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The Surgeon's Roles in Stemming the Prescription Opioid Abuse Epidemic

2016; Elsevier BV; Volume: 74; Issue: 7 Linguagem: Inglês

10.1016/j.joms.2016.05.001

1531-5053

James R. Hupp,

Anesthesia and Pain Management

The management of pain after extractions and other forms of oral-maxillofacial surgery is both an art and science. Surgeons learn post-operative pain management strategies from their dental and residency faculties and co-residents. They then refine and personalize that knowledge through clinical experiences. In general, surgeons are successful in helping their patients handle pain after surgery. However, are the techniques we tend to use producing unintended consequences? Like other surgeons, I always try my best to make patients as comfortable as possible. This includes obtaining profound local anesthesia and utilizing nitrous oxide and/or advanced forms of pain and anxiety control when indicated. Keeping the patient as comfortable as possible after surgery is also important, since almost all surgical procedures produce post-operative discomfort. The discomfort ranges from a mild soreness that typically follows the atraumatic ∗Atraumatic exodontia usually signifies tooth removal without a flap or the need to cut bone.∗Atraumatic exodontia usually signifies tooth removal without a flap or the need to cut bone. removal of an asymptomatic erupted tooth to much more significant pain that follows surgery for jaw fractures, large tumors and major maxillofacial reconstruction. In the past, I felt I was prudent in my use of post-operative analgesics. I would advise patients to use ibuprofen and/or acetaminophen after the atraumatic removal of teeth. If the extraction required a limited flap and an alveoloplasty I would usually prescribe a codeine-containing compound, typically acetaminophen with 30 mg of codeine. I'd write for the patient to take one or two doses every four hours as needed for pain and typically order them 25 to 30 tablets, with one refill. If I removed partial or full bony impactions my standard prescription was for a compound containing oxycodone. Again, I would order the drug be taken prn for pain and order 25 doses. I would also use long-acting local anesthesia and high-dose intravenous corticosteroids preoperatively. These regimens seemed to work well since I rarely got calls requesting more pain medication. However, there were several facts about the pain prescriptions I wrote for my patients that I did not know:1)How often could the patient have had their pain adequately managed with a less potent narcotic or even a non-opioid analgesic?2)How often patients needed far fewer doses than I provided?3)How often the drugs I prescribed were used by someone other than my patient?, and4)If any of the drugs I prescribed helped lead to or continue someone's opioid addiction? But just because I don't know the answers to these questions for my own patients does not mean I have nothing to guide my prescribing writing practices. First, there is more and more data showing that many patients receive more potent and more doses of opioid medications than they need to manage their post-operative pain. Second, it is clear that doctors often prescribe too many doses of narcotics that end up being used by other members of the patient's family, including children. Third, we are all aware that some patients give away or sell the opioids we prescribe for them. Fourth, many individuals with narcotic addiction were, in part, led to or carry on that addiction using opioids legally prescribed for them by their doctors. It is true that a large percentage of those addicted to opioids use legally obtained drugs that are intended for chronic pain conditions. As oral-maxillofacial surgeons (OMSs) we may encounter patients suffering from chronic facial pain disorders that may benefit from opioid medications. The potential for these type of patients to seek prescriptions from multiple healthcare providers to help supply their addiction should not be underestimated. Each of us as practitioners can only guess how the opioid drugs we prescribe are eventually used, but there is sobering data on the US population that provides some insights.•In 2010, enough prescription narcotics were prescribed to medicate every American adult every four hours for one month.•The number one source of prescription drugs used by teenagers is from their parent's medicine cabinet.•Three out of four people abusing prescription opioids obtained them from a friend or family member.•Since 1999 the number of overdose deaths from prescription pain medications increased by 300%. The amount surpasses deaths due to the combined total of overdoses from heroin and cocaine. Therefore, even though I do not know how the pain relievers I prescribed were used or by whom, there is little doubt that some of them may have been used inappropriately. Strategies to combat this national epidemic of the non-medical use of prescription painkillers are being discussed at the national and state levels. Legislation is under consideration in Congress to try to comprehensively address the problem of prescription drug addiction. An act being discussed addresses the issues from both prevention and treatment angles. Preventive tactics include expansion of prescription drug take-back programs and abuse awareness campaigns. Treatment-focused strategies include addiction recovery programs and increasing the availability of opioid reversal drugs. Since states have licensing authority over those who prescribe drugs, initiatives are occurring in several states addressing the problem. These include increasing the monitoring of narcotic prescription writing by individual practitioners, and improving the ability of pharmacies to detect excessive use of prescription pain relievers by individual patients through greater sharing of data between pharmacies. Partial filling of prescriptions, by say, permitting a doctor to write prescriptions where only a few doses of the drug are initially dispensed, but allowing the patient to obtain additional doses, if needed, without a new prescription, is being promoted at both the national and state levels. Our parent organization, the AAOMS, is actively promoting programs to alert and educate clinicians about the prescription opioid abuse epidemic. While at our recent Day on the Hill in Washington, D.C., members voiced their support for national efforts to address the issue with our elected representatives. In the end the most effective means of combating the problem of prescription opioid abuse comes down to actions each of us can take at the local level. Measures such as the regular use of preemptive analgesic regimens are already used by some OMSs, but as yet are not widely utilized. Preemptive techniques take advantage of the well-known ability of non-steroidal anti-inflammatory drugs (NSAIDs) to mitigate the intensity of post-operative pain when administered in appropriate doses and given a sufficient time prior to surgery. Successive doses of NSAIDs are then used post-procedure as needed, with a prescription narcotic compound kept in reserve as a rescue medication. Obviously, the use of long-acting local anesthesia can help reduce pain during the first 48 hours after surgery and this may be enough to allow the patient to not need a prescription analgesic. Surgeons performing dentoalveolar or implant procedures may find it effective to use less potent and less addictive narcotics, or give fewer doses before the patient is required to get a refill. Oxycodone, and to a somewhat lesser extent, hydrocodone and hydromorphone, compounds have higher abuse potentials and street-value; therefore, surgeons may opt to use codeine containing compounds when possible, despite a national trend away from the use of codeine in the pediatric population. Patient education with respect to post-surgery pain management is also an avenue for OMSs to address prescription opioid abuse. We as doctors have commonly led patients to believe the goal of post-operative pain control is the elimination of all pain; while, in reality, the goal should be modulation of pain to a level that it does not overly interfere with daily functions and sleep. Patients are able to handle all kinds of daily pains without resorting to narcotics, so they should be educated that some post-operative pain does not require narcotics. This may take some convincing, since many patients have routinely received pain prescriptions after dentoalveolar surgery and assume the drug will be necessary. When discussing post-procedure pain management surgeons should also discuss how to best use prescription analgesics. In some cases the patient may be fine just taking the prescription drug at bedtime, using non-prescription drugs during the day. Also, augmenting a prescription drug with a non-prescription one may help limit how many prescription doses the patient requires. Surgeons should consider limiting the number of doses prescribed and explain to the patient why they are doing so. Patients can already request their pharmacy to partially fill a prescription and get the remainder later on if needed. Surgeons can alert patients of this option, which will save them some money; more importantly, it is less likely they will have pills left over after they no longer need the opioid. A major service to patients requesting or receiving narcotic compounds from OMSs is for the surgeon to educate them about the problem of family members using the remainder of a narcotic prescription for a non-medical use. This will help patients who are parents since their own children, and perhaps their children's friends, might have easy access to narcotic drugs in the home medicine cabinet. Encouraging patients to participate in leftover drug discard programs or otherwise making it impossible for leftover drugs to fall into the wrong hands is important. Once patients understand the hazards of having excess doses of opioids in their home they may be more inclined to turn down a prescription or be satisfied with a lower potency and/or quantity of drug. OMSs also have another means of helping fix our nation's prescription opioid abuse problem. In most dental schools OMSs play a major role in teaching dental students and residents about post-operative pain control. This is perhaps how we as a specialty can have our greatest impact. Surgery educators should incorporate information about the abuse problem into courses in which pain management is taught. Discussions should be held of how students and residents can best help their patients and society limit opioid abuse by using non-prescription pain control strategies when possible and prudently using prescription narcotics. This knowledge may also need to be shared with other dental faculty who are not OMSs since many of them may not be familiar with the problem and ways to help in the fight. Too often we as OMSs try to teach patient management techniques to students only to have them ignored or undermined by other school faculty, thus the reason for school-wide in-service training on this topic. The didactic discussion of opioids abuse needs to be followed by application of sound prescription writing principles when students and residents are learning to treat actual patients. This will need to include teaching them how to explain to patients who present assuming they will need a prescription of why in many cases it will not be needed. Also students and residents need to be trained how to spot drug-seeking and other forms of adverse drug related behavior. With more and more state licensing boards monitoring the narcotic prescribing practices of their licensees, trainees need to have competency in the proper approach of post-procedure pain management including prescribing drugs. Academic OMSs can also play an important role in solving the problem of the non-medical use of prescription opioids by designing and conducting research into this area. Ripe areas of investigation include prospective clinical trials of the use of preemptive analgesic approaches versus traditional prescribing of post-operative narcotic compounds. The use of neuromodulating drugs such as gabapentin, pregabalin and lamictal may also have much to offer OMS patients undergoing major procedures where pain is expected to be significant and last longer. The efficacy of topical analgesics or local injections of drugs like Exparel is also a fertile ground for research, as is the use of opioid compounds that contain abuse-limiting chemicals. Like in most societal problems, there is no silver bullet for the issue of prescription opioid abuse. Coordinated and noncoordinated actions at many levels are likely to be the most effective in reversing the troubling trends in this area of health care. If we as a specialty can do our part and partner with other groups, associations and government representatives, we may be able to find the most effective approaches. Hopefully we can then avoid over-zealous and non-evidence based regulatory and punitive actions against doctors that may be handed down by politicians and regulators. Guidelines developed by the Centers for Disease Control and Prevention are available that provide clinicians with recommendations of how they can manage painful conditions while helping limit prescription opiate abuse.1Frieden T.R. Houry D. Reducing the risks of relief - The CDC Opioid-Prescribing Guideline.NEJM. 2016; 374: 1501Crossref PubMed Scopus (175) Google Scholar One final caution is for each of us to remember that we cannot lose sight of the patient who has a clinically legitimate need for an opioid medication. As with all other aspects of surgical care, our responsibilities to our patients do not end with the placement of the final suture or pressure gauze sponge on the extraction site. Pain that overly interferes with a patient's usual routines, their ability to consume enough fluids and calories, or their ability to sleep often requires a narcotic, at least until the pain subsides. This is where we cannot let our concern for the national opioid abuse problem or the mandates of regulators impede the appropriate use of clinically valuable medications when needed by those under our care. Changing an aspect of one's clinical practice that seems to not be broken can be difficult, particularly for more experienced surgeons such as myself. However, circumstances arise that should prompt reexamination of our patient management strategies. The prescription opioid abuse epidemic is one of those realities, affecting millions of our fellow citizens and some of our own patients. Adopting post-operative tactics such as preemptive approaches, raising one's threshold for using very potent narcotics, and limiting the number of doses prescribed to patients are worthy of consideration. Such rethinking of long used forms of patient management shows a healthy vibrancy in one's clinical care armamentarium.