Due to drastically increased opioid addiction and death from opioids in recent years, medical associations, clinicians, and lawmakers are seeking to find ways to mitigate this epidemic. Below we explore 3 different initiatives that address opioid abuse.
1. Recommendations for CRNAs — A Holistic Approach to Pain Management
Initiative by: The American Association of Nurse Anesthetists (AANA)
Targeted at: Certified Registered Nurse Anesthetists (CRNAs)
Initiated: Adopted by the AANA Board of Directors July 2016
This initiative by the AANA posits that CRNAs are well positioned to provide assistance with treating and managing all types of pain in a variety of settings, including hospitals, ambulatory surgical centers, offices, and pain management clinics.
Treatment for pain should be individualized for each patient, depending on the patient’s “preferences, age, culture, beliefs, social environment, healthcare history, and physical and psychological condition.”
In the future, pain care may become even more personalized with the development of new diagnostic techniques such as pharmacogenomic testing, which examines how inherited genetic differences affect an individual’s response to drugs.1,2
CRNAs can work with patients to create a multimodal plan for pain management, and can participate in all steps of the process, including:
- Preoperative: Develop a patient-specific treatment plan based on patient history
- Intraoperative: Design a multimodal pain management paradigm, which may include regional and/or neuroaxial blockade when applicable, antiemetics, or normothermia
- Postoperative: Educate patients and caregivers, prevent and manage postoperative nausea and vomiting
- Home recovery period and post anesthesia follow-up: Encourage alternative pain management, such as mindfulness, relaxation, and exercise. Opioids may be prescribed, but patients should be re-assessed before refilling opioid prescription
- Treating and Managing Chronic Pain: Provide treatment that includes non-pharmacologic as well as pharmacologic modalities. The Prescription Drug Monitoring Programs should be checked whenever opioids are prescribed. Consistently re-assess patients’ pain and treatment plan. Realistic pain management goals that focus on improving quality of life should be established
- Cancer Pain or Pain in Palliative and/or Hospice Care: Provide a treatment that includes non-pharmacologic as well as pharmacologic modalities. Manage side effects resulting from opioid treatment such as constipation, nausea, and drowsiness. Provide counseling to patients and caregivers. Adjust treatment as necessary, depending on patient’s response to treatment and levels of pain. Develop an interdisciplinary plan to manage pain that focuses on functional goals and quality of life.
“Acute and chronic pain is best treated and managed by an interdisciplinary team that actively engages the patient to diagnose and manage their pain for improved well-being, functionality, and quality of life,” wrote the AANA statement authors.
“Careful assessment and treatment of acute pain, which may include appropriate opioid prescribing may reduce the probability of acute pain transitioning to chronic pain and of the developing opioid dependency or abuse.”3
2. Five Ways Clinicians Can Take the Lead in Addressing the Opioid Crisis
Initiative by: Michael Wong, JD, Executive Director of the Physician-Patient Alliance for Health & Safety (PPAHS)
Targeted at: Clinicians
Initiated: September 6, 2016
Michael Wong, JD, Executive Director of the PPAHS, noted that despite an increased awareness of the opioid epidemic and a call for restricting opioid use and prescribing, “it must not be forgotten that opioids play a vital role in the management of pain, such as during surgery or to relieve chronic pain.”
Using the Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain,4 Mr Wong created 5 recommendations for clinicians to work towards appropriate opioid prescribing, especially for those with chronic pain.
The recommendations are as follows:
- Ensure that opioids are warranted and are prescribed at an appropriate dosage. Higher doses of opioids have not been shown to provide further analgesia over the long term, and doses at or above 50 morphine milligram equivalent (MME)/day increase the risk by at least 2-fold, compared with doses of less than 20 MME/day
- prescribing a non-opioid treatment According to the principles of chronic pain treatment by the CDC, opioids should not be the first line of therapy for treating pain that is not cancer pain, palliative care, or end-of-life care, and non-opioids can be effective.
- Be conscious that patients react in different ways to opioids. While patients are on opioids in the hospital, it is important to use end-tidal CO2 monitoring, as some patients are more prone to respiratory depression than others. Pharmacogenomic testing may identify patients at higher risk of respiratory depression.
- Reduce opioids in patients who have been using them long-term. Especially consider this in patients who exhibit certain warning signs. Starting gradually with a 10% reduction or less in opioid dosage is a reasonable starting point.
- Ascertain that highest risk patients are monitored both inside and outside the hospital. While patients outside the hospital are not under end-tidal CO2 monitoring, they should be followed-up employing alternated methods
3. Are Physicians Able To Treat Opioid-Use Disorder With Buprenorphine Effectively?
Initiative by: The RAND Corporation
Targeted at: Policymakers and Clinicians
Initiated: Research letter published in the Journal of the American Medical Association (JAMA) on September 20, 2016.
Currently, physicians who complete an 8 hour course and obtain a US Drug Enforcement Administration waiver can treat up to 30 patients at once with buprenorphine for opioid use disorder. After 1 year, they can request that the number be raised to 100.
The RAND Corporation conducted a study to determine whether these limitations were negatively affecting the number of patients physicians could treat.5 This study showed that physicians are treating far fewer patients with buprenorphine than they are allowed to.
“The monthly patient censuses for buprenorphine-prescribing physicians were substantially below patient limits at the time; more than 20% treated 3 or fewer patients, and fewer than 10% treated more than 75 patients,” wrote Bradley D. Stein, MD, PhD, from the RAND Corporation and the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania, and colleagues.
Some of the reasons physicians cited for not treating more patients with buprenorphine includedinsufficient access to substance abuse counseling for patients, and to buprenorphine prescribers for clinicians.
The researchers suggested that these issues might be addressed with phone or online counseling for patients, as well as mentoring or phone consultation from more experienced buprenorphine prescribers for physicians.
“Strategies to help current prescribers treat more patients safely and effectively could complement policy initiatives designed to increase access to treatment by increasing patient limits and number of waivered prescribers,” the authors wrote.
- Ting S, Schug S. The pharmacogenomics of pain management: prospects for personalized medicine. J Pain Res. 2016;9:49-56.
- Ko TM, Wong CS, Wu JY, Chen YT. Pharmacogenomics for personalized pain medicine. Acta Anaesthesiol Taiwan. Mar 2016;54(1):24-30.
- Katz J, Seltzer Z. Transition from acute to chronic postsurgical pain: risk factors and protective factors. Expert Rev Neurother. May 2009;9(5):723-744.
- Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1–49. doi:http://dx.doi.org/10.15585/mmwr.rr6501e1.
- Stein BD, Sorbero M, Dick AW, Pacula RL, Burns RM, Gordon AJ. Physician Capacity to Treat Opioid Use Disorder With Buprenorphine-Assisted Treatment. JAMA. 2016;316(11):1211-1212. doi:10.1001/jama.2016.10542.