Managing the Risk of Opioid Use for Pain
By KJ Fields
When Karen DeBella ruptured a disc in her back in 2005, the pain was so severe she couldn't walk. But she was concerned about coping with the recovery period that recommended surgery might involve, so she decided to postpone it for a few years until she could retire.
She relieved the pain with physical therapy and morphine. When Jim Xing Yi, MD, a primary care physician at our Tacoma South clinic, became DeBella's doctor four years later, he raised serious concerns about the morphine.
"He showed me a chart of the incidence of deaths for patients on long-term medications. Those taking morphine [and other opioids] had the highest fatality rate," recalls DeBella. "I was afraid to experience excruciating pain again, but Dr. Yi convinced me to try alternative pain medications."
Chronic Pain Is a Big Problem
When time-released versions of opioid medications became available in the 1990s, the number of patients taking opioids for chronic pain increased significantly. Approximately 25 percent of the U.S. population has persistent, noncancer-related pain, and 10 percent report significant impairments in work and family life.
Using opioids for short-term pain management and end-stage diseases like terminal cancer isn't controversial. However, opioids such as morphine, oxycodone (Oxycontin), and hydrocodone (Vicodin) present challenges when taken over time. Most patients using these medications long term continue to have moderate or severe pain and improvements in functioning are often modest, although benefits can differ. Because of this, doctors and patients need to evaluate the benefits and risks of pain treatments together.
"It's possible to become addicted to opioids, and you can develop a tolerance to them so you need more to have the same effect," says Claire Trescott, MD, Group Health medical director of Primary Care. "Unlike most drugs, when you're dealing with higher amounts of opioids, there is much less margin between a safe dosage and overdose." The latter can require hospital care or even lead to death.
Managing Opioid Medication
This small margin is one reason that about six years ago Group Health clinicians began to examine how opioids were prescribed and how prescription refills were handled. That work was validated in January 2010 when the Group Health Research Institute published the first-ever findings on opioid prescription, dosage-related fatalities.
By the following August, Group Health had developed and implemented a new initiative around the prescribing of opioids. Physicians, nurses, pain specialists, and pharmacists came together to design a standardized care plan for opioid use in chronic noncancer pain. The goal was to help patients with pain, keep them safe in the process, and treat each patient with respect.
"This multidisciplinary approach helped create wide consensus, and made sure the plan can actually be implemented in Group Health Medical Centers clinics," explains Dr. Trescott.
Within one year, 96 percent of all Group Health members on opioid medications for chronic noncancer pain — 7,500 patients — have formal care plans.
Under the plan, one physician is responsible for prescribing and monitoring the patient's opioid medication. The care plan is created with active patient involvement and it details the diagnosis, medication's purpose and dosage, refill processes, and planned follow-up visits.
Apart from the risks of overdose and addiction, opioids have significant side effects that can accumulate over time, including increased sensitivity to pain, depression, and negative effects on hormones and cognitive function. So it's important to explore alternative ways to manage pain, says Ryan Caldeiro, MD, chief of chemical dependency services for Group Health Behavioral Health Services.
"Aerobic exercise is one of the most helpful things for patients with chronic pain, but patients should pace themselves and progress steadily into more exercise," says Dr. Caldeiro. "If you decide to try alternative therapies, don't go off opioids abruptly. Be sure the process is managed by your health care provider."
When DeBella decided to stop using opioids, Dr. Yi slowly tapered her off morphine and switched her to non-opioid medications. Over time, DeBella discovered she no longer needed pain medication. "If Dr. Yi had not suggested I try something else, I would still think morphine was my only way to live a normal life," says DeBella. "It's such a relief to be free from that psychological addiction."