Professor André Boezaart heads the Acute and Perioperative Pain Medicine and Acute Pain Service at the University of Florida. He has a special interest in applied anatomy, microanatomy and continuous nerve blocks, especially ambulatory continuous nerve block and opioid-sparing pain management. He is working on a number of projects including projects on microanatomy of nerves and intraneural injections and is the Editor-in-Chief for RAEducation.com
The Acute Pain Physician’s role in Combatting the Current Opioid Epidemic
Alarmingly, rates of opioid use disorder (OUD) and opioid overdose death (OOD) have reached unprecedented levels over the past two decades, and have risen much faster in the United States than in most other countries. U.S. Department of Health and Human Services data suggest that at least 2 million Americans have an UOD involving prescribed opioids and at least 600,000 have an OUD involving heroin, with at least 90 Americans dying every day from overdoses that involve an opioid. Recently, in 2016, the FDA charged the National Academies of Sciences, Engineering, and Medicine (The National Academies) with characterizing the epidemic and recommending actions that the FDA and other public and private organizations should take to address the problem (View). Their directive was to balance society’s interest in reducing opioid-related harms with the needs of individuals suffering with pain, and the National Academies issued a very comprehensive report that addressed the problem in a multidisciplinary fashion. They concluded that the opioid epidemic will not be controlled without deploying multiple policy tools.
The Editorial Board of RAEducation.com endorses these recommendations. We opine that it is a cultural and behavioral problem rather than a statutory or legislative problem, and we agree that:
- Increasing access to treatment for individuals with OUD is imperative.
- Substantial programs of research to develop new non-addictive treatments for pain is needed.
- Regulating, advisory, and controlling bodies should reshape and monitor the legal market for opioids and facilitate the use of safe and effective agents for treating patients with OUD and reducing overdose deaths.
- Law enforcement agencies should continue to be responsible for curtailing trafficking in illegally manufactured opioids, most recently, low-priced fentanyl manufactured in clandestine laboratories domestically and abroad.
- A multidisciplinary medical approach is required and the inputs from all disciplines should be sought. Given that family physicians, pain specialists and orthopaedic surgeons, in that order, are the top prescribers of opioids, their input should also be sought as a high priority.
The Editorial Board of RAEducation.com
Although RAEducation.com is a non-political group with a strictly educational mission, we believe that we can and should play an integral part in the national debate, even if we can only add a few pieces to the puzzle – namely, through education and by making our blocks work – especially our continuous in-hospital and ambulatory nerve blocks. We agree and are convinced that effective continuous peripheral nerve blocks CPNBs (see here) are the only way to minimize perioperative opioid use, but before we can propose this as a viable alternative, we must make our blocks work; not only on the day of surgery, but also on the days following surgery – our secondary blocks. Blocks that suffer secondary (or primary) failure are totally counterproductive, but unfortunately very prevalent. We acknowledge that pain is a complex syndrome, often difficult to measure and treat, and is associated with comorbidities, disability, and social cost, including work absenteeism and increased utilization of medical resources. From our viewpoint, this includes acute pain, perioperative pain, chronic pain, and end-of-life cancer pain. The complexity of pain is matched by the complexity of achieving the appropriate use of opioids in the context of the often-suboptimal clinical management of pain within the fragmented U.S. health care delivery system. (Please refer to opioid pharmacology by clicking here).
Years of sustained and coordinated effort will be required to contain the current opioid epidemic and ameliorate its harmful effects on society. We do recognize that legislation, control, and regulation is only a (small) part of the solution, and a cultural change is required for an eventual maintainable and positive outcome to the problem. The Editorial Board of RAEducation.com will withhold itself from commenting on the regulatory responsibilities and instead will focus on where we can help to influence the culture. (Please participate in the debate and air your views and opinions by clicking here). We see our role in this in a specialized and limited way, as a contribution to one piece of the greater puzzle – the educational aspect of pain management. A comprehensive approach recognizes that the prescription opioid epidemic is interwoven with the illegal drug market and that one cannot develop a sensible response to the national opioid problem by adjusting only policies concerning prescription opioids. For example, only a minority of heroin users start with heroin (Fig. 1). The majority start with prescription opioids and “graduate” to heroin and, more recently, to cheaper fentanyl.
We also recognize that an integrated systems perspective has three corollaries that bear discussion:
- An ongoing research program is needed to continuously improve understanding of how the various opioids in all their combinations are used and misused, as opposed to just as intended.
- Investment is warranted in an underlying data infrastructure, as opposed to piecemeal efforts locally to particular considerations.
- The capability to monitor, understand, and model that behavior can be shared among all involved parties.
The National Academies proposed an approach that address restricting supply and reducing demand of opioids and reducing the harmful consequences. We wholeheartedly agree with this, but would like to express areas where we can influence these topics:
Restricting Supply and Reducing Demand
- Regulating the approved products (e.g., abuse-deterrent formulations): We have no role to play here other tan advisory if requested.
- Restricting lawful access:
Scheduling: We have no role to play here other than advisory if requested.
Preventing and penalizing diversion: We have no role to play here. We, however, are of the opinion that penalizing those who divert would in fact be counterproductive.
Drug take-back programs: We have no role to play here, but we strongly believe that this should be state run and could have a significant impact on the availability of opioids. The caveat here is that we believe previous programs have failed because they were voluntary. We strongly believe that any program should still be voluntary, but there should be a substantial monetary reward for patients to bring their unused opioids back; the financial reward should at least be in the same ballpark as the relative “street value” of these drugs minus the monetary equivalent of the risk of illegally selling the drugs “on the street.”
Other state and local policies restricting access: We have no role to play here, although we are of the opinion that a time restriction on opioid prescriptions (e.g., allowing only 3-, 5-, or 7-day prescriptions) is inappropriate. While it may be appropriate in the case of acute and perioperative use of opioids, it is certainly not in the case of chronic pain conditions. The focus should rather be on recognizing patients at risk and tailoring the prescription accordingly. For example:
Recognize that the risk factors for persistent postsurgical opioid use (PPOU) – defined as using opioids beyond 90 days after surgery or trauma, are recognized and well-studied. Some risk factors are modifiable and some not. Dr. Michael Kent of Duke University provided an excellent discussion on this topic (view). These factors include:
- Surgical type
- Preoperative opioid use
- A lower risk in patients that:
- Are opioid naïve
- Use Tramadol
- Use opioids intermittently
- A higher risk in patients that:
- Use scheduled opioids
Thus, during the preoperative period, we should encourage and educate practitioners to avoid providing opioid-naïve patients with scheduled opioids and extended-release opioids, and prescribe opioids for a shorter duration (perhaps 7 days only) and only on an as-needed basis (PRN). Also, to prescribe Tramadol in favor of more potent drugs and combine it with other drugs such as acetaminophen and nonsteroidal anti-inflammatory drugs.
- Influencing prescribing practices:
Provider education: This forms the mainstay of and chief contribution that RAEducation.com can and should make. Most practitioners realize that effective in-patient and ambulatory continuous nerve blocks can and do virtually replace the use of potent opioids in opioid-naïve patients, yet the vast majority of anesthesiologists and anesthetists are not equipped to perform these procedures and thus revert to counterproductive single-injection nerve blocks. There are two main reasons (in our opinion) for this: lack of a sufficient skill set, and, more importantly, lack of sufficient remuneration for practicing these, and thus, the lack of the development of this skill set [Please click herefor our proposed opioid-restriction protocol. Also click hereor our proposed protocol for the routine management of postoperative pain after total joint replacement and click here for our proposed protocol for the routine management of pain after major abdominal surgery. Please click here for our proposed protocol ambulatory (outpatient) total joint arthroplasty, and click herefor our proposed protocol for managing pain in patients with double lung transplants]. We acknowledge that all of these protocols assume properly placed and functioning CPNBs, which is not a safe assumption in a number of institutions. We strongly feel that a concerted effort should be made toward educating anesthesiologists and instituting mature acute pain services (APS) (see here
We strongly feel, as well, that the funding institutions should appropriately remunerate the use of in-hospital and outpatient APS and CPNB use, which will in turn encourage practitioners to acquire the needed skill sets. The physicians doing the educating should be highly qualified and appropriately remunerated for providing this education. The above, we believe, will not happen on a voluntary basis. The Joint Commission accepted the University of Florida’s model of an APS into their Library of Best Practices (click hereto view), and this model should perhaps be adopted and adapted by members. (Members, please voice your opinions here)
Prescribing guidelines: Pain Committees can draw up these guidelines based on scientific evidence, but they would require statutory or institutional regulatory help to “encourage” the use of these guidelines. For example, it would be easier for a physician to refuse to write a long-term opioid prescription for long-acting opioids if s/he can tell a patient that in [YOUR STATE/INSTITUTION], it is against the law/policy to prescribe OxyContin for opioid-naïve patients preoperatively, for example. Also, that it is against the law in Florida to prescribe potent opioids for longer periods than, perhaps, 7 days preoperatively. Such guidelines and legislation should be created in full cooperation between the legislators and The Pain Committee. Patients at risk of PPOU could be identified and specifically targeted and treated appropriately as outlined above. Restrictions on opioid prescriptions should not apply to patients with chronic pain, but only for those with acute pain.
Electronic medical record (EMR) and decision support: EMRs are widely used. A specific person in an institution or practice may be appointed to monitor that institution’s or practice’s opioid usage and be able to compare it to the use of other institutions in a state-wide database.
Insurer policies: We strongly believe that insurers should heavily redirect their focus toward appropriately remunerating non-opioid postoperative measures, especially in-hospital and ambulatory CPNBs. Members are encouraged to enthusiastically lobby for this and air their opinions and views here
There is currently no financial incentive for practitioners to acquire the needed skill sets, nor is there any financial or other incentive to follow-up on such patients. We believe it should be (much) more profitable for practitioners to provide outpatient CPNBs than to not provide them. Also, outcome studies should be performed and compared between institutions and practices, and institutions and practices with effective opioid-sparing programs should be encouraged by appropriate remuneration.
Prescription drug monitoring programs: We would encourage this, but we believe that this should be done internally by institutions and practices and not by regulatory bodies.
- atient and public education: This should be a primary task of RAEducation.com. Institutions and practices should be strongly encouraged to follow the model of the Department of Orthopaedic Surgery at the University of Florida to educate patients prior to joint replacement surgery (please see for the UF Joint Replacement Educational Program (JREP). Please also click hereto view our patient education package, which you should feel free to share with your patients. Access to this is free of charge and open on RAEduction.com. Orthoinfo.org also has a large collection of patient education material that is freely available). These models could easily be expanded to other disciplines. The CMS and the “Bundled Payment Program” (CCJR) sparked this initiative. Please click hereto view our proposed TJR pain management protocol.
- Increasing access to, availability, and utilization of medical treatment for OUDs: The Pain Committee does not see itself in an active role here other than an advisory role, but would encourage legislators to take a page from the Portugal playbook and decriminalize addiction, instead focusing on rehabilitation by calling addiction a disease rather than a crime.
Reducing the Harmful Consequences
- The use of naloxone to reverse overdose: We strongly believe that all first responders and family members of patients at risk of OOD should be educated in the use of naloxone and that it should be readily available to such individuals. After undergoing an educational program (RAEducation.com can help with this), individuals in this category should freely have naloxone available at all times.
- Reducing disease transmission: We strongly encourage these measures, which include syringe exchange, supervised injection facilities, drug checking, behavioral intervention, but we do not see a role for ourselves here, other than to cynically observe that these are totally unfeasible measures until drug addiction has been decriminalized and is viewed as a disease and not a crime.
Some Final Thoughts:
Depending on the specific situation, opioids, non-opioid medication, nerve blocks, topical medication, physical and occupational therapy, non-traditional “alternative” measures, temperature treatments, and other measures should be employed individually or in a multimodal approach. Opioids should be used only when non-opioid alternatives are deemed inappropriate; as a second-line medication and not a first-line one, as is the prevailing tradition.
The idea of pain as the “fifth vital sign” should be actively discouraged and abandoned. Furthermore, the idea and tradition of pain-free surgery should likewise be actively discouraged and abandoned. The focus should shift to function and away from pain. Patients should be educated to understand that pain is a normal and natural consequence of trauma and surgery, and “no pain as a patient right” does not and should not exist nor should it be promoted. This cannot be achieved before medical practitioners of all disciplines are educated on this. An active educational campaign should stress that if the pain that exists does not interfere with function (eating, drinking, sleeping, mobilization, toilet, etc., it is not pain that requires further (opioid) intervention. Furthermore, “no pain” as a marketing strategy to provide surgeons and institutions a competitive edge should be discouraged and disincentivized.
Patient satisfaction as a metric of doctor and institution performance (and even more dangerous, remuneration) is a dangerous trend and should be discouraged and abandoned. It is well-recognized that there is a direct relationship between patient satisfaction and opioid prescription. There is also a direct relationship between patient satisfaction and morbidity and mortality. This concept should be actively opposed and abandoned.
Members are encouraged to air their opinions and views on this and any other topic by clicking here.Please tell us and your colleagues what you think.
André P. Boezaart, MD, PhD