pain. This is the reason why back surgery, hip surgery, shoulder surgery, knee surgery, carpal tunnel surgery, thoracic outlet surgery all do not work. This is the reason why many physicians to give out terms of opium derivatives to treat pain. You can't touch the pathology of muscle derive pain with any chemical. No matter how much you give are try. In the archives, one can review muscle pathologies and pathogenesis of disease that as muscle microscars increase in densities so does the signs and symptoms, so neuropathic pain, CRPS, and TN are all long-standing untreated muscle-derived pain and dysfunction. Healthcare will fail, Wall Street will fail if our leaders do not reinstate the full forces and spectrums of physical medicine and rehabilitation. Oh, by the way, acupuncture-needles, not so must the Chinese art, the tools are the primary key which will unlock the healing deeply embedded in muscle tissues. In this construct, a needle is a needle. A thin needle is not a hypodermic needle they are two different instruments. The hypodermic needle is the most potent ignitors of healing. Did you know that the FDA still considers Acupuncture experimental and investigational and is not a covered Medicare benefit to the elderly??!! What I have discovered in the Archives of PM&R and PT therapeutics is these treatment regimens always work. This is because there is a natural and innate guaranteed of workings. As long as the providers are free to customize the regime and the patient is free to orchestrate and guide the treatment processes. Mother Nature does all of the rest! Just like nature intended healing to be!
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