Gaining on pain: Area ERs part of statewide program to find alternatives to addictive opioids

Colorado has the 12th highest rate of misuse and abuse of prescription opioids. Now, emergency-room physicians whose previous pain-management practices may have contributed to the drug-addiction problem are working to solve it.

Eight Colorado hospitals and three freestanding emergency rooms are in the midst of a six-month pilot program launched by the Colorado Hospital Association to reduce administration of opioids by 15 percent or more. Participants in the Colorado program include MCR as well as UCHealth’s Poudre Valley Hospital and Harmony Road emergency room in Fort Collins, its Emergency and Surgery Center in Greeley, and Boulder Community Health’s Foothills Hospital in Boulder and Community Medical Center in Lafayette.

Many ER physicians used to regard the level of pain a patient reported, on a 0-to-10 scale, as the “fifth vital sign” along with temperature, heart rate, respiration rate and blood pressure, said Dr. Jamie Teumer, who leads the emergency departments at UCHealth’s Medical Center of the Rockies in Loveland and the new Longs Peak Hospital, which opened Aug. 31 in Longmont. “We had this huge push to give everybody pain relief. That’s when we started this problem. We should have seen this trend going on. We should be solving it.”

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Upon conclusion of the pilot program, CHA will compile and release data from all participating hospitals, with the goal of generating new guidelines for reducing opioid use that ultimately will be implemented in emergency departments across the state.

President Trump in early August declared the opioid epidemic a national emergency after the commission he empowered to study the matter reported that 142 Americans die of drug overdoses every day. Although much of the publicity has focused on Medicaid recipients, a report by Amino, a company that compiles public-health and medical-pricing data, found that “1.4 million privately insured patients were diagnosed with opioid use disorder in 2016 — six times more than in 2012.”

The rate at which potent drugs such as morphine, codeine and fentanyl are prescribed has quadrupled since 1999, according to a BCH statement that said opioids, both prescription and illegal, have become the leading cause of accidental death in the United States.

A study by researchers at Harvard University’s T.H. Chan School of Public Health found that people seen by an emergency-room physician who tends to prescribe opioids frequently are about 30 percent more likely to take them for at least six more months in the ensuing year.

“Fifteen years ago, the culture surrounding pain management and expectations were really confusing,” said Dr. Tim Meyers, who runs the emergency departments at BCH. “The expectation was that opioids represented the serious approach, and if patients weren’t getting it, then physicians weren’t taking patients’ complaints seriously.

“We’ve been able to reframe our conversations with patients about what our best practices are,” Meyers said. “Just because they’re not getting narcotics as the first line of treatment doesn’t mean the doctor isn’t taking their pain seriously.”

“We still assess pain, but don’t do it so early in the approach,” Teumer added. “It’s just not feasible to stop pain 100 percent, but we can make it tolerable so it will continue to get better and their pain level will go down. Now, we’re asking, ‘What would be acceptable level for you to go home at?’ ”

Participants in the pilot program are following guidelines developed by the Colorado chapter of the American College of Emergency Physicians about when and how opioids can be avoided by using alternative treatments and strategies. Teumer and Meyers say they’ve discovered that those alternatives often provide more-effective pain relief.

“They’re often not only competitive but better,” Meyers said, especially for relief of pain related to kidney stones, migraine headaches, back pain and spasms. Injectable forms of Tylenol (Acetaminophen) and ibuprofen often do a much better job.” Ibuprofen is the less-costly alternative.

“Injectable Tylenol is very expensive, but we use it orally,” Teumer said. Meyers speculated that the cost difference is because injectable Tylenol still is under trademark, while Ibuprofen isn’t.

Meyers said he learned first-hand that Toradol, the brand name for Ketorolac, a non-steroidal anti-inflammatory drug similar to Ibuprofen, really did provide better relief for acute pain than did the addictive narcotics.

“Every now and then you’ll find yourself on the other side of the table as a patient,” Meyers said. “I developed a kidney stone while on a bike trip. I was miserable. My pain was excruciating. I sort of went into the ER with skepticism about the injectable Ibuprofen — but within five minutes, I was completely pain-free.

“Now I’m sensitive to it when patients come in and they’re miserable with a kidney stone,” he said. “A huge percentage become totally pain free. The narcotic medications absolutely don’t have that response. They get euphoria, sleepy, distracted — but in terms of the actual prime response, they really don’t compare with Toradol.”

Teumer said his ERs used to administer morphine for patients with kidney-stone pain, but have found that intravenous Lidocaine is more effective in most cases.

“Migraine headaches, too,” Meyers said. “Narcotics can do an OK job of treating a headache acutely, but when you give it to them you put them at risk for a rebound headache when that medicine wears off. The anti-nausea meds we give are terrific for migraines.”

Even older patients who suffer broken hips can benefit from the alternative treatments, Meyers said. “That population in particular is really vulnerable with the side effects of narcotics because they slow down their breathing and create some demand and stress on their body because of their ability to ventilate.”

Both Meyers and Teumer said efforts at their ERs to find alternatives to addictive opiates preceded the pilot program.

“We’ve been out in front of this issue for a few years,” Meyers said, “but the CHA project expanded scope of what we were doing and helped us work in a common framework with other hospitals. We actually learned some new techniques we weren’t really employing in our department in the past — such as using trigger-point injections of a local anesthetic deep into the muscles and fascia (the sheath of hard connective tissue that surrounds muscles) to treat muscle spasms and migraine headaches.”

At PVH and MCR, Teumer said, emergency departments “were working on protocols to use other medicines a year ago, but when we were approached by CHA to utilize their protocols, we found that they were exactly the ones we use plus a few more. Based on a thing called morphine milligram equivalents, a basic way of measuring pain meds in the ER and prescriptions, even though their goal initially was reducing the opioids by 15 percent, we think we’ve had a minimum of 50, 60, 70 percent already.”

Hospitals always are cautious about people who falsely complain of pain in order to receive the narcotics to which they’re already addicted, because, Teumer said, “the word gets out on the street.”

His hospitals’ patient treatment committee “reviews 30 cases a month that, because of their history, we will not give them stuff,” Teumer said. “But when you come in with a broken leg, we’re not going to mess around. You’ll still get the pain meds you need.”

Even so, noted Dr. Steve Wright, vice president of the Colorado Pain Society and treasurer of the Colorado Society of Addiction Medicine, “it takes quite a skill set to determine whether this person is subject to addiction and this one isn’t. It may be more important to develop addiction treatment — but the key element is early detection, and that’s the real challenge.

“There are some individuals who do not have a life if they are not on opioids,” he said.

Wright emphasized that blame for the opioid epidemic shouldn’t be laid exclusively at the feet of doctors or Big Pharma.

“There’s a supply side and a demand side of the problem,” he said. “The supply-side issues may have some utility, but the demand side might have better utility. A couple studies addressing why overdose deaths occur found that 80 percent in one study and 95 percent in another had addiction characteristics before death. We need to employ risk management, identify individuals in trouble with opioids and get them off of them.

“Yes, prescribers in general probably deliver more opioids for acute pain than we should,” Wright said, “but 70 percent of the opioids end up not being used. They sit on the shelf, and then some neighbor kid comes and picks them up and launches his addiction career. That’s why to give 30 days of opioid for somebody who had a tooth extracted is totally unnecessary and puts the community at risk.”

Wright said the focus shouldn’t be limited to addictive medications.

“The anti-inflammatories may be just as effective, but they have risks too,” he said. “We can’t be cavalier about not risk-managing other substances that we write prescriptions for.

“You want to make sure you have analgesia — pain relief,” Wright said. “I’m confident there is a lot more out there available for pain relief that we really know and understand right now. It may well be that there are certain situations where opioids are most effective, but any way we can minimize them is a good thing.”

Those ways should include delivering fewer of them in acute-pain settings but also getting rid of the unused pills on people’s shelves by using “take-back days. “Individuals can bring their meds into places — typically police stations — and drop them off,” he said. “We had 20,000 take-backs alone across the state on a rainy day last April.”

Meanwhile, Teumer and Meyers said they were optimistic about the pilot program.

“People that are truly there for pain relief don’t give us a lot of pushback” about using the alternative medications now, Teumer said. “At some point, we make it clear that there are things we are and aren’t going to do.”

“The key is just having a good conversation with your patient about what’s going on,” Meyers added. “Take a minute or two to explain why they’re not getting narcotics. If they’re having real pain, they’re on board with it. They want their doctor to do what’s in their best interests and get them feeling better quicker.”

Given the extensive coverage of the opioid epidemic now, Teumer said he doesn’t expect pushback from the drug industry either, even though pharmaceutical manufacturers once profited handsomely from heavy marketing of addictive pain relievers such as OxyContin.

“They don’t want a bad rap on this. You’d think they’d be fools not to” develop non-narcotic pain-management alternatives, Teumer said. “If they can come up with Plan B, there’ll be a tremendous market for those types of things.”