Opioid Safety, Patient Safety

Can Clinicians Reduce Opioid Dependence Through Multimodal Approaches to Pain Management?

By Sean Power
November 17, 2015

Mary Rechtoris, writer at Becker’s Healthcare, reported on the North American Spine Society’s 30th Annual Meeting held in Chicago, at which experts discussed whether multimodal pain management approaches could reduce opioid dependence.

Ms. Rechtoris writes:

“In the United States, 70 million patients are prescribed opioids for postsurgical pain each year. Of those patients, one in 15 will go on to experience long-term use or abuse.”

According to Sheeraz Quereshi, MD, MBA, Spine Surgery Specialist, Mt. Sinai Medical Center:

“If we specifically look into spine, there have been studies that have shown a year after elective spine surgery, one-third of all patients are still using opioids and 18 percent of those people were not previously taking narcotic medications. This is happening across the board, in elderly patients and in young patients.”

According to the article, the American Society of Anesthesiologists advises physicians to shift toward “a multimodal approach to pain management”, beginning with local anesthetic when possible.

According to Dr. Quereshi:

“We have to understand that a unimodal approach to pain treatment can’t be expected to provide efficient pain relief.”

A multimodal approach would include non-opioid medications including Nonsteroidal Anti-inflammatory Drugs (NSAIDs).

Others have advocated for combining both pharmacologic and non-pharmacologic interventions to attack more than one underlying pain mechanism.

Chris Pasero, MS, RN-BC, FAAN, Pain Management Educator and Clinical Consultant described the unimodal approach as a “recipe for disaster” for inpatient settings.

According to Ms. Pasero:

“When someone has some mild pain, we give them opioids. They have a little more pain, we give them more opioids. They have severe pain, we give more opioids. And, of course, at the top of this pyramid is where we see adverse events including patient deaths. What’s happening nation-wide is a focus on opioid-only treatment plans. This is problematic.”

Outside the clinic, opioids can be equally troublesome. A report by Trust for America’s Health and the Robert Wood Johnson Foundation revealed the extent of drug misuse and abuse.

Drug overdose deaths are now the leading cause of death from injury in the United States and every year, nearly 44,000 people die from drug overdose.

The Centers for Disease Control and Prevention have said that the United States is in the middle of an “epidemic” when it comes to prescription painkiller overdose. Since 1999, the amount of prescription painkillers prescribed and sold has nearly quadrupled, yet overall, Americans report the same amount of pain.

The number of overdose deaths in the United States involving opioid pain relievers has increased three times over since 2001 and consistently exceeds the number of overdose deaths from heroin and cocaine.

National Opioid Overdose Deaths

Given these staggering challenges, multimodal pain management plans hold promise, but not without drawbacks.

Choll Kim, MD, Associate Clinical Professor of Orthopaedic Surgery, Spine Institute of San Diego, explained that interventions such as NSAIDs are “not nearly as potent as a narcotic”, and that gastric acid can present issues and an increased risk of bleeding.

For spinal surgeons, NSAIDs are problematic because they inhibit fusion.

According to Dr. Kim:

“In an effort to decrease our reliance on powerful narcotics, we don’t have a single drug that can replace them. Therefore, we are replacing them with multimodality therapy strategies. One of those components includes NSAIDs, and those can be used safely in certain doses and for certain time periods.”

But the challenge remains. How can clinicians reduce America’s dependence on opioids, and should they do so?

What do you think? Can physicians reduce dependence on opioids through multimodal approaches to pain management?

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