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Managing Pain in an Era of Opioid Abuse

October 22, 2018
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Managing pain is complicated. Not that long ago, perhaps 50 years or so, pain was understood to be a multidisciplinary issue requiring many different approaches. Doctors would recommend lifestyle changes, complementary therapies and medications to treat chronic pain.

Then something changed.

Opioids began being marketed as “nonaddictive.” Pain became the “5th vital sign,” and physicians were encouraged to treat it aggressively. Insurance companies stopped paying for nonpharmaceutical treatments, and pain management clinics became a hub for prescribing opioid medication.

Taken together, those factors ultimately contributed to the opioid crisis the nation now faces.

So how should pediatric providers manage patients with pain in an era where some families are drug-seeking, some are afraid of medications and reject them outright, and insurance companies still balk at covering nonpharmaceutical treatments?

“One of the first steps is to have honest conversations with patients and families about pain,” says Tarun Bhalla, MD, MBA, vice chairman of Comprehensive Pain Services at Nationwide Children’s Hospital. “The goal is to keep pain to a manageable and tolerable level. We’re going to provide medications and other techniques to help to minimize pain; however, it may not be completely at a 0 out of 10.”

Improving pain to a tolerable level to allow the patient to function is the goal, and it may be a different pain score for each patient, adds Sharon Wrona, DNP, CPNP-PC, administrative director of the Comprehensive Pain and Palliative Care Service.

Honest conversations are part of the collaborative approach needed to manage pediatric pain successfully. In 2016, a team of physicians, nurses and administrators at Nationwide Children’s formed the Opioid Safety Taskforce as a collaborative effort to address questions about prescribing practices and education. The result was a new spotlight on areas in need of attention and quality improvement plans to make the necessary changes.

"One of the first steps is to have honest conversations with patients and families about pain." – Tarun Bhalla, MD, MBA

QUALITY IMPROVEMENT TO DRIVE CHANGE

According to Dr. Wrona, who is also the leader of the taskforce, initial surveys and research indicated that clinicians were prescribing more pills than were needed for pain.

“Children who were prescribed opioids for acute pain after procedures generally use a fraction of what was prescribed for them,” she says. “One of our first objectives was to lower the number of pills prescribed per home-going prescription.”

Limiting the number of home-going prescriptions not only protects the child who gets the prescription, but it also reduces the number of leftovers available for misuse. According to a study in a 2007 issue of Addiction, 8 of 10 adolescents who report misusing prescription opioids stated that they accessed leftover drugs from family and friends.

In addition to the Nationwide Children’s quality improvement initiative, state legislators also began introducing new laws to limit prescribing. In August 2017, new prescribing rules in Ohio for acute pain limited the prescriptions of opioids to minors to 5 days.

“Our efforts, combined with changes in legislation and insurance policies, led to a 30 percent reduction in doses prescribed per home-going opioid prescription overall across the institution,” says Dr. Wrona. “Some department-specific efforts saw even greater reductions.”

For example, an otolaryngology-specific initiative used non-opioid medications, such as acetaminophen and ibuprofen, on a schedule to help lower the need for opioids. Through the project, they decreased home-going doses of opioids prescribed per patient following a tonsillectomy and adenoidectomy from 45 doses to 20 doses – or in some cases, no doses of home-going opioids.

The taskforce has also created the Nationwide Children’s opioid safety website to educate patients and families about safe use, storage and disposal. Resources are available in Spanish and Somali in addition to English.

Many times, leftover medications are accessed by those who intend to misuse or abuse them because caregivers don’t know how to safely dispose of them. To aid in safe disposal, Nationwide Children’s Outpatient Pharmacies will install medication drop boxes by the end of 2018. But other options are already available. Drug take-back days organized by local police and fire stations provide a safe place to drop off unused medications. And commercial products to neutralize medications for disposal are available at online retailers, pharmacies and community resource centers. Medication disposal pouches, for example, provide a safe way to deactivate up to 45 pills or 6 ounces of liquid before throwing it in a normal trash can.

OPIOIDS FOR CHRONIC PAIN

While opioids should never be the first line of defense against chronic pain, some patients still may have a need for longer-term opioid use. At Nationwide Children’s, these patients are managed in the Chronic Pain Clinic and regularly screened for use and misuse. Algorithms for managing risk level and opioid misuse in this population ensure appropriate adjustments in care and referrals for addiction treatment as necessary.

As part of a taskforce initiative, the team is working to improve the quality and frequency of risk assessment. In addition to risk of abuse, prescription opioids carry a high risk of diversion – being sold or used by patients or caregivers.

“We need to screen patients and family members for risk of opioid abuse and diversion at each appointment,” says Dr. Wrona. “Opioid abuse and addiction doesn’t discriminate, and the current crisis increases the temptation to divert medications.”

The hospital’s Prescribing and Education QI Initiative aims to increase the percentage of patients who are engaged in a formal Opioid Risk Assessment for abuse and diversion from less than 5 percent to at least 75 percent. During assessment, key topics that nurses discuss with patients prescribed opioids long-term include:

  1. Family and patient history of substance abuse
  2. Family and patient history of mental health problems
  3. Patient history of sexual or physical abuse

Opioid safety patient education compliance can now be tracked through the electronic medical record. And a free medication lock box is supplied to all of Nationwide Children’s patients who are prescribed an opioid, says Dr. Wrona.

"We need to screen patients and family member for risk of opioid abuse and diversion at each appointment. Opioid abuse and addiction doesn't discriminate." – Sharon Wrona, DNP, CPNP-PC

WHAT ARE NON-OPIOID OPTIONS FOR PAIN MANAGEMENT?

In addition to assessing and monitoring risk, experts in the Chronic Pain Clinic utilize non-opioid treatments for pain. Using a holistic approach, they incorporate behavioral health supports, healthy diet and exercise recommendations and complementary alternative medicine (CAM) to meet the needs of chronic pain patients.

“We like to approach pain multimodally,” says Dr. Bhalla. “Whether we are talking about acute pain for a surgical procedure, chronic pain or even palliative care for someone with a terminal illness, we believe in using all the tools available to us to provide the best quality of life at the lowest risk to the patient.”

One of the most powerful tools is regional anesthesia, which can be used to numb parts of the body by addressing central or peripheral nerves. This method enables surgeons to perform some procedures without general anesthesia, which in some cases may lead to a sooner discharge from the hospital. It is also helping patients in palliative care manage pain while preserving their quality of life. The anesthesiology team is studying how to expand the technique’s use.

“Regional anesthesia is a great way to limit the amount of anesthesia and opioids we need to use,” says Dr. Bhalla. “We perform about 200 regional anesthesia procedures a month, which is one of the busiest pediatric regional anesthesia services in the country. And we’re continually learning how to improve and expand the benefit that it can have in pediatrics.”

Other tools don’t require medication at all. CAM harnesses the mind-body connection to reduce stress, reduce pain and support medical care. And yes, these tools have a place in the recovery room and chronic pain clinics, says Dr. Bhalla.

Parents and caregivers of young children frequently observe that mind-body connection.

Have you ever watched a young child fall down, get up and keep running? He’s completely fine until minutes later when he sees a drop of blood on his knee. Then, it’s the worst injury he’s ever experienced – until you give him a Paw Patrol Band-Aid®. After that bandage sticks, he’s good to go again.

“It’s important to recognize that children’s pain manifests differently than adult pain, and differently across the spectrum of ages that we treat,” says Dr. Bhalla. “Especially in kids, pain is both mental and physical. Mental can be even more influential for younger kids. They haven’t dissociated the mental and physical as much as adults.”

CAM includes the use of acupuncture, physical therapy, aromatherapy, distraction techniques, mindfulness, biofeedback, hypnosis and other integrative medicine techniques. Success of CAM for pain management support depends on the patient and family, says Dr. Bhalla, who recently published an article in the Journal of Pain Research about caregivers’ knowledge and acceptance of CAM.

“If it is done right and the patient and family are willing, it can be really effective,” he says. “With the opioid crisis, more people are open to trying something that will keep their children away from the medications. We’re happy to be able to do that in an appropriate way.”

Integrative medicine techniques such as acupuncture, physical therapy, aromatherapy, distraction techniques, mindfulness, biofeedback hypnosis and others are used to manage pain and minimize opioid abuse.
Integrative medicine techniques such as acupuncture, physical therapy, aromatherapy, distraction techniques, mindfulness, biofeedback hypnosis and others are used to manage pain and minimize opioid abuse.

References:

  1. Ebert KM, Jayanthi VR, Alpert SA, Ching CB, DaJusta DG, Fuchs ME, McLeod DJ, Whitaker EE. Benefits of spinal anesthesia for urologic surgery in the youngest of patients. Journal of Pediatric Urology. 2018 Aug 17. [Epub ahead of print]
  2. McCabe SE, West BT, Morales M, et. al. Does early onset of non-medical use of prescription drugs predict subsequent prescription drug abuse and dependence? Results from a national study. Addiction. 2007;102:1920-1930.
  3. Trifa M, Tumin D, Walia H, Lemanek KL, Tobias JD, Bhalla T. Caregivers’ knowledge and acceptance of complementary and alternative medicine in a tertiary care pediatric hospital. Journal of Pain Research. 2018 Mar 1;11:465-471.
  4. Tumin D, Drees D, Miller R, Wrona S, Hayes D Jr, Tobias JD, Bhalla T. Health care utilization and costs associated with pediatric chronic pain. Journal of Pain. 2018 Sep;19(9):973-982.

Image credits: Nationwide Children’s