SARAH O'NEILL: When we talk about opioids, we refer to things like,
narcotics, is another name for opioids.
And this includes medications like oxycodone or morphine, fentanyl.
There are many opioids.
And all of them are used for pain.
And some of them are natural occurring opioids, such as morphine and codeine.
And there are some that are semisynthetic,
such as hydrocodone, oxycodone, and hydromorphone.
And then, we have fully synthetic drugs, like methadone and fentanyl.
So all of these drugs are used for both chronic cancer
pain and chronic noncancer pain, as well as in some acute situations
when it's appropriate.
HOWARD J. SHAFFER: Opioid use is a very common medical treatment
for pain and a few other disorders.
If you need opioids, you should talk with your doctor about that need.
And if it's specific to pain, for example,
you might ask whether there are other pain
relievers that are less powerful that will still do the job.
If you decide to undertake opioid treatment with your physician,
I think it's very important that you not exceed the prescribed dose
and the prescribed frequency.
Once you have taken opioids for a while, it's then important
not to stop without talking to your doctor
and developing a plan for reducing that use.
SCOTT G. WEINER: Pain is one of the most common things
that we treat in the emergency department.
It's by far the most common reason why patients
present to the emergency department.
There's different studies, but definitely over 50% of patients
present because there's some sort of a pain.
That could have been because they sprained their ankle
and that hurts or their chest hurts or their abdomen hurts.
But it's pain.
We as clinicians, want to do whatever we can to alleviate the pain.
This is part of our moral obligation.
We use medications like acetaminophen, ibuprofen as best we can.
But we do have this class of medications, which are the opioids.
Even in the course of my career, probably starting around 2000 or so,
there started to be this recognition that we were undertreating pain.
Many studies came out that showed that we were allowing patients
to suffer needlessly.
We weren't giving them adequate medication.
And this led to lots of different standards that happened.
There's an initiative that says, pain is the fifth vital sign, for example.
They started asking about pain treatment on satisfaction surveys
that patients got.
They started using it as a quality measure as well too.
So I that what happened was clinicians, their first inclination
was to use the medications that we knew worked for pain.
And those are opioids.
They're the most potent medications we have for pain.
And so we started prescribing more and more.
And I can tell you that we used to go from one or two
Tylenol with codeine to then using one or two tablets of oxycodone
to then using lots of hydromorphone, a really strong opioid.
And we started using more and more at a time,
to the point where the pendulum definitely swung
too far to the side of overtreatment.
And now, we're in this phase right now.
It's not just the emergency physicians.
We know that it's basically all clinicians.
We know that the prescribing of opioids increased
markedly, probably at least fourfold.
If you look at the actual numbers of milligrams,
probably tenfold over the past 20 years.
And so now, we're in this area where we are right now.
I think that the current strategy that we have,
at least in the emergency department, is to minimize the use of opioids
as much as possible.
So we do try and use acetaminophen, ibuprofen.
We use patches that have lidocaine that help with the symptoms.
We're trying to do a better job with regional blocks.
These are where we inject a little bit of anesthetic around a nerve.
And this can make the paying for that area completely go away
for a significant amount of time.
We're also recognizing that we still need to use opioids in some situations,
but we don't need to use so much.
We now know that acute pain, that really severe pain,
probably lasts only two to three days.
And so there's no point in giving a prescription with 30 pills.
It's probably sufficient to have 8 or 10 pills.
Because we know that those leftover 20 pills then stay in the medicine
cabinet, they get diverted, they get abused,
and that's where people get into trouble.
So I think that there's this new recognition about the problem.
And I think there's a new sophistication with how
we're using these medications as well.
In addition to multimodal pain treatment, that's
using every opportunity we have to treat pain before we reach for the opioid.
Frequently, in the emergency department when someone has pain,
they want to feel better.
And sometimes they equate feeling better with the opioid medications.
This new era of sophistication where we're
trying to be very good about how we're using opioids,
we're trying to reduce their utilization as much as
possible, that's sometimes tricky.
Patients want to have the strong medication.
They want a certain amount.
But we know that there's harm associated with it.
If a patient comes in and they are requesting an opioid,
I now sit down with the patient and have a discussion.
We have good research that came out that showed that if you have back pain
and you get an opioid, your outcomes are exactly the same at five days as
if you hadn't had the opioid.
So what's the point of having the risk of that medication?
We know that if you maximize the nonopioid medications, ibuprofen,
acetaminophen, pain patches, like lidocaine patches,
for example, then often, people will feel entirely better.
So why take the risk of the opioid?
The number that sticks in my head that I often tell patients is 15%.
And I've seen that over and over again in many studies,
whether it be having minor surgery, getting
a first prescription for an opioid naive patient in the emergency department.
It seems that about 15% of them will still be on opioids at a year,
even if they were opioid naive before and that
was their very first prescription.
So I tell patients, about 15% of patients
that I give that first prescription to will still be dependent on them
at a year.
It's not worth the risk in most cases.
So when treating pain, opioids are extremely powerful.
And there's clearly a role for them.
The problem that we have currently is that practitioners
are literally all over the map.
Some people will not prescribe anything for any condition.
And some people will give 30, 60, 90 pills of oxycodone or hydrocodone.
And so I think what's happening is that we're
creating this severe problem of expectations
for patients, because they don't know what
they're going to get from which doctor.
We need to do a better job with that.
We're starting to see guidelines that are coming up, such as from the CDC,
which made guidelines.
We need to get on the same page, even after procedures.
For example, after a normal childbirth or a cesarean section,
we found that obstetricians are extremely varied
with the numbers of pills that they give for patients.
We see that after orthopedic surgery as well, after general surgery,
like appendicitis, for example.
Some people were give no opioids and some will give a lot of opioids.
And this is creating a problem.
So we need some form of standardization.
Obviously, we need to recognize that every patient is different
and their needs will be different.
But we can't have this tenfold difference
in the amount of pain medications that are given to people.
The thing that I'm most concerned about is not the treatment of acute pain,
it's those leftover pills that are in the medicine cabinet,
because we know that the vast majority of patients, people
that nonmedically use opioids, they get them from a friend or family for free.
And what that means is that there were medications that
were prescribed that were left over.
We need to do a better job with rightsizing those prescriptions.
And I think we're starting to do that.
At my own hospital, we actually just started
speaking about getting all of the specialties that prescribe,
talking about their most common, most frequent procedures,
and then getting all of the faculty on the same page,
as far as what the guidance will be for how many pills should be prescribed.
And the good thing about this is that they often emphasize nonopioids
first and the opioids only for the severe pain, if the other medications
and other modalities are not working.
Despite all the attention given to not prescribing opioids
and to reduce our utilization of opioids, they clearly have a role.
In the environment where I practice, we often
see patients with severe chest pain, abdominal pain, bad infections,
particularly trauma, fractures, for example.
So it's clear from some of these problems that patients can have,
fractures, severe trauma, abdominal pains, even cancer or chronic pain,
there is certainly a role for opioids.