September 6, 2018

Keep Opioid Naïve Patients Opioid Naïve

Chandana Fitzgerald
This is part-two of our blog series on the opioid crisis. This week, Scott Weiner MD, Assistant Professor of Emergency Medicine at Brigham and Women's Hospital who has spent many years researching and advocating for solutions to curb the opioid epidemic explains why he became interested in the topic, how hospitals can more effectively deal with this crisis and how the story of Ms. Jessica Moss from last week resonated with his own experience.

From the eyes of a physician

I am an emergency physician by training, although I also direct our hospital’s opioid stewardship program (more on that later). My area of research and advocacy is about finding solutions to the opioid epidemic. People often ask me why I became interested in that topic. Was it a close friend or family member that lost their life to the disease of addiction? Was it from my own personal experience with pain? Fortunately, it wasn’t either of these things, but rather, a result of my experience with patients with addiction who were driving me to “burn out.” I needed to find a solution.

Allow me to explain. People who are satisfied with their careers enjoy going to work and thrive on the stimulation and rewards that the career provides. In medicine, it’s easy to find this satisfaction. I can think of several different recent cases – a man with severe seizures who needed to be sedated and placed on a mechanical ventilator that we rapidly stabilized, a woman with an acute heart attack who we rushed to the cardiac catheterization lab to open the blocked blood vessels in her heart, and a stabbing victim whose life we saved because of the amazing speed and skill of our trauma team. These are frenetic and stressful cases, but even in the tragic cases where we are not able to save the life, we are consoled by the feeling that we did everything we possibly could to help.

In the past, patients with addiction did not provide that same satisfaction for me. For example, I’d see patients with “drug-seeking” behavior, demanding prescriptions for opioids and insulting me if I declined. Ms. Moss referred to them as the “odd injuries” that would bring her to the hospital for opioid prescriptions. We clinicians know when it’s suspect, but sometimes it’s easier to write the prescription than argue. In one memorable case, hospital security had to be called to remove a patient so upset that I wouldn’t write him opioid pills for his chronic shoulder pain that he screamed obscenities and threatened to sue. Situations like that do not make for a satisfying career.
Scott Weiner MD, Brigham and Women's Hospital
Scott Weiner MD

"All then there the deaths: case after case of young, otherwise healthy people who all deserved along and prodcutive life, whose time was cut short because of overdose"

And then there are the deaths: case after case of young, otherwise healthy people who all deserved a long and productive life, whose time was cut short because of overdose. They often arrive by ambulance already dead. We try our best with CPR and a host of medications, but when it’s too late, it’s too late. I’ve had to call too many parents in the middle of the night to let them know that their child had died. For most of them, it is the end of a long nightmare in which they wondered where their loved ones were, if they were safe, or if they had relapsed – combined with the pain and guilt families feel when they realize they were not able to save them. These are not cases that are conducive to a rewarding career, but rather instill a feeling of helplessness.
Prescription Opioid Factsheet - Fentanyl Fatalities
I knew we could do better. I began by researching prescription drug monitoring programs – statewide databases that allow prescribers to tell where patients are getting their opioid prescriptions. This objective data is extremely powerful when treating a patient with potential addiction, and can be a teachable moment and an opportunity to offer help. Next, I started working on screening tools, to help determine which patients are at risk for opioid abuse and addiction even before the first prescription is written. I then worked on state-wide guidelines to help reduce unnecessarily prescriptions of opioids.

The work blossomed, and I eventually proposed the creation of a program at our hospital called B-CORE: the Brigham Comprehensive Opioid Response and Education Program. The goal of the program is to be a responsible steward of opioids by: 1) treating acute pain first with non-opioids and then using only the smallest strength and course needed to ensure adequate pain management when opioids are used, 2) ensuring safe practices for patients on chronic opioid therapy, such as ensuring medication agreements are on file, that toxicology screening is done to ensure compliance and detect abuse of other drugs, and safely and slowly tapering down opioids when indicated, and 3) offering state-of-the-art, on-demand treatment for patients with opioid use disorder.

Understanding the patient

Ms. Moss’ story resonates with me because of a very recent experience, which happened just a few weeks ago. We are doing some work on our house, and I was far too aggressive with lifting heavy boxes. I felt a pull in my back, but kept going. Before I knew it, I could barely move from the excruciating pain I felt – a sharp knife piercing my spine every time I moved. I’ve never experienced pain of that intensity before. I checked in the ED (remarkably for the first time in my life) and had an MRI which showed what I suspected: two large herniated discs, one at L4-L5 and one at L5-S1.
I had an injection of Toradol (a strong, non-opioid anti-inflammatory), a patch with lidocaine to put on my low back, and the maximum allowable dose of acetaminophen (Tylenol). None of it helped. My colleague who cared for me was great – he was hesitant to write the hospital’s “opioid czar” an opioid prescription, but offered. I refused.

I tried ibuprofen and acetaminophen around the clock but it just wasn’t working. I went back to the ED the next day and, in desperation, asked another colleague for a small prescription of oxycodone – the medicine in Percocet and Oxycontin. I felt embarrassed for even asking, but was at my wit’s end. The pain was just too much. Every step was a challenge. To my surprise, my colleague declined and advised: “Stick it out. Just give it a little more time. It will get better.” I continued the over-the-counter medications around the clock. Sure enough, the next day I started to feel a little better. It took 2 weeks before I could walk without pain but it did improve – and I wasn’t exposed to the risks of long-term opioid use because I never started on them in the first place.

Educating in the emergency room

Training physicians how to do this is key. Some degree of pain is normal. It’s our body telling us that something is wrong, and is part of the human experience. Plus, lots of research shows that, for acute pain, the non-opioids work just as well as the opioids (if not better) so why use them in the first place? We now know that it is best to keep opioid naïve patients opioid naïve. To be clear, I’m not advocating for undertreating pain or cutting off patients with chronic pain who rely on opioids to function, but we must use these medicines with the utmost care and minimize their use whenever possible.
We now know that it is best to keep opioid naïve patients opioid naïve. To be clear, I’m not advocating for undertreating pain or cutting off patients with chronic pain who rely on opioids to function, but we must use these medicines with the utmost care and minimize their use whenever possible.

One more point: Ms. Moss was able to conquer her addiction without the help of medications, but many people are not able to. In those cases, adding a medication for addiction treatment, like buprenorphine (Suboxone) or methadone, can literally be a life-saver. I have witnessed so many cases of patients who were able to get their lives back together, and be productive and happy, with the assistance of buprenorphine. The data is there to support it, too. Training and use needs to be more wide-spread and insurers need to reimburse for this treatment.

With all of these tools: prescription drug monitoring program, hospital initiatives to help guide safe treatment of pain, increased availability of treatments for addiction, the patients I see with opioid use disorder are no longer a burden because I finally have hope and options for them – a feeling which is immensely satisfying. Like Ms. Moss, everyone deserves a chance to be the person they want to be, and we clinicians are striving to better care for our patients with addiction.