Making a decision: Opioid or non-opioid treatment

Zach Vance • Updated Aug 4, 2016 at 9:06 AM

As opioid overdose deaths rise, a growing stigma can obscure the medicinal benefits of the pain medication.

But is doing without opioid prescriptions — having a patient live without something to douse the excruciating pain — worth extinguishing the addiction?

Dr. Jim Batson, chairman of the Tennessee Medical Association Board of Trustees, doesn’t believe opioids will ever be withdrawn by the U.S. Food and Drug Administration. 

“They have such a long history and they are so effective for pain management when used properly,” Batson said. “I don’t think, realistically speaking, that we could say they would be eliminated from pain control.” 

Batson said there is no doubt that opioids have legitimate uses, especially when treating cancer patients and as an end-of-life treatment. 

“There are definitely legitimate uses (for opioids),” Batson said. 

Opioids are likely to remain a key component of pharmacology, but in March, the Centers for Disease Control and Prevention responded to the opioid epidemic by issuing strict guidelines for doctors to follow when prescribing medicines to treat pain.

The CDC says opioid prescriptions have quadrupled since 1999, which has incited the addiction intensification.

“More than 40 Americans die each day from prescription opioid overdoses, we must act now,” said CDC Director Dr. Tom Frieden. “Overprescribing opioids — largely for chronic pain — is a key driver of America’s drug-overdose epidemic.”

The updated CDC guidelines now say opioids should not be considered “first-line” or routine therapy for managing chronic pain, except for patients seeking cancer treatment, palliative care or end-of-life care.

The guidelines encourage doctors to prescribe non-opioid therapies and medications, such as acetaminophen, NSAIDs, serotonin and topical agents, for chronic pain and ailments before turning to an opioid prescription.

Since graduating from medical school in 2005, Dr. Anastasia Brown, an urgent care physician in Kingsport, said the medical community’s views on the treatment of pain have shifted. 

“When I first graduated, they were really starting to be concerned about patient satisfaction and customer service. That’s around the time these pain scales were becoming popular in the ERs (emergency rooms). Physicians and other providers were instructed to control everyone’s pain,” Brown said.

“So I think opioids probably were being, well they were definitely being, overprescribed in an effort to make everybody happy, and now the pendulum is swinging back as we realized there are definite risks to doing that. We have to be judicious and you don’t necessarily need Lortabs to treat kidney stones or an abscess.”

In the past five years, Dr. Kenneth Olive, associate dean for academic and faculty affairs at East Tennessee State University’s Department of Internal Medicine, said the curriculum has been updated with more pain management and pain therapy education.

In fact, Olive also said ETSU will soon implement CDC’s new opioid guidelines into the medical program’s curriculum.

Olive said a student going through ETSU’s medical program would have had less opioid addiction education than today.

“There would be much less emphasis on problems related to opioid abuse — and say prescribing — than there is today,” Olive said.

Olive said students first begin learning about prescribing medications, including opioids, during their second year in medical school, before gaining firsthand experience during a third-year clerkship.

“Virtually all of our third-year clerkships include issues on pain management in patients,” Olive said.

Olive said ETSU’s location gives medical students the advantage of direct exposure to treating the opioid epidemic.

“This is not a theoretical problem we’re talking about, because they see it every day when they’re on the clinical rotations, so it helps in that sense,” said Olive, who’s been an associate at ETSU for more than a decade.

Every day, Brown and thousands of other physicians across the state face a decision: Does a particular patient really need an opioid to treat their pain?

Now those decisions are based more on objective measures and professional judgement, and less on a pain scale.

“The way one person experiences (pain) may be different from another. So it’s very subjective. As a physician, you want to be able to take everyone for their word, you don’t want to have to feel suspicious of your patients. You want to make them feel better,” Brown said.

“So it can be a very difficult balance in trying to treat them properly without causing further harm to the patient and community by increasing risk of addiction.

Brown added, “Patient satisfaction is certainly important, but if the patient is only going to be satisfied if they get a narcotic so they can go down the street and sell it or get a high, then that person is not going to leave satisfied.”

Because Brown works in an urgent care clinic, she primarily treats acute pain, which is short-term, temporary pain that can typically be measured in hours and days.

Medication prescribed for acute pain requires less oversight since it’s bestowed in smaller, lower dosages. Brown said prescribing for acute pain is easier and simpler than for a chronic pain or ailment.

Now doctors can use a database established by the Tennessee Department of Health to monitor the prescription of Schedule II, III, IV and V drugs and whether a patient is “doctor shopping” for narcotics.

“I don’t want patients to think that if they come to the doctor or urgent care and complain of pain, we’re automatically going to think they’re a drug-seeker, because that’s not the truth at all,” Brown said.

“We’re not suspicious of everyone, and we do try to treat everyone appropriately.”

Email Zach Vance at [email protected] Follow Zach Vance on Twitter at @ZachVanceJCP. Like him on Facebook.com/ZachVanceJCP


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