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May 10, 2017

Opioid misuse often starts at the hospital. Here's how providers are fighting back.

Daily Briefing

To combat the opioid misuse epidemic, some hospitals are holding off on traditional, opioid-based methods of pain relief in favor of non-addictive alternatives—and discovering some unintended benefits in the process, Julie Neergaard writes for the Associated Press.

How to integrate pharmacists into primary care

When patients end up in the hospital, the need for pain relief is typically a top priority for doctors. Opioids such as Percocet, Vicodin, and OxyContin are exceptionally effective at relieving pain, so much so that they've become the go-to method for pain relief in most hospitals, Neergaard reports. But providers have become more hesitant to prescribe the drugs in the midst of a nationwide epidemic that, according to Neergaard, takes an average of 91 American lives a day.

An estimated two million people in the United States misuses prescription painkillers, and the misuse often starts as a result of a prescription, Neergaard reports. According to a Harvard study in the New England Journal of Medicine, for every 48 patients prescribed an opioid for the first time in the ED, one will use the drug for at least six months over the following year—and the longer a patient uses the drug, the higher his or her risk for dependency.

Finding an alternative

The new approach to pain relief is referred to as "multimodal analgesia," Neergaard reports, and it aims to make opioid use the last resort instead of the starting point for pain management. The technique mixes multiple different medications with various procedures such as spinal anesthesia, nerve blocks, and numbing lidocaine. These methods attack pain from various directions, rather than solely relying on opioids, which dampen brain signals that cause people to feel pain.

For instance Ron Samet—an assistant anesthesiology professor at the University of Maryland School of Medicine—used an ultrasound-guided nerve block to cover a specific nerve in anesthetic and numb the leg of a patient who came in with a shattered femur. To do this, Samet placed an ultrasound probe over the patient's pelvis and searched for different key nerves. He fed a tiny tube directly to the patient's femoral nerve, which allowed for repeated infusions of a non-addictive numbing medication for the next three days.

Samet said the patient eventually did require opioids after the nerve block wore off, but it was at a far lower dosage than otherwise would have been prescribed. "Provide them with good pain relief initially, for the first 24 to 48 hours after surgery, the pain that comes back after that isn't necessarily as hard and as strong," Samet said.

Samet's not alone. MedStar Georgetown University Hospital is also finding alternatives to opioids. Joseph Myers, an anesthesiologist at the hospital, uses Exparel, a version of the numbing agent bupivacaine that is squirted into wounds before they're closed up. While Exparel is more costly than standard painkillers, Myers said it lasts many hours longer. He said he recently used it for a cancer patient who had both of her breasts removed and did not have to resort to opioids at all.

And at the University of Pittsburgh Medical Center (UPMC), doctors choose from a mix of different painkilling options—including IV acetaminophen, NSAIDs, anti-seizure medications that calm nerve pain, and muscle-relaxing drugs—instead of defaulting to opioids.

The shift has produced unexpected benefits, Neergaard reports. A UPMC program called "enhanced recovery after surgery" is getting abdominal surgery patients home two to four days faster after it swapped opioids with non-opioid alternatives—which are gentler on the digestive system.  

Jennifer Holder-Murray, a UPMC colorectal surgeon who helped start the enhanced recovery program, explained that patients may find it easier to eat solid foods and get back on their feet when they don't have to contend with opioid side effects, such as nausea, vomiting, and constipation. And for the patients who can go home a bit earlier, she added, the approach can save several thousand dollars.

"It's not just changing a medication or two," she said. "It's a whole culture change" (Neergaard, AP/STAT News, 5/2).

Learn the 8 steps for deploying clinical pharmacists in ambulatory care

As the number of medications rises, so does the opportunity for medication errors, such as incorrect dosages, drug interactions, and serious side effects. By some estimates, the U.S. spends as much money correcting these medications problems as we do on the drugs themselves.

Check out our infographic to learn eight steps for how to deploy clinical pharmacists in outpatient clinics.

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