PRESIDENT'S MESSAGE
A new patient established care with me and requested a refill of their pain medications. I asked, “On a scale of 0-10, what has your average pain been over the past two weeks?”
My new patient told me it is manageable at a 4 with the Norco they take twice daily. After receipt of their records, I find that this patient was in a car accident 10 years ago and has been “stable” on 60 tabs for chronic back pain ever since. Records from the previous care team shows that they have conducted consistent drug screens, avoided sedating drugs, and never requested early refills. My patient would like to continue medications indefinitely. My patient is 35 years old.
As physicians, we try to do everything we can to relieve pain and suffering. But with the growing evidence of the harms of chronic opioid use, including opioid use disorder, overdose, neuroendocrine dysfunction, osteoporosis, chronic constipation, bowel obstruction, and tooth decay, maybe it’s time for us to rethink how, and when, we prescribe opioids to our patients. It’s also time to commit to treating opioid use disorder and to talk about alternative approaches to pain management.
Many of us are aware of the unintended consequences caused by the use of the “fifth vital sign,” a metric created by the American Pain Society. Doctors and health systems were penalized if they didn’t manage pain to a patient’s satisfaction. Opioids were found to be extremely effective at helping physicians improve pain metrics and became a primary resource for pain management. But ultimately, this push proved to exacerbate opioid addiction and opioid-related deaths.
Fortunately, AMA advocated to stop treating pain as the fifth vital sign and pushed health systems to develop better methods for assessing pain and offering treatment alternatives.
In early 2016, St. Joseph’s University Medical Center was the first hospital system to develop and launch ALTO®, the Alternative to Opioids Program. The ALTO Program uses targeted non-opioid medications, trigger point injections, nitrous oxide, and ultrasound guided nerve blocks to tailor its patients’ pain management needs and avoid opioids whenever possible — for example, in cases of kidney stones, acute low back pain, broken bones, acute headache and migraine pain.
St. Joseph's has the busiest emergency department in New Jersey. Through ALTO, the hospital has reduced the number of opioid prescriptions it has issued by 80% and the use of opioids in the ED has gone down by 38%. While the national average is for prescriptions issued through the ED for opioids is about 17%, St. Joseph's only issues about 2%.
Opioids obviously have a place, such as short-term use post-op, but it’s time for us to learn how to properly use opioids, embrace more alternatives to opioids and understand how to effectively screen and treat opioid use disorder.
In many cases, opioids should never be the first-line treatment. The multi-billion dollar lawsuit against Perdue Pharma that was recently settled for the costs associated with opioid addiction caused by easy access, in addition to DEA prosecutions of physicians for the overuse of opioids in prescriptions and decisions by pharmacists to limit their inventory of opioids, should send a clear message that it’s time to take a new approach.
In my group practice, we’re in the process of developing a non-interventional pain management service line. It involves the wraparound services patients need to avoid, reduce, or eliminate the use of opioids. Rather than just masking the pain, patients need services such as physical rehabilitation, independent and group behavioral therapy, weight management, physical conditioning and more to manage it properly. Patients also need access to alternative approaches such as acupuncture and osteopathic manipulation treatment. It is incredibly frustrating to realize that while drug costs are usually easily covered by insurance, the other services that can reduce opioid use aren’t. That needs to change.
Additionally, we need more physicians trained in addiction medicine. That, along with greater access to medication assisted treatment — MAT — could have a huge impact on really addressing the opioid addiction crisis.
From an equity standpoint, a study at Harvard showed that in the wake of an opioid-related event such as an overdose, infection, or detox admission, white patients received medication for opioid use disorder up to 80% more frequently than Black patients and up to 25% more frequently than Hispanic patients. More work needs to be done to address the disparities in access and treatment for opioid use disorder.
The road to addiction can begin subtly. It often begins with back pain or an injury, such as from a car accident like my patient experienced, and involves a prescription for Norco or something similar. Patients feel good while their pain resolves. But back pain tends to recur, so patients return and ask for what worked for them the last time they hurt. Before long, there’s a cycle of reliance that can only end when a physician says no, but that can force patients to seek illicit sources. When that happens, contaminated pills can be fatal, as the Sacramento Opioid Coalition has so poignantly shown through the Gone Too Soon project.
While deaths from fentanyl get most of the attention in the press and even among physicians, there is a much larger but more unseen problem among Americans of all ages who are on chronic opioids. Many could do better with a comprehensive care plan that works to minimize their pain and opioid use while also improving their overall health outcomes. Addressing this problem needs an assertive effort to get more comprehensive services in place and implement new approaches such as the ALTO pathways and wraparound services in both acute and outpatient settings.
Just saying we’re not going to prescribe certain meds anymore won’t do the job. The emphasis needs to be on managing pain with non-opioids and rehabilitative services.
I can’t deny that this path will be long and hard, but it is necessary. But if we follow it, we can make a huge difference.
