Reforming Pain Medication Practices

By John Gregory | 10/07/17 8:00 AM

For years, it’s been standard protocol for doctors to prescribe enough narcotics to eliminate the discomfort of a patient suffering acute pain.

But as the crisis of opioid addiction continues to escalate, one University of Kentucky physician wants to change how health care professionals and patients think about pain. He wants doctors to expand their treatment options for acute pain and educate patients so that they can tolerate manageable levels of pain without resorting to a potentially addictive painkiller.

“This is one of those things where things are easier said than done,” says Dr. Phillip Chang, chief medical officer at UK HealthCare. “Actually doing it is hard, but it’s worthwhile.”

Chang appeared on KET’s Connections to explain his efforts to encourage doctors and hospitals to minimize their reliance on powerful narcotics to treat pain.

 

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A Reliance on Narcotics
In 2013, Chang was doing back-to-back rotations at UK’s trauma center when he treated a young man who had been in a car accident. After a brief hospital stay to treat him for contusions and multiple rib fractures, the young man was released with a prescription for narcotic pain relievers.

But a week later, he was back in the trauma center, still complaining of pain and seeking more drugs. Chang says a follow-up check of the young man’s pharmacy records revealed a shocking discovery.

“When we added all the prescriptions, he had been given over 1,000 pills in about four weeks,” Chang says. “Some of them from us, some of them from another hospital and other clinics.”

A urine test proved the young man was abusing his medications, so Chang referred his patient to a substance abuse counselor within UK HealthCare who got the young man into treatment.

The incident got Chang thinking about how readily his clinic, as well as doctors and hospitals nationwide, prescribe narcotics to treat acute pain. Although they want to alleviate the very real discomfort their patients experience, in the process their over-prescription of painkillers may contribute to an addiction in those individuals.

“I do believe, at least in my institution, the intentions are all good and perhaps not well-enough informed,” says Chang.

Safer, Simpler Options
According to Chang, acute pain is defined as pain that will end once an injury has healed. He says the standard treatment for acute pain has been to administer a low dose of an opioid pain reliever such as morphine, hydrocodone, or oxycodone. If the low dose doesn’t eliminate the pain, doctors can administer higher doses or more frequent doses of the narcotic. If that doesn’t work, they try ibuprofen or acetaminophen as a last resort.

Opioids are effective for treating acute pain for three to five days, says Chang. After that, he says their effectiveness is debatable and the risk of side effects is substantial. Those can include nausea, drowsiness, and constipation or even addiction. Studies indicate that about two-thirds of people who get hooked on opioids started using them when they received a legitimate prescription for the drugs.

So why, Chang began to wonder, do doctors start pain treatment with a powerful and potentially addictive narcotic when they have other options as safe and simple as Tylenol and Advil?

“That’s the first baby step that we took in 2013, which is to recognize that there are painkillers other than opioids,” he says.

Customizing Pain Treatment
Chang began experimenting with a new pain treatment protocol for his clinic that relies on fewer opioids. First, his staff tells patients that they will reduce but not necessarily eliminate their pain. The goal is to get the pain to a level where the patient can function and be comfortable.

Then they make it clear to the patients that opioid pain relievers are still an option, but that they want to explore additional options for helping them control their pain. To his surprise, Chang says most patients have welcomed the new approach.

“They embrace this quickly,” he says. “Our patients don’t want more and more opioids. They want pain control.”

The customized pain control regimen that Chang and his staff create for their patients may not include pills at all. By partnering with the integrative medicine department at UK, Chang is exploring non-pharmaceutical approaches to pain management, including touch and music therapy, mindfulness, massage, and acupuncture. He says the anecdotal results of these customized pain control regimens have been positive.

“We are worried that patients don’t get the right pain treatment that they deserve,” Chang says. “But at the same time if we think about pain management as a totality, then we need to look at the patient holistically and figure out what it is that could work for this patient.”

Chang admits the process of exploring alternatives and developing a customized pain control plan does take longer than a routine office visit, which typically lasts seven to 15 minutes.

“The extra time we spend on day one to set expectations, to talk about the pain management regime, how we’re going to approach the pain control… is going save physicians’ time down the road, it’s going to save the patients some agony or confusion about what’s going on with their pain control,” he says. “I think it’s time well spent up front.”

Being Part of the Solution
As Chang spreads the word about this new approach, he says he’s finding a receptive audience among health care professionals. He says the key to changing how opioids are used depends on educating doctors, nurses, and pharmacists currently on the job as well as those coming up through medical schools.

He praises recent efforts to reduce opioid prescriptions, including legislation passed by the Kentucky General Assembly earlier this year that will limit most patients to a three-day supply of narcotic painkillers. The new law does give doctors the flexibility to prescribe opioids for longer durations as long as they document the reasons for that decision.

Chang contends doctors have been part of the addiction problem in the past by over-prescribing narcotics. Now, he says it’s time for them to be part of the solution.

“I don’t want us to be like some of these pharmaceutical companies [that make opioid painkillers] and say that’s not our problem. I want us to step up and say we can help with this,” Chang says.
Explore more of KET’s coverage of the opioid crisis.