By Lynnus Peng, MD
Practicing anesthesiologist with Allied Anesthesia in Orange County, Calif.
[email protected]

 

Hundreds of thousands of deaths, billions of dollars in healthcare costs: Fueled by an addiction epidemic, America’s opioid crisis is graver than ever. Experts estimate that more than 130 Americans die every day from opioid overdose(1).

Lynnus Peng, MD

Across the healthcare spectrum – from practitioners to researchers to manufacturers – we share a common goal: to improve the lives of patients. Those of us who deal heavily in pain relief and management are closer to the opioid epidemic than many of our colleagues.

Anesthesiologists are probably best known for helping patients sleep through medical procedures. And while administering general anesthesia during operations is undoubtedly a large part of our work, our expertise also includes pain management before, during and after surgery and the management of chronic or acute pain unrelated to surgery, like neck and back pain.

As doctors who aim to relieve the pain of our patients, we face a collective dilemma: How can we manage our patients’ pain while still doing our part to fight the opioid crisis?

As we grapple with this question, it’s important to understand that the opioid crisis has come about in response to a number of different but interrelated factors, specifically(2):
• Doctors over-prescribing opioids for pain management
• Misinformation about the addictiveness of prescription opioids
• Hospitals, doctors and health systems focusing on patient-reported pain control as a primary indicator of success
• A complicated and skewed reimbursement system
• The increasing availability of illegal opioids like heroin

Given the complex nature of the opioid crisis, it’s no surprise that there is no simple solution. Recent attempts to reduce opioid use illustrate this difficulty perfectly.

For example, a recent effort to restrict the prescription (and therefore availability) of opioids aimed to cut opioid-related deaths. The restriction was successful, in part; the number of prescriptions decreased. But an unforeseen and dangerous consequence arose: With less prescription opioids available, people began to use unregulated, illegal opioids instead – because they were less expensive and more accessible. A further complicating consequence of the cutback was that people living with acute or chronic pain – who relied on opioids to function normally – had a harder time getting the prescriptions they needed.

Another measure took the form of legislation that limited opioid prescriptions for acute – but not chronic – pain. Under this legislation, prescriptions for acute pain (like post-surgery pain) were limited to just seven days. Though undoubtedly well-intentioned, this legislation is likely to pose significant problems for people in chronic pain, since acute pain and chronic pain are often related. Given that the National Institutes of Health reports that 25.3 million adults experienced pain every day over the previous 3 months and nearly 40 million adults report severe levels of pain, it’s clear that drastically limiting opioid prescriptions poses a significant problem for many Americans.

Those of us in the medical field need to help our patients manage pain in a way that is both effective and responsible. Sometimes, this will include opioids – used carefully and mindfully – but we should also make use of the many other available methods of pain relief, like individual and regional nerve blocks, epidurals and steroid injections.

Though these pain relief methods are not as well-known among patients (and some doctors) as opioids, they can be incredibly effective – and don’t come with the often unpleasant side effects of opioids. We have found that patients who receive regional nerve blocks prior to procedures are often completely pain-free for 24-72 hours afterwards. By the time the nerve block wears off, over-the-counter medications like Tylenol or non-steroidal anti-inflammatory drugs (NSAIDs) provide sufficient relief and opioids are not needed.

Opioids are sometimes necessary for severe chronic pain that does not respond to other forms of pain management. But as more opioid alternatives become available, it is important that we – doctors, insurers, pharma and governmental regulatory bodies – work together to take care of our patients and, when needed, use opioids responsibly and conscientiously.

 

Sources:
(1) DC/NCHS, National Vital Statistics System, Mortality. CDC WONDER, Atlanta, GA: US Department of Health and Human Services, CDC; 2018. https://wonder.cdc.gov
(2) How Good Intentions Contributed to Bad Outcomes: The Opioid Crisis. Teresa A. Rummans MD, Caroline Burton MDD, Nancy L. Dawson MD. May Clin Proc. March 2018: 93 (3): 344–350. https://www.mayoclinicproceedings.org/article/S0025-6196(17)30923-0/fulltext