Pain Management: Balanced Approach Combats Opioid Epidemic

by OR Today Magazine | Mar 1, 2020 | Cover Story, Features, Magazine

The opioid crisis is one of the greatest health threats facing Americans today. Between 1999 and 2017, 218,000 people in the U.S. died from opioid overdoses, according to the Centers for Disease Control.

In 2017 alone, opioid overdoses took the lives of more than 47,000 people in the U.S. One out of every three of these deaths involved prescription opioids – a number that was five times higher in 2017 than in 1999.

Finding the Right Balance

Given the role that health care professionals play in prescribing opioids to help manage patient pain, it’s critical that perioperative professionals find the right balance between relieving pain and lowering the risk of opioid addiction for patients.

In an effort to help professionals find this balance, the Department of Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force has issued a set of best practice recommendations in pain management.

“Our report emphasizes safe opioid stewardship, recommending approaches that mitigate opioid exposure,” says Vanila M. Singh, MD, MACM, Chief Medical Officer, HHS Office of the Assistant Secretary of Health, and Chairperson of the Pain Management Inter-Agency Task Force.

The report’s recommendations stress the importance of providing balanced, individualized patient-centered pain management to ensure better clinical outcomes for pain. These outcomes should improve quality of life and functionality for patients dealing with acute injury, chronic and perioperative pain.

A Multi-disciplinary Approach

The HHS Task Force encourages the use of a multidisciplinary approach for pain management across various disciplines. It recommends a broad framework of multidisciplinary approaches for treating pain, including the following:

• Medication, including both opioid and non-opioid
• Restorative therapies such as physical therapy, aqua and movement therapy
• Interventional procedures
• Behavioral health approaches
• Complementary and integrative health such as yoga, tai chi and acupuncture

One or more treatment approaches should be used when clinically indicated to improve outcomes, notes the report. These approaches are reinforced by cross-cutting themes such as risk assessment, stigma, education and access to care.

Comprehensive risk assessment is empowered by open dialog with patients, notes Singh. Conducting a risk assessment helps minimize potential adverse consequences while facilitating treatment of active substance abuse disorders. Meanwhile, the risks of prescribing opioids must be balanced against potential benefits such as improved quality of life and improvements in medical condition, according to the report.

Singh says the task force emphasized the importance of individualized patient-centered care in the diagnosis and treatment of acute and chronic pain. At the same time, it acknowledged that empathetic, compassionate and patient-centered pain care cannot be delivered effectively through a one-size-fits-all approach.

“Each patient has their own unique set of medical, genetic, environmental and sociocultural factors that affect their medical conditions and lives,” says Singh. “A biopsychosocial approach is absolutely needed to address each patient’s unique challenges and achieve the best possible clinical outcomes.”

This biopsychosocial approach utilizes the patient’s history, a physical examination, diagnostic screening tools and a prescription drug monitoring program (PDMP).

Barriers to Pain Management

The HHS Task Force identified a number of barriers to adequate pain management. These include insufficient insurance coverage for pain management services, complex opioid management requirements, clinicians’ underestimation of patients’ reports of pain and the need for more research on innovative and effective pain management approaches.

“Pain and substance use disorder management is insufficiently covered in medical education and training programs,” says Singh. “This has a downstream impact on the extent to which patients are educated about pain and substance use disorders.”

Stigmatization of patients with pain is another big barrier to pain management, notes the task force report. The different facets of stigma at the patient, clinician and societal levels collectively serve as a significant barrier to effective pain treatment and management.

According to the report, stigma has far-reaching effects not only on patients and their families, but on everyone involved in patient care. Feelings of guilt, shame, judgement and embarrassment resulting from stigma can increase the risk of anxiety and depression, which can also contribute to chronic pain.

Due to stigma, only 12 percent of people who require treatment for substance abuse disorders actually seek treatment, notes the report. About 17 percent of those who don’t seek treatment say they’re concerned about negative judgements by friends or the community at large.

A Personal Perspective

Rodrigo Garcia, MBA, APN-BC,MSN, CRNA, can relate to all of this from a personal perspective. He is the CEO of Parkdale Center for Professionals in Chesterton, Ind., which specializes in helping impaired professionals who are dealing with addiction on the road to recovery.

Before founding Parkdale Center, Garcia became addicted to prescription opiates after surgery for a traumatic sports injury.

“It was the first time in my life I had ever taken an opiate,” says Garcia. “I soon realized that the medication was treating much more than just the physical pain — it also seemed to do wonders for conditions I didn’t even know I suffered from like insomnia, anxiety, depression and stress.”

Garcia believes that stigma is the single greatest hindrance when it comes to addiction treatment and pain management. “Removal of this barrier will improve the likelihood of recovery and effective pain management exponentially,” he says.

“As long as we as a society continue to treat addiction as a moral shortcoming, chronic pain patients as ‘drug seekers’ and addiction as a personal choice rather than a disease process, we will continue to be ineffective in treating this patient population,” Garcia adds.

Garcia believes that nurses are in a unique position to change this mindset. “With a collective voice of nearly four million across the country, nurses can change the stigma borne by pain patients from one of shame and disgrace to one of healing, wellness, compassion and empathy,” he says.

Striking a Balance

Singh stresses the importance of striking a balance between mitigating opioid exposure while ensuring that adequate pain treatments are available for patients to have the best quality of life possible.

“It’s important to ensure that the patient is educated on risks and alternatives,” he says. “The patient’s history and medical condition are critical components of this assessment.”

According to Singh, the HHS Task Force does not recommend the indiscriminate removal or forced tapering of opioids as a treatment option. “We acknowledge that opioids have the potential to lead to physical dependence and possible opioid use disorder, particularly in certain at-risk populations,” he says.

“Therefore, risk assessment and periodic re-evaluation and monitoring are required and should be a part of the treatment plan,” says Singh. “When the benefits are deemed to outweigh the risks, opioid therapy should be administered for the shortest duration and at the lowest dose of medication required to optimally control the pain.”

Garcia recommends that the entire perioperative team work together to create a robust and comprehensive care plan that includes pain management.

“As a nurse anesthetist, I always appreciate the suggestion from other team members to include regional and local anesthetics or non-opiate medication options,” Garcia says. “Often I will use a longer acting intrathecal medication for post-op pain or ask the surgeon to use supplemental local anesthesia on the field.”

Discuss Pain Management Openly

Perhaps the most important step to reducing the risk of addiction is discussing pain management with patients and their families before surgical procedures. “It’s also critical to start pain management procedures early – well before the pain level is at a 10 out of 10,” says Garcia.

“The most important conversation to be had with patients should be focused on addiction risk,” Garcia adds. “Whether they are currently addicted or have ever been addicted to mood- or mind-altering substances should be a standard pre-op question asked of every patient.”

Garcia stresses that all patients, whether they’re addicts or not, deserve to have their pain controlled. “But it’s our responsibility to not put them in harm’s way while trying to achieve effective pain management,” he says.