Halting a Crisis: Opioids or Not?

This article is the first in a series about the epidemic of addiction to prescription pain medications, and how NEOMED is training future physicians and pharmacists to help.

What’s the point of treating pain?

William Smucker, M.D., doesn’t ask the question rhetorically. There’s a real goal, one that is critically important to patients with pain, as the associate director of the Family Medicine Center at Summa Akron City Hospital knows from years of experience. The goal? To improve function in the patient.

That theme was a mantra throughout Dr. Smucker’s recent presentation to third-year NEOMED College of Medicine (M3) students. About 40 percent of the people who walk into a primary care practice have chronic pain, according to Dr. Smucker, who is the family medicine residency director at Summa Health in Akron. Figuring out how to best assess and treat pain is something that every NEOMED medicine student will have to tackle.

Ibuprofen, NSAIDs, opiates? Heat, ice, massage? The right series of steps can ease pain and improve function. An incorrect solution can lead a patient down a path that ends in addiction.

As Jeff Susman, M.D., dean of the NEOMED College of Medicine, said in a recent conversation, ‘’The intractable nature of many people’s pain and suffering makes this a very challenging area. How do you get the focus on living with pain instead of eliminating pain? How do you concentrate on functional ability, doing the things the patient needs to do and wants to do in life?”

“And how do you have a conversation that weighs appropriately the risks and benefits of opioids?? Because with appropriate use, there are times when their use can be effective.”

Sorting out the Options

In a “Prerequisite to the Clinical Curriculum” session that helps prepare students for their third year, Dr. Smucker took students through a series of case studies to begin sorting out the important question of when – and when not—to prescribe opioids after they make a diagnosis.

He reviewed the importance of relieving acute severe pain in hospitalized patients using evidence-based dosing strategies. He also stressed the importance of screening for risk factors that increase the risk of serious side effects from opioids.  Students were instructed in proper monitoring for serious side effects during opioid treatment. He contrasted the difference between acute pain due to injury or illness with the problem of chronic pain in the outpatient setting.  

Just prior to Dr. Smucker’s class, the students were required to complete a free, one-hour, online prescriber training program called Smart Rx. The Ohio State Medical Association created Smart Rx with the goal of reducing prescription misuse and opioid addiction in Ohio, which has one of the five highest rates of death from drug overdoses in the entire nation (source: Centers for Disease Control).

This alarming fact makes learning about the issues an even bigger priority for NEOMED students, said Lisa Weiss, M.D., a family physician and associate dean of curriculum at NEOMED’s College of Medicine.

Dr. Smucker introduced his student session with a couple of statistics:  Opioid prescriptions quadrupled between the years 1999-2010 And—not coincidentally—between 2004 and 2014, there was a 400 percent increase in overdoses, according to the CDC and the Ohio Governors Opiate Action Team   (Paulozzi LJ Morbidity and Mortality Weekly Report 2011;18 1166-75).

Here’s the kicker: “For chronic pain, opioids have no proven long-term benefit for reported pain or improved function,’’ said Dr. Smucker.  He added that opioids are most useful when treating acute pain—that is, pain that the patient has felt for fewer than 12 weeks.

In other words, a lot of people are taking opioids who shouldn’t be. But what if a patient has had pain for a long time?

Medications that are not opioids – acetaminophen (Tylenol) or non-steroidal anti-inflammatory drugs (NSAIDs), such as aspirin, ibuprofen (Advil) or naproxen sodium (Aleve)—can help alleviate their pain, including chronic pain, Dr. Smucker told the students. Other solutions: Cognitive Behavioral Therapy (CBT), exercise therapy, so-called adjuvant pain medications such as anticonvulsants or anti-depressants that boost the effect of pain medicines—or a combination of the items listed.  

Case Studies

Time to put yourself in the physician’s place with a few edited examples from Dr. Smucker’s presentation:

Your Uncle Joe loves oysters and beer. Last night, after a particularly good feast, he started feeling throbbing in his right toe, which is now swollen. Would opioids help?  

This is probably a gout attack, and in addition to a medicine to control gout and a medicine for inflammation, he may need opioids for a few days to allow him to move around. He should follow his attack with a history, lab work and exam to look for causes of gout. He should be counseled about how to reduce gout attacks by changing his diet.

Your sister Kacey, who is 26, often gets terrible pulsating headaches brought on by lights and loud noises. Would opioids help? These attacks are likely migraines. Opioids should be avoided for the treatment of migraines because more effective treatments exist, and opioids are not very effective for the pain of migraine. The foundation of migraine care is lifestyle modification; regular rest, avoiding environmental triggers like certain foods or alcohol, and use of preventive medicines to reduce the frequency and severity of attacks. When attacks occur, migraine specific medicines and medicines for inflammation are best to control the pain.  

Your neighbor, Ted, who is 38, has had low back pain since picking up a heavy flower pot a month ago. Would opioids help? Most cases of back pain are best treated with physical therapy and over-the- counter pain medicines. Opioids do not improve function for patients with back pain, and may even contribute to a worse long-term outcome.

Your grandmother, age 79, has had diabetes for 20 years and wakes up in the night from burning leg pain that she rates as 9 on a scale of 10. She has decreased sensation in her feet. Would opioids help?  This is probably pain from nerve damage due to diabetes. The best treatment for this condition is blood sugar control and medicines that reduce the pain signals from damaged nerves. If these treatments do not allow proper sleep or function, research shows a benefit from opioids.

Dr. Smucker led a discussion of when, and how, medications should be tried before prescribing opioids and instances in which they should not be used at all, because research has shown that they do not help. Among these examples, the answers would be different for people with gout, migraines, low back pain and diabetic neuropathy, respectively. If inflammation is the problem, a NSAID will likely help. For diabetic nerve damage (neuropathy), gabapentin is a potential solution to be considered.

Armed with Dr. Smucker’s “Principles of Opioid Treatment’’ handout, knowledge of the online reference globalrph.com (which includes a guide to dosages) and discussions of case studies, NEOMED M3s gained tools and experience in how to evaluate and diagnose—even when the situation isn’t clear-cut.

“I am not sure how all of this training will affect the upcoming generation of providers,’’ said Dr. Weiss, “but I believe that they will be more alerted to the problem of opioid abuse and that it can’t be ignored or pushed to the next provider. This training prepares them to ask the right questions and gives them resources for answers.”

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