A guest column by the American Society of Anesthesiologists, exclusive to KevinMD.com.
With the holiday season upon us, there is no better time to reflect on how we as physicians can better serve our patients — not only in the treatments we provide — but in how we tackle growing health issues such as the overuse and abuse of prescription opioid painkillers.
The United States is facing a prescription painkiller overdose epidemic. Approximately 44 people die each day from prescription opioids, and more than 80 percent of these deaths are accidental or unintentional. It is estimated that up to 60 percent of opioid overdose deaths occur in people without a prior history of substance abuse. Why have opioid-related fatalities tripled since the nineties? The answer may surprise you.
Opioids are commonly prescribed to treat various types of moderate to severe pain following surgery, injury or related to cancer. They also play an important role in the treatment of chronic pain, which affects more than 100 million Americans.
Although physicians have a moral and ethical duty to treat pain, we may be dispensing more medication than necessary. In fact, the Centers for Disease Control (CDC) report that since the ‘90s, there’s been a fourfold increase in the number of prescription painkillers prescribed without a change in the amount of pain experienced by Americans and, in 2012 alone, health care providers wrote 259 million prescriptions for opioid or narcotic painkillers. The most commonly prescribed drugs are hydrocodone, oxycodone, oxymorphone, and methadone.
Although these drugs have a true therapeutic value for individuals who suffer from intense pain, leftover medication may remain unused and can be “diverted” — the transfer of a prescribed drug to another person for illicit use — that has also contributed to the widespread abuse of prescription opioids.
Safe opioid use
Long-term care professionals should be made aware of the issues that face individuals with pain. It is vital for physicians to engage in a serious discussion with both the patient and the caregiver about these medications when they are prescribed. To help facilitate conversations between patients suffering from pain and physician anesthesiologists about what care is really necessary, the American Society of Anesthesiologists (ASA) developed a list of targeted, evidence-based recommendations as part of the ABIM Foundation’s Choosing Wisely campaign.
There are many ways physicians can advocate for the safe use of opioids, including instructing patients to take medication as directed, educating them on the potential harmful interactions with other medications and/or alcohol, and teaching them the signs and symptoms of overdose. Physicians should also support other overdose prevention measures including increased patient access to naloxone, an opioid antidote, so that family or loved ones can rapidly intervene in the event of an opioid overdose at home.
Of course, the best thing to do is to prevent an emergency from ever occurring, but if it does, being prepared is a priority. The ASA collaborated with the White House Office of National Drug Control Policy to develop a wallet-sized card to help families identify the signs and symptoms of an overdose, as well as tips for responding to an overdose. The ASA’s Opioid Overdose Resuscitation Card is available for download.
We should also deliver clear instructions regarding the disposal of leftover drugs and remind patients of the potential for others to misuse the medication. Currently, there is no consensus on the best way to dispose of these drugs. Solid guidelines need to be established by governmental entities so that we can clearly and effectively provide this information to patients.
Technology and innovation
In addition to providing instruction and resources for the safe use of opioids, technology can be used to curb the prescription opioid epidemic. The American Medical Association Task Force to Reduce Opioid Abuse encourages more physicians to register and use state Prescription Drug Monitoring Programs (PDMP) — electronic databases that provide a history of the controlled substances patients may have taken — to help make more informed decisions when prescribing. PDMPs can also be used to help physicians identify patients at risk for opioid abuse. In conjunction with PDMPs, health care practitioners should review the “Stakeholder’s Challenges and Red Flag Warning Signs Related to Prescribing and Dispensing Controlled Substances” consensus document. Created by the ASA and other medical, pharmacy and supply chain companies and organizations, the document outlines the shared responsibility to ensure that all controlled substances are prescribed and dispensed for a legitimate medical purpose as well as providing guidance on which red flag warning signs warrant further scrutiny. Enhancing physicians’ education through CME courses and webinars on best practices for safe prescribing is also paramount.
Medical innovations may someday reduce the need for, and possibly the amount of, opioids used to treat pain. Current research has led to the development of medications that can decrease nerve irritation and depression caused by pain. Some of these new medications are being designed using nanotechnology or medications that may reverse an opioid overdose such as naloxone. Moreover, the increasing use of genetic testing for personalized medicine may make crafting an effective pain regimen easier for doctors. One of the most promising research areas involves harvesting stem cells from the patient’s bone marrow and injecting them into affected areas. The hope is that the stem cells will build new, healthy tissue and relieve pain permanently.
While research is ongoing, the commitment to tackling this issue should be at the forefront of all physicians’ minds. Let’s use these resources to take care of our patients battling acute and chronic pain.
Anita Gupta is an anesthesiologist.
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