Pain is primal. It can terrify and overwhelm. I’ll never forget what a patient once taught me: Intense chronic pain can literally drive a person insane.
This young woman endured extreme pain from a chest wall injury, and narcotics adversely affected her ability to function in life. It took courage for me to open the door to her hospital room; in the few hours since her admission, she had gained a reputation for throwing objects and verbal invectives. She yelled and screamed, becoming paranoid when anyone approached her. I was grateful when the steely-eyed pain specialist entered the room. He calmly and respectfully completed his exam, then shared his plan for an intercostal nerve block with a short-acting local anesthetic – if successful, he would follow later with a permanent neurolytic agent. It worked almost instantly. I marveled as this woman became quiet and relaxed. She calmly pulled on a pair of jeans and a t-shirt from the bedside drawers and politely informed us all that she was ready to go home.
I learned, over the years, that her case’s ending was rare. For too many patients, a familiar story unfolds – an opioid prescribed after an accident or surgery can become a pathway to addiction or death. Right now, bottles of prescription opioids like oxycodone or hydrocodone sit in medicine cabinets across the country. Up to one quarter of patients prescribed long-term opioids by their primary care providers will eventually struggle with addiction, and more than 40 people die every day from prescription opioid overdoses, according to the CDC.1
Pain As a Vital Sign
According to data from the athenahealth Provider Network, pain ranks high among reasons for office visit, with musculoskeletal pain (back, knee, neck, shoulder, foot, hip) and headache among the top complaints. Even so, many patients suffer chronic pain in silence. A 2012 national survey2 revealed that 11.2% of adults self-reported experiencing daily pain. Advocates from multiple sectors recommend including pain as a vital sign, to uncover unrecognized chronic pain. The question is: How well are clinicians prepared to handle it?
Managing chronic pain can be stressful for the healthcare team. Opioids are highly effective for short-term pain, so it’s easy to understand why clinicians consider them for chronic pain unresponsive to other options. The CDC report accompanying their new opioid prescribing guideline notes that an estimated 20% of patients presenting with non-cancer pain end up with an opioid prescription. These prescriptions are on the rise, varying greatly across geographies in ways that can’t be explained by the health status of the population.
The Toll of Long-Term Opioids
Some patients fare well on chronic opioids, and for many, these drugs are their best option. However, the risks are legion, overdose and abuse among them. While deaths from heart disease and cancer are declining, death from opioids, including prescribed opioids, are on the rise, according to the CDC. Dependence-related withdrawal symptoms can occur after only a few weeks of use, and in some cases those symptoms set patients up for cycles of addiction. As many as 1 in 4 patients on long-term opioids in a primary care setting will eventually struggle with addiction, according to the CDC. A prescribed opioid taken for non-cancer pain can become the gateway drug for illicit substance abuse. The heartbreaking toll that addiction takes on families, communities, and businesses is incalculable.
Concrete solutions for clinicians
The instinct to relieve pain is as primal as pain itself. Pain can be terrifying and life-altering, so clinicians are understandably protective of their ability to treat it. Alleviating pain is one of the most humane acts that clinicians are called upon to do. Researchers at Geisinger Health System recently announced findings from an analysis of the EHRs of more than 2,000 patients admitted to the hospital for overdoses between April 2005 and March 2015. Their report asserts that “EHRs can be a powerful tool in reducing the risks associated with opioid overdoses by providing alerts to providers about potential red flags.” At athenahealth, we’re supporting clinicians as they navigate the evolving mechanics of pain management, grapple with abuse issues, and improve care for patients suffering from pain. Here’s how how we’re doing it:
Encouraging appropriate prescribing. We collaborated with the CDC to transform their new Guideline for Prescribing Opioids for Chronic Pain into a point-of-care Epocrates Guideline Synopsis tool for clinicians, available free in the Epocrates mobile app and online. It’s designed for tailoring specific guidance to an individual patient in around a minute or less. We’re also getting the word out through mobile-device DocAlert messages to Epocrates readers.
Among the CDC’s new prescribing guidelines:
- If opioids are used for acute pain, 3 days or fewer will often suffice; more than 7 days will rarely be needed.
- Consider the full range of therapeutic options for chronic pain, including combinations of nonopioid and nonpharmacologic therapy.
- When starting opioids for chronic pain, prescribe immediate-release formulations instead of extended-release/long-acting opioids.
- Use the lowest effective dose. Reassess benefits and risks if the dose reaches 50 morphine milligram equivalents (MME) per day; avoid or carefully justify a dosage of 90 MME/day.
- When starting opioids, and periodically, order urine testing and review state prescription drug monitoring program (PDMP) pharmacy tracking data.
- Avoid prescribing opioids and benzodiapezines concurrently.
Alerting on opioid safety issues. Epocrates drug interactions are native inside the athenaClinicals EHR. Clinicians are alerted when they prescribe an opioid along with other drugs that could raise the risk of overdose.
Supporting e-prescribing. Several states have mandated the E-Prescribing of Controlled Substances in an effort to reduce paper-prescription fraud and prevent patients from obtaining duplicate or multiple prescriptions. athenahealth has made this feature available to all clinicians in our athenaClinicals EHR.
Pain As a Complex Social Problem
We all want the reassurance of access to effective pain treatment when we need it, and we can’t afford to lose sight of that during the opioid epidemic. Excessive opioid prescribing is merely one facet of a complicated problem. Will optimizing the way clinicians prescribe opioids singlehandedly solve the epidemic? Clearly not. Yet, by refining our prescribing patterns, we can at least narrow one gateway into some of the suffering associated with this imperfect class of drugs. If even a few of our patients, friends, and family members are spared the devastation of opioid addiction or death, then efforts to manage the prescribing component of this complex problem are well worth it. The ultimate solution to this epidemic may require a deeper understanding of what goes on in the hearts, minds, and bodies of patients who end up suffering more than they benefit from opioids. What we can do today is bring the best possible guidance to clinicians through the Epocrates app and the athenaClinicals EHR.
1 CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR. March 18, 2016 / 65(1);1–49; Press Release March 15, 2016.
2 Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. J Pain 2015;16:769–80.
Submitted by Susan C Smith - Friday, June 17, 2016
Very interesting article. I absolutely appreciate the issues related to utilizing opioids for short terms needs. However, what I have not seen addressed are patients struggling with chronic, intractable pain. Sometimes these patients are on various medications including opioids for many years. What should not happen is for insurance companies, in their zeal to curtail short term opioid prescribing, start restricting access to these necessary products without unnecessarily burdening both doctor and patient.
Submitted by R. Keiver - Thursday, June 16, 2016
What happened to the term 'dependence '. For chronic pain I've always thought people became dependant on opiods, not addicted. Calling everyone an 'addict' doesn't help this problem. I don't believe the word dependant was used at all in this article.
Submitted by Shobhana Patodia - Wednesday, June 15, 2016
Primary physician with little training in treating chronic pain, prescribes opioids until pt. becomes addicted and then try to send it to specialist , who has a very difficult job trying to either wean or discipline this difficult group of pt.