The Opioid Crisis: Anatomy of a Doctor-Driven Epidemic

Laird Harrison

Disclosures

April 01, 2016

Pain Management Is Still Educated Guesswork

But for postoperative pain management, Dr Morris still writes plenty of prescriptions for opioids. And he acknowledges that all his research has not helped much in figuring out how much of the drugs to prescribe for postoperative pain management. That's still a matter of educated guesswork, he says, because patients vary tremendously in their response to pain.

Many other orthopedists are struggling with the same question. After reviewing charts in her department at Regions Hospital in St Paul, Minnesota, Dr. Kalliainen found a huge range in the quantity of opioids prescribed for pain management after the same procedures.

Bothered by this, she calculated the average amount of opioids physicians in the department were prescribing for each procedure and listed them on a card. The other side of the card lists alternatives to opioids, such as nerve block, NSAIDs, ice, and elevation. She printed the card on pink paper, laminated it, and distributed it throughout the department.

Then she once again surveyed charts. "About half the number of pills was being used, and peoples' pain was better controlled," she says.

And Dr Kallianen has other evidence that patients can survive with fewer opioids. Currently on sabbatical in New Zealand, Dr Kalliainen has noticed far less reliance on opioids in surgery departments there. "Patients are maybe a little bit sturdier," she says. "They're not asking for these medications. They understand that with surgery, there will be some discomfort."

New Zealand is not an outlier. The United States uses more opioids than any other country, including virtually all of the hydrocodone and 81% of the oxycodone in the world.[23] One study comparing the United States with The Netherlands found that 85% of patients with hip fractures treated in the United States were prescribed opioids after discharge, compared with none of the Dutch patients.[24]

With more research, Dr Morris, too, believes we can take an approach more like these other countries. "Better understanding of the risks and benefits will help physicians and patients to be on the same page," he says. "And I think we will continue to improve."

The American Pain Society is now working to put the genie back in the bottle. In a press release last February, it announced new guidelines for pain management, calling on physicians to avoid relying on any one single class of medication to treat postoperative pain.[25]

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