When used correctly, opioids can be a valuable tool for managing moderate to severe pain. Considering one in every four people in the United States has suffered from pain lasting longer than 24 hours, according to the National Institutes of Health, that’s important. It means pain affects more Americans than diabetes, heart disease and cancer combined.
Yet this type of prescription medication, which includes hydrocodone, oxycodone and codeine, is notoriously misused and abused, which can cause dangerous side effects and lead to addiction. In 2016, the United States recorded an average of 47 deaths per day from prescription opioid overdoses, according to the Centers for Disease Control and Prevention (CDC).
"But the ‘opioid crisis’ is not just about addicts — that’s the biggest misconception,” said
Timothy Furnish, MD, pain management specialist at UC San Diego Health. “It’s not just other people running into problems with opioids, like people abusing the drugs trying to get high. It can also be patients who might legitimately be prescribed opioids and take them responsibly who are overdosing or having other serious problems.”
MedSafe at a glance
What: Collection bin for secure disposal of personal, unused prescription opioids
Where: Pain Management Clinic, first floor, Koman Family Outpatient Pavilion, UC San Diego Health, La Jolla
When: During clinic operating hours, weekdays 8 a.m. to 5 p.m.
Who: Anyone, including patients, visitors and the public. Employees may use MedSafe only for their own personal medications.
Why: Do your part to combat the opioid crisis by reducing opportunities for their abuse
Not for: illegal drugs, needles, lancets or liquids of more than four ounces
Furnish describes six ways UC San Diego Health physicians, staff and even patients are making efforts to reduce opioid prescriptions, ensure they are used and disposed of correctly and getting help to those who need it.
1. Provide better guidance for primary care providers.
UC San Diego Health has long had internal guidelines to help health care providers, especially in primary care, know what to prescribe for pain and when they should refer a patient to a pain management specialist, rather than continuing to escalate the opioid dosage. The UC San Diego Health guidelines have recently been updated to reflect new CDC guidelines.
2. Minimize opioid prescriptions.
For inpatients, UC San Diego Health’s pain management team has re-written the pain order sets to emphasize non-opioid and multimodal pain management options. They still prescribe opioids after surgery when necessary, but they also use other drugs to minimize opioids and provide better pain management.
And they’re not just guessing what might work. UC San Diego Health researchers are conducting studies to determine how they can best help a patient control pain without opioids. For example, in a study published October 2018 in the journal
Anesthesia & Analgesia, Furnish and colleagues, including Rodney Gabriel, MD, and Engy Said, MD, found that the implementation of an acute pain service — basically, pre- and post-surgery pain management planning led by anesthesiologists rather than surgeons — was associated with a more than 50 percent reduction in total opioid consumption during the first four hospital days after a complex cancer surgery.
Likewise, for outpatient patients at the
Pain Clinic at UC San Diego Health, Furnish said the goal is to wean people completely off opioids when possible, or at least lower the dose to 50 milligrams or less per day.
“Even if a person is not misusing opioid medication, simply being on opioids increases their risk of side effects, including drowsiness, falls and car accidents. So there are lots of good reasons to be on less or no opioids, even if you’re not abusing them,” Furnish said.
“Very frequently we hear patients say ‘I can’t do that! Opioids are the only thing that helps!’ But when we can work with them to slowly lower their dose, they often find that even at half their previous amount or less, there isn’t a difference in their pain, but they feel better — they are more alert and less ‘cloudy.’”
3. Ensure prescribers check the “doctor shopping” database.
When prescribing opioids for a patient, all California health care providers are required to first check the Controlled Substance Utilization Review and Evaluation System (CURES) site, a database maintained by the California Department of Justice to track all controlled substances prescribed in the state. The goal is to prevent “doctor shopping” — when a patient sees multiple doctors in order to obtain more opioid prescriptions. At UC San Diego Health, the electronic medical record system won’t allow a provider to enter a new prescription for an opioid unless they document that they have first checked CURES.
4. Arm patients with more information.
UC San Diego Health is standardizing and expanding the information given to all patients who are prescribed opioids for pain management after a hospital stay. Now, information about the risks, potential side effects and how to safely dispose of the medications is automatically included in a patient’s discharge summary.
5. Provide a place for secure opioid disposal.
MedSafe — a collection bin for the disposal of unused, unneeded prescription opioids — was recently installed in the Pain Management Clinic at the Koman Family Outpatient Pavilion at UC San Diego Health in La Jolla.
“It’s simply not safe to leave unused narcotics laying around,” said Sam Martinez, PharmD, associate clinical professor at Skaggs School of Pharmacy and Pharmaceutical Sciences and pharmacy manager at UC San Diego Health, who oversaw the installation. “We need to get these medications not only off the streets, but out of our own medicine cabinets and trash in order to keep people, especially teenagers, from getting access to them.
6. Improve access to medication-assisted addiction treatment.
UC San Diego Health is expanding its addiction clinic to help primary care providers, women’s health care providers, internal medicine physicians and other specialists identify patients with opioid use disorders. Addiction experts are also helping more people access medications for long-term treatment of opioid addiction, such as methadone, buprenorphine and naltrexone. These medications are typically prescribed by psychiatrists specializing in addiction, but now non-psychiatrists, including primary care providers, are being trained on how and when to use these treatments. In addition, team members have launched a project to initiate medication treatment in hospitalized patients, so that they are more likely to continue the treatment after they are discharged.
“The best substance abuse treatments take into consideration everything about your life, the people in your life, the role the substance plays and how you want to address all those factors,” said
Carla Marienfeld, MD, board-certified addiction psychiatrist at UC San Diego Health. “But with opioids we’re lucky that we also have medications to prevent cravings and withdrawal symptoms.”
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