We cannot guarantee that the content will display correctly while using Internet Explorer. To have the best browsing experience, please upgrade to Microsoft Edge, Google Chrome or Safari.

September 6, 2018

Keep Opioid Naïve Patients Opioid Naïve

Commentary
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.

We can provide an introduction on your behalf so that you can contact them directly with any questions/queries on this topic. Simply click on the link below to request an introduction.

We can provide an introduction on your behalf so that you can contact them directly with any questions/queries on this topic. Simply click on the link below to request an introduction.

Request an Introduction

We can provide an introduction on your behalf so that you can contact them directly with any questions/queries on this topic. Simply click on the link below to request an introduction.

Request an Introduction

Ready to read more? HealthXL members can access the full peak of the report on the HealthXL Community Hub.

Not yet a member of HealthXL? Download your 11 page snapshot of the report.

Download your 11 page snapshot

Connect with peers and share insights

Don't miss out on the discussion of the latest insights and reports on digital health. Meet with peers and take a deep dive for 75 minutes. Unlike at webinars, you can freely exchange experiences and insights to solve challenges and design the future of DTx.

Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

DTx last mile delivery - HCPs and patients adoption

2nd November @ 11:45AM EDT

Join us in this informal conversation where we will discuss the main challenges around HCP and Patient adoption of DTx. Apply now to connect with peers and learn from fellow thought leaders in this space.

Featuring
Shrawan Patel
Shrawan Patel
Founder & MD, Strategy Health
Céline Ulmann
Céline Ulmann
Head of R&D Digital, Almirall
Featuring
Shrawan Patel
Shrawan Patel
Founder & MD, Strategy Health
Céline Ulmann
Céline Ulmann
Head of R&D Digital, Almirall
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

Tech Giants, Start-ups or Incumbents, who will disrupt healthcare?

4th November @ 11:30AM EDT

Join our Digital Health Meeting as discuss How do we define disruption in the healthcare industry? What is the ‘extinction event’ healthcare needs and why has it not happened yet? And what are the learnings from Tech Giants’ moves in healthcareApply now to join the conversation and share your thoughts on the topic.

Featuring
Amanda Goltz
Amanda Goltz
Principal, Business Development, Alexa Health & Wellness at Amazon
Anish Shindore
Anish Shindore
Head of NeuroTech & Open Innovation, Biogen
Featuring
Amanda Goltz
Amanda Goltz
Principal, Business Development, Alexa Health & Wellness at Amazon
Anish Shindore
Anish Shindore
Head of NeuroTech & Open Innovation, Biogen
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

Masterclass: How to get your DTx product reimbursed in the US?

4th November @ 11:45AM EDT

Are you a DTx company seeking reimbursement in the US? Then this masterclass is for you. Join us in this US-focused interactive masterclass led by Mike Pace, who will walk us through how to get your DTx product reimbursed in the US.

Featuring
Michael Pace
Michael Pace
Founder and President at PalmHealth.co
Featuring
Michael Pace
Michael Pace
Founder and President at PalmHealth.co
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

Masterclass: DiGa - Entering the digital health space in Germany

10th November @ 10:45AM EDT

Join us in this interactive masterclass led by Flying Health, as they discuss what you need to know to navigate the DiGa framework. Apply now to learn valuable insights from thought leaders in this space.

Featuring
Laura Nelde
Laura Nelde
Startup Relationship Manager at Flying Health
Len-Philipp Ortlepp
Len-Philipp Ortlepp
Junior Startup Relationship Manager, Flying Health
Featuring
Laura Nelde
Laura Nelde
Startup Relationship Manager at Flying Health
Len-Philipp Ortlepp
Len-Philipp Ortlepp
Junior Startup Relationship Manager, Flying Health

Are you a HealthXL Member? See the Full Report Here

Non-HealthXL Member? You can purchase the report HERE

HealthXL Digital Health Meetings

Want to join the discussion now?

Join our Digital Health Meetings and take a deep dive for 75 minutes into topics like digital therapeutics, patient support, telehealth, clinical trials, dermatology and many more. These Meetings are not regular webinars: No audience, no recording and no hiding behind a screen. You actively participate in a discussion to solve your present challenges and design the future of digital health. And with a free account on our Community Hub, you stay connected and up-to-date on the latest news and insights, allowing you to fully immerse yourself in the topic before, during and after.

Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

DTx last mile delivery - HCPs and patients adoption

2nd November @ 11:45AM EDT

Join us in this informal conversation where we will discuss the main challenges around HCP and Patient adoption of DTx. Apply now to connect with peers and learn from fellow thought leaders in this space.

Featuring
Shrawan Patel
Shrawan Patel
Founder & MD, Strategy Health
Céline Ulmann
Céline Ulmann
Head of R&D Digital, Almirall
Featuring
Shrawan Patel
Shrawan Patel
Founder & MD, Strategy Health
Céline Ulmann
Céline Ulmann
Head of R&D Digital, Almirall
Telemedicine & Virtual Care Delivery
Telemedicine & Virtual Care Delivery
Telemedicine & Virtual Care Delivery
Telemedicine & Virtual Care Delivery

Commercialisation models for Virtual Care in Respiratory Diseases

3rd November @ 11:45AM EDT

Join our Digital Health Meeting as we discuss commercialisation models for Virtual Care in Respiratory Diseases. Apply now to hear from fellow peers in this space and share your own thoughts and experiences on this topic.

Featuring
Peter Small
Peter Small
Chief Medical Officer, Hyfe
Caleb Bank
Caleb Bank
Product Marketing at NuvoAir
Featuring
Peter Small
Peter Small
Chief Medical Officer, Hyfe
Caleb Bank
Caleb Bank
Product Marketing at NuvoAir
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

Tech Giants, Start-ups or Incumbents, who will disrupt healthcare?

4th November @ 11:30AM EDT

Join our Digital Health Meeting as discuss How do we define disruption in the healthcare industry? What is the ‘extinction event’ healthcare needs and why has it not happened yet? And what are the learnings from Tech Giants’ moves in healthcareApply now to join the conversation and share your thoughts on the topic.

Featuring
Amanda Goltz
Amanda Goltz
Principal, Business Development, Alexa Health & Wellness at Amazon
Anish Shindore
Anish Shindore
Head of NeuroTech & Open Innovation, Biogen
Featuring
Amanda Goltz
Amanda Goltz
Principal, Business Development, Alexa Health & Wellness at Amazon
Anish Shindore
Anish Shindore
Head of NeuroTech & Open Innovation, Biogen
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)
Digital Therapeutics (DTx)

Masterclass: How to get your DTx product reimbursed in the US?

4th November @ 11:45AM EDT

Are you a DTx company seeking reimbursement in the US? Then this masterclass is for you. Join us in this US-focused interactive masterclass led by Mike Pace, who will walk us through how to get your DTx product reimbursed in the US.

Featuring
Michael Pace
Michael Pace
Founder and President at PalmHealth.co
Featuring
Michael Pace
Michael Pace
Founder and President at PalmHealth.co

What’s a Rich Text element?

The rich text element allows you to create and format headings, paragraphs, blockquotes, images, and video all in one place instead of having to add and format them individually. Just double-click and easily create content.

Static and dynamic content editing

A rich text element can be used with static or dynamic content. For static content, just drop it into any page and begin editing. For dynamic content, add a rich text field to any collection and then connect a rich text element to that field in the settings panel. Voila!

How to customize formatting for each rich text

Headings, paragraphs, blockquotes, figures, images, and figure captions can all be styled after a class is added to the rich text element using the "When inside of" nested selector system.

We cannot guarantee that the content will display correctly while using Internet Explorer. To have the best browsing experience, please upgrade to Microsoft Edge, Google Chrome or Safari.