Never use a milligram of opioids, and you’ll never get addicted to them. There’s no denying that.
But could stopping the increasing reach of the national opioid crisis really be that simple?
Some physicians, depending on the situation, are avoiding opioids to every reasonable degree, doing their part to keep patients off the drugs that killed more than 42,000 people in the United States in 2016. Fort Worth anesthesiologist Aaron Shiraz, MD, (left) and his group, Trinity Medical Associates, are taking it to a rarely seen extreme.
Dr. Shiraz says Trinity is finding success with a “zero narcotics” approach to surgery pain control that uses nerve-blocking and other nonopioid treatment techniques.
“We are trying to provide a partial solution to this problem. There’s no perfect solution; there’s no magic bullet to resolve this mess that we’re in,” he said. “But we know that many people who are addicted started with an exposure related to a hospital visit or surgery. Traditionally, opioids are given during and after anesthesia — so [if] we can reduce or eliminate the amount of opioids, then we reduce that initial exposure. That’s our goal.”
But not every physician believes a zero-narcotic future is attainable.
Mesquite pain management specialist C.M. Schade, MD, a director emeritus of the Texas Pain Society (TPS), says opioids have a permanent place in pain management, along with other drugs and approaches. Many of the drugs used in lieu of opioids, Dr. Schade says, come with their own serious potential complications.
“Beware of what you ask for,” Dr. Schade said. “Just because you are an opio-phobe — in other words, someone who is afraid of or doesn’t know how to prescribe opioids — doesn’t mean you aren’t going to cause more harm.”
Shooting for zero
“When this whole opioid crisis became a bigger issue in the last couple of years, it seemed initially that there was a lot of blame going around as [to] how it started and why it started,” Dr. Shiraz said. “But what I didn’t like was the lack of solutions that were being suggested, and [lack of saying], ‘How can we fix this problem?’ ”
Nerve-blocking techniques are a major part of Trinity’s approach to avoiding initial opioid exposure. Trinity performs two types of nerve blocks, depending on the surgery and patient involved: a one-time numbing injection that lasts approximately 48 hours, or a microcatheter drip placed near the nerves for about 72 hours, which allows slow infusion of the local anesthetic.
“Not every surgery is a candidate for one of those continuous catheters,” Dr. Shiraz said. “But when they are, it works very well to prolong the nerve block.”
Providing a nerve block prior to surgery will reduce the inflammatory mediators the body secretes during the procedure, Dr. Shiraz says, which means the patient’s pain also will be reduced once the nerve block subsides. Keeping the pain at bay for those first few days is supposed to shepherd the patient through the worst of it, reducing the chance that opioids will ever be necessary.
“And there’s good evidence that there’s a reduction in the incidence of patients developing chronic pain afterwards,” Dr. Shiraz said.
Along with nerve-blocking procedures, Dr. Shiraz and his colleagues turn to other nonopioid medications when appropriate, including acetaminophen; ketorolac, a nonsteroidal anti-inflammatory drug (NSAID); gabapentin; and the anesthetics ketamine and dexmedetomidine (Precedex).
Dr. Shiraz finds that many anesthesiologists and surgeons want to use nerve-blocking or nonopioid medications, which in the past were not part of a traditional anesthesiology training program. Nerve blocks do carry small risks of infection, bleeding, and nerve injury, Dr. Shiraz says, but those instances are rare, and permanent nerve injury is extremely rare.
“Sometimes we run into some barriers with the hospital administration because there are some minor additional costs to the nerve block equipment or the other medications,” Dr. Shiraz said. “But once the patient satisfaction scores go up, and once the overall rate of readmission decreases, the hospital will end up coming out better financially.
“It may take a little initial investment from the hospital, but usually we find that once the program’s implemented properly, and those benefits are readily apparent, that the cost more than pays for itself.”
Dallas sports medicine orthopedic surgeon Karim Meijer, MD, who uses Trinity for his operations, says he writes significantly fewer narcotic prescriptions for his patients than he used to.
“I don’t want to say they’re not taking narcotics, because I think that’s an overstatement,” he said. “But we minimize [it], and narcotics are only a supplement, if needed, to control pain, and the amount of narcotics written is also significantly reduced. I really don’t write much at all after major operations such as ACL reconstructions and rotator cuff surgery. For me, getting my athletes into rehab as quick as possible is important, and pain control is vital early in the post-operative period. It also allows me to do joint replacements as an outpatient [procedure].
“I do shoulder replacements, and they’ll go home the same day. I sometimes try and convince them to stay overnight just for precautionary reasons, but they routinely will go home. Years ago, they’d be in the hospital for three or four days.”
Other approaches — and opinions
Pain physicians, however, say opioids themselves aren’t the problem.
Dr. Schade says his approach to prescribing opioids “really has not changed” over his 40 years of experience. Some patients’ cases are appropriate for opioids, and they do extremely well on them, he says, increasing their functioning without side effects. Meanwhile, many of the drugs patients might use in lieu of opioids come with their own potential complications.
Over-the-counter NSAIDs, Dr. Schade says, bring increased potential for heart problems, and he’s taken essentially all his patients off those drugs “unless they have a dramatic improvement.” Dr. Schade also noted a late 2017 PLOS Medicine study of patients in Ontario, Canada, from August 1997 through the end of 2013. The study found that when patients used opioids and gabapentin together, their risk of dying from an opioid overdose increased by 49 percent.
On the other hand, Dr. Schade says he can vouch for the effectiveness of nerve blocks, in spite of health plans’ unwillingness to cover them.
“As an anesthesiologist, I’ve used nerve blocks my entire career,” he said. “The usual hurdle is insurance reimbursement. They’re highly effective and work extremely well. And then there’s multiple studies out there showing earlier time to discharge from the hospital and decreased complications when you use particularly continuous nerve blocks; in other words, where you put in a catheter and have a pump. But they’re much more expensive.
“So you have this tradeoff. And I much prefer being able to do a block or a continuous block infusion, because the patient’s pain is gone.”
But Dr. Schade says anesthesia nerve blocks are an adjuvant treatment and cannot replace opioid therapy.
The prescribing that helped cause the widespread misuse of opioids mostly arose from acute pain and post-surgery treatment. But Daniel Clauw, MD, a rheumatologist and the director of the University of Michigan’s Chronic Pain and Fatigue Research Center, has made it a mission to avoid prescribing opioids for chronic pain, as well. Dr. Clauw says it’s been more than a decade since he last did so.
Many other drugs are more effective for both acute and chronic pain, Dr. Clauw says, and data show the most effective single treatment for chronic pain is exercise. Sleep also is key, he notes. Other treatments popular in Eastern medicine, such as acupuncture, yoga, and meditation, are increasingly being shown to be helpful, he says.
Opioid addiction isn’t Dr. Clauw’s main concern with chronic pain patients; it’s the fact that opioids simply don’t work very well for chronic pain, he says. In a video posted on the Michigan Health Lab blog, he said opioid use in the chronic-pain realm should be reserved only for “patients that have tried all of the other drug and nondrug treatment options.”
“If there was evidence that opioids worked to treat chronic pain, I wouldn’t be so anti-opioid,” he told Texas Medicine. “There are a lot of problems with opioids, like addiction and all those things like that, but … you don’t see that many patients with chronic pain actually become addicted [to] opioids. But they still have all the other side effects of opioids, and they can still die of overdoses. The fact that they simply don’t seem to work very well at all for chronic pain and they have all those side effects, is what makes me not want to use them.”
A future without opioids?
United Nations data for 2015 showed the United States accounted for 99.7 percent of global consumption of hydrocodone. And other data estimate 80 percent of all opioid consumption happens in the United States. In fact, when it comes to morphine, data show the United States has access to many times more than the supply it needs, while other countries are largely cut off from the popular pain reliever. (See “The Morphine Access Gap,” below.)
In late 2016, the U.S. Drug Enforcement Administration released an order to reduce the allowed manufactured amount of every Schedule II opioid by at least 25 percent in 2017. An order for this year mandated an additional 20-percent decrease in opioid production.
So federal authorities are on board with reducing the availability of the drugs. And Dr. Shiraz believes his approach — featuring low-narcotic anesthesia, nerve blocks, and adjuvants — is the direction pain treatment is headed.
“It’s the way to go for the future, now that we know all these side effects that opioids have, how patients just don’t do as well with them. … The impetus is there to make the changes that we need to modernize our anesthetic techniques for the future,” he said.
But Dr. Schade says opioids “absolutely” have their place and the issue is not the drugs themselves, but substance use disorder (SUD). While opioids may be a gateway to addiction, he says, “SUD is a disease. It is not caused by opioids — period. End of discussion.”
“For 41 years, I haven’t had a problem because of the screening. I know what substance use disorder is, and addiction is addiction; you send [those people to] treatment. You don’t treat them with narcotics,” Dr. Schade said. “But where narcotics are indicated, you use them.”
In a 2013 report, the United Nations General Assembly said denial of pain treatment can constitute “cruel, inhuman, or degrading treatment or punishment,” depending on the circumstances.
"We need a more medically informed approach to treating people with severe, chronic, intractable pain,” Dr. Schade said.
Dr. Meijer, the sports medicine surgeon working with Dr. Shiraz, believes a zero-narcotic future is feasible “because here’s the bottom line: Pain is subjective.”
“I don’t want to be the doctor where a narcotic addiction started,” he said. “We have the technology now to perform big surgeries on athletes while minimizing narcotic use. I have had multiple patients after shoulder, elbow, and knee surgeries never take a narcotic. I’m doing my part to help out.”
THE MORPHINE ACCESS GAP
A 2017 study by The Lancet examined what it called the “access abyss” in pain relief in part by demonstrating the global divide in morphine access. The study found that nearly 90 percent of the world’s prescription-available morphine goes to the world’s richest 10 percent. The United States and Canada get more than 30 times their share of morphine, while other countries get only a fraction, according to the study. Here’s how the United States stacks up against selected countries’ morphine supply: