You can hardly open up a newspaper these days, or swipe your screen to read, without seeing something about the opioid epidemic. With 50,000 deaths a year from this scourge, it deserves to be front and center for all of us – patients and clinicians.
I was like many other physicians who practiced over the past 20 years, prescribing more opioids than were necessary.
The Joint Commission, an independent group responsible for hospital accreditation nationwide — the guys who decide if a hospital is safe and well-run — were part of this. They listed pain as the fifth vital sign, right next to temperature, blood pressure, pulse and respiration.
The idea, very well-founded, was that we should ask each and every patient in the hospital if they were in pain. Nurses would do a pain assessment and we clinicians would then address the problem — more often than not with opioids. We thought the abuse potential for these drugs was lower than it turned out to be.
The Joint Commission was right in putting pain front and center, so kudos to them. But we were too quick to prescribe these potentially dangerous medications in amounts that were way too high.
In addressing pain, we didn’t emphasize physical therapy, massage therapy and acupuncture enough. We didn’t send people to psychologists for instructions in cognitive behavioral therapy, a method of learning how to deal with and adapt to pain.
Here’s a letter I received that highlights one issue involving opioids.
Dr. Z: I had an experience that I found alarming. I was scheduled for a minor outpatient ankle surgery. The surgeon wrote a prescription for 100 hydrocodone pills when I left the hospital.
Before filling the scrip, I called the doctor’s office, thinking he must have meant 10 instead of 100. His office told me he wrote the same for all surgeries — whether fixing an ankle or a hip, or doing carpal tunnel surgery. Everybody got 100 tablets.
Is this a common practice? — D.C. from Binghamton, N.Y.
Dear D.C.: Unfortunately, yes, it is. Surgeons often do this so they don’t get a call in the middle of the night asking for a refill.
However, new guidelines from the Centers for Disease Control and Prevention are to give three to five days of medications and, if a patient needs more, re-evaluate and decide. There should be no blanket large prescriptions like this unless you can document the need.
There are many patients who do need these doses, and that’s where clinical judgment comes in. The doctor should treat each patient appropriately for their needs.
We shouldn’t just forget opioids. Not at all, in fact. They are useful drugs that allow many people to function and live well.
Let me give you a perfect example: A patient of mine has been on opioids for many years. He’s a former athlete — college football, semi-pro hockey — with military service and three back surgeries behind him. He’d been on opioids for years, having been stabilized by his doctors in Alabama before moving to our lovely state.
Wisconsin has joined many other states in making rules meant to limit the long-term use of opioids. The rules are designed to encourage physicians to see if they can at least lower each patient’s opioid dose or eliminate them completely.
So during a recent visit with this patient, I laid out the facts explaining that we should try to taper down his opioid dose and see what happens. At first he wasn’t interested, but when I explained what the issues were — that perhaps he was safer on a lower dose — he was game. Cautious but game.
We worked together in tapering the dose, emphasizing back exercises, regular use of ibuprofen and daily walking. Now, he’s off of them. Completely. He was surprised at the outcome and so was I.
Will this happen with every chronic opioid user? Of course not, but it will with some.
You can fault me for not doing this before the new state rules came out, but I joined many of my colleagues who thought that if a patient was stable, why rock the boat? The winds have changed.
My spin: If you’re on chronic opioids, think about tapering down and trying to get off of them completely. Tapering down under medical supervision just might improve your life. Stay well.