The Role of the Acute Pain Physician in Combatting the ...the national opioid problem by adjusting only policies concerning prescription opioids. For example, the minority of heroin

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The Role of the Acute Pain Physician in Combatting the Current Opioid Epidemic

Alarmingly, rates of opioid use disorder (OUD) and opioid overdose death (OOD) have reached

unprecedented levels over the past two decades, and have risen much faster in the United States than

in most other countries. U.S. Department of Health and Human Services data suggest that at least 2

million Americans have an UOD involving prescribed opioids and at least 600,000 have an OUD involving

heroin, with at least 90 Americans dying every day from overdoses that involve an opioid. Recently, in

2016, the FDA charged the National Academies of Sciences, Engineering, and Medicine (The National

Academies) with characterizing the epidemic and recommending actions that the FDA and other public

and private organizations should take to address the problem (View https://www.raeducation.com/wp-

content/uploads/2015/08/Picture81.png ). Their directive was to balance society’s interest in reducing

opioid-related harms with the needs of individuals suffering with pain, and the National Academies

issued a very comprehensive report that addressed the problem in a multidisciplinary fashion. They

concluded that the opioid epidemic will not be controlled without deploying multiple policy tools.

The Editorial Board of RAEducation.com endorses these recommendations. We opine that it is a

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cultural and behavioral problem rather than a statutory or legislative problem, and we agree that:

• Increasing access to treatment for individuals with OUD is imperative. • Substantial programs of research to develop new non-addictive treatments for

pain is needed. • Regulating, advisory, and controlling bodies should reshape and monitor the

legal market for opioids and facilitate the use of safe and effective agents for treating patients with OUD and reducing overdose deaths.

• Law enforcement agencies should continue to be responsible for curtailing trafficking in illegally manufactured opioids, most recently, low-priced fentanyl manufactured in clandestine laboratories domestically and abroad.

• A multidisciplinary medical approach is required and the inputs from all disciplines should be sought. Given that family physicians, pain specialists and orthopaedic surgeons, in that order, are the top prescribers of opioids, their input should also be sought as a high priority.

The Editorial Board of RAEducation.com

Although RAEducation.com is a non-political group with a strictly educational mission, we

believe that we can and should play an integral part in the national debate, even if we can only add a

few pieces to the puzzle – namely, through education and by making our blocks work – especially our

continuous in-hospital and ambulatory nerve blocks. We agree and are convinced that effective

continuous peripheral nerve blocks (CPNBs) (see here https://www.raeducation.com/acute-pain-

medicine/blocks/andre-boezaarts-high-yield-blocks-section/ )are the only way to minimize perioperative

opioid use, but before we can propose this as a viable alternative, we must make our blocks work; not

only on the day of surgery, but also on the days following surgery – our secondary blocks. Blocks that

suffer secondary (or primary) failure are totally counterproductive, but unfortunately very prevalent.

We acknowledge that pain is a complex syndrome, often difficult to measure and treat, and is associated

with comorbidities, disability, and social cost, including work absenteeism and increased utilization of

medical resources. From our viewpoint, this includes acute pain, perioperative pain, chronic pain, and

end-of-life cancer pain. The complexity of pain is matched by the complexity of achieving the

appropriate use of opioids in the context of the often-suboptimal clinical management of pain within the

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fragmented U.S. health care delivery system. (Please refer to opioid pharmacology by clicking here

https://www.raeducation.com/acute-pain-medicine/pharmacology/opioid-pharmacology/ ).

Years of sustained and coordinated effort will be required to contain the current opioid

epidemic and ameliorate its harmful effects on society. We do recognize that legislation, control, and

regulation is only a (small) part of the solution, and a cultural change is required for an eventual

maintainable and positive outcome to the problem. The Editorial Board of RAEducation.com will

withhold itself from commenting on the regulatory responsibilities and instead will focus on where we

can help to influence the culture. (Please participate in the debate and air your views and opinions by

clicking here https://www.raeducation.com/participate/discussion-forum/ ). We see our role in this in

a specialized and limited way, as a contribution to one piece of the greater puzzle – the educational

aspect of pain management. A comprehensive approach recognizes that the prescription opioid

epidemic is interwoven with the illegal drug market and that one cannot develop a sensible response to

the national opioid problem by adjusting only policies concerning prescription opioids. For example,

the minority of heroin users start with heroin (Fig. 1). The majority start with prescription opioids and

graduate to heroin and, more recently, to fentanyl.

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We also recognize that an integrated systems perspective has three corollaries that bear

discussion:

1. An ongoing research program is needed to continuously improve understanding of how the various opioids in all their combinations are used and misused, as opposed to just as intended.

2. Investment is warranted in an underlying data infrastructure, as opposed to piecemeal efforts locally to particular considerations.

3. The capability to monitor, understand, and model that behavior can be shared among all involved parties.

The National Academies proposed an approach that address restricting supply and reducing demand of

opioids and reducing the harmful consequences. We wholeheartedly agree with this, but would like to

express areas where we can influence these topics:

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Restricting Supply and Reducing Demand

• Regulating the approved products (e.g., abuse-deterrent formulations): We have no role to play here.

• Restricting lawful access:

Scheduling: We have no role to play here.

Preventing and penalizing diversion: We have no role to play here. We, however, are of the opinion

that penalizing those who divert would in fact be counterproductive.

Drug take-back programs: We have no role to play here, but we strongly believe that this should be

state run and could have a significant impact on the availability of opioids. The caveat here is that

we believe previous programs have failed because they were voluntary. We strongly believe that

any program should still be voluntary, but there should be a substantial monetary reward for

patients to bring their unused opioids back; the financial reward should at least be in the same

ballpark as the relative “street value” of these drugs minus the monetary equivalent of the risk of

illegally selling the drugs “on the street.”

Other state and local policies restricting access: We have no role to play here, although we are of

the opinion that a time restriction on opioid prescriptions (e.g., allowing only 3-, 5-, or 7-day

prescriptions) is inappropriate. While it may be appropriate in the case of acute and perioperative

use of opioids, it is certainly not in the case of chronic pain conditions. The focus should rather be

on recognizing patients at risk and tailoring the prescription accordingly. For example:

Recognize that the risk factors for persistent postsurgical opioid use (PPOU) – defined as using

opioids beyond 90 days after surgery or trauma, are recognized and well-studied. Some risk factors

are modifiable and some not. Dr. Michael Kent of Duke University provided an excellent discussion

on this topic here https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-

medicine-section/ . These factors include:

• Surgical type

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• Preoperative opioid use

• A lower risk in patients that:

o Are opioid naïve

o Use Tramadol

o Use opioids intermittently

• A higher risk in patients that:

o Use scheduled opioids

o Use extended-release opioids

Thus, during the preoperative period, we should encourage and educate practitioners to avoid

providing opioid-naïve patients with scheduled opioids and extended-release opioids, and prescribe

opioids for a shorter duration (perhaps 7 days only) and only on an as-needed basis (PRN). Also, to

prescribe Tramadol in favor of more potent drugs and combine it with other drugs such as

acetaminophen and nonsteroidal anti-inflammatory drugs.

• Influencing prescribing practices:

Provider education: This forms the mainstay of and chief contribution that RAEducation.com can

and should make. Most practitioners realize that effective in-patient and ambulatory continuous

nerve blocks can and do virtually replace the use of potent opioids in opioid-naïve patients, yet the

vast majority of anesthesiologists and anesthetists are not equipped to perform these procedures

and thus revert to counterproductive single-injection nerve blocks. There are two main reasons (in

our opinion) for this: lack of a sufficient skill set, and, more importantly, lack of sufficient

remuneration for practicing these, and thus, the lack of the development of this skill set [Please click

here https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-medicine-section/

for our proposed opioid-restriction protocol. Also click here https://www.raeducation.com/acute-

pain-medicine/mike-kents-acute-pain-medicine-section/ for our proposed protocol for the routine

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management of postoperative pain after total joint replacement and click here

https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-medicine-section/ for

our proposed protocol for the routine management of pain after major abdominal surgery. Please

click here https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-medicine-

section/ for our proposed protocol ambulatory (outpatient) total joint arthroplasty, and click here

https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-medicine-section/ for

our proposed protocol for managing pain in patients with double lung transplants]. We

acknowledge that all of these protocols assume properly placed and functioning CPNBs, which is not

a safe assumption in a number of institutions. We strongly feel that a concerted effort should be

made toward educating anesthesiologists and instituting mature acute pain services (APS) (see here

https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-medicine-section/

. We strongly feel, as well, that the funding institutions should appropriately remunerate the use of

in-hospital and outpatient APS and CPNB use, which will in turn encourage practitioners to acquire

the needed skill sets. The physicians doing the educating should be highly qualified and

appropriately remunerated for providing this education. The above, we believe, will not happen on

a voluntary basis. The Joint Commission accepted the University of Florida’s model of an APS into

their Library of Best Practices (click here https://www.raeducation.com/acute-pain-medicine/mike-

kents-acute-pain-medicine-section/ to view), and this model should perhaps be adopted and

adapted by members. (Members, please voice your opinions here

https://www.raeducation.com/participate/discussion-forum/ ).

Prescribing guidelines: Pain Committees can draw up these guidelines based on scientific evidence,

but they would require statutory or institutional regulatory help to “encourage” the use of these

guidelines. For example, it would be easier for a physician to refuse to write a long-term opioid

prescription for long-acting opioids if s/he can tell a patient that in [YOUR STATE/INSTITUTION], it is

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against the law/policy to prescribe OxyContin for opioid-naïve patients preoperatively, for example.

Also, that it is against the law in Florida to prescribe potent opioids for longer periods than, perhaps,

7 days preoperatively. Such guidelines and legislation should be created in full cooperation between

the legislators and The Pain Committee. Patients at risk of PPOU could be identified and specifically

targeted and treated appropriately as outlined above. Restrictions on opioid prescriptions should

not apply to patients with chronic pain, but only for those with acute pain.

Electronic medical record (EMR) and decision support: EMRs are widely used. A specific person in

an institution or practice may be appointed to monitor that institution’s or practice’s opioid usage

and be able to compare it to the use of other institutions in a state-wide database.

Insurer policies: We strongly believe that insurers should heavily redirect their focus toward

appropriately remunerating non-opioid postoperative measures, especially in-hospital and

ambulatory CPNBs. Members are encouraged to enthusiastically lobby for this and air their opinions

and views here https://www.raeducation.com/participate/discussion-forum/ . There is currently no

financial incentive for practitioners to acquire the needed skill sets, nor is there any financial or

other incentive to follow-up on such patients. We believe it should be (much) more profitable for

practitioners to provide outpatient CPNBs than to not provide them. Also, outcome studies should

be performed and compared between institutions and practices, and institutions and practices with

effective opioid-sparing programs should be encouraged by appropriate remuneration.

Prescription drug monitoring programs: We would encourage this, but we believe that this should

be done internally by institutions and practices and not by regulatory bodies.

• Patient and public education: This should be a primary task of RAEducation.com. Institutions

and practices should be strongly encouraged to follow the model of the Department of

Orthopaedic Surgery at the University of Florida to educate patients prior to joint replacement

surgery (please see http://www.ortho.ufl.edu/jrep for the UF Joint Replacement Educational

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Program (JREP). Please also click here https://www.raeducation.com/patients/ to view our

patient education package, which you should feel free to share with your patients. Access to this

is free of charge and open on RAEduction.com. Orthoinfo.org also has a large collection of

patient education material that is freely available). These models could easily be expanded to

other disciplines. The CMS and the “Bundled Payment Program” (CCJR) sparked this initiative.

Please click here https://www.raeducation.com/acute-pain-medicine/mike-kents-acute-pain-

medicine-section/ to view our proposed TJR pain management protocol.

• Increasing access to, availability, and utilization of medical treatment for OUDs: The Pain

Committee does not see itself in an active role here other than an advisory role, but would

encourage legislators to take a page from the Portugal playbook and decriminalize addiction,

instead focusing on rehabilitation by calling addiction a disease rather than a crime.

Reducing the Harmful Consequences

• The use of naloxone to reverse overdose: We strongly believe that all first responders and family

members of patients at risk of OOD should be educated in the use of naloxone and that it should be

readily available to such individuals. After undergoing an educational program (RAEducation.com can

help with this), individuals in this category should freely have naloxone available at all times.

• Reducing disease transmission: We strongly encourage these measures, which include syringe

exchange, supervised injection facilities, drug checking, behavioral intervention, but we do not see a role

for ourselves here, other than to cynically observe that these are totally unfeasible measures until drug

addiction has been decriminalized and is viewed as a disease and not a crime.

Some Final Thoughts:

Depending on the specific situation, opioids, non-opioid medication, nerve blocks, topical

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medication, physical and occupational therapy, non-traditional “alternative” measures, temperature

treatments, and other measures should be employed individually or in a multimodal approach. Opioids

should be used only when non-opioid alternatives are deemed inappropriate; as a second-line

medication and not a first-line one, as is the prevailing tradition.

The idea of pain as the “fifth vital sign” should be actively discouraged and abandoned.

Furthermore, the idea and tradition of pain-free surgery should likewise be actively discouraged and

abandoned. The focus should shift to function and away from pain. Patients should be educated to

understand that pain is a normal and natural consequence of trauma and surgery, and “no pain as a

patient right” does not and should not exist nor should it be promoted. This cannot be achieved before

medical practitioners of all disciplines are educated on this. An active educational campaign should

stress that if the pain that exists does not interfere with function (eating, drinking, sleeping,

mobilization, toilet, etc., it is not pain that requires further (opioid) intervention. Furthermore, “no pain”

as a marketing strategy to provide surgeons and institutions a competitive edge should be discouraged

and disincentivized.

Patient satisfaction as a metric of doctor and institution performance (and even more

dangerous, remuneration) is a dangerous trend and should be discouraged and abandoned. It is well-

recognized that there is a direct relationship between patient satisfaction and opioid prescription.

There is also a direct relationship between patient satisfaction and morbidity and mortality. This

concept should be actively opposed and abandoned.

Members are encouraged to air their opinions and views on this and any other topic by clicking

here https://www.raeducation.com/participate/discussion-forum/ . Please tell us and your colleagues

what you think.

André P. Boezaart, MD, PhD

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Editor-in-Chief

RAEducation.com