There was a time when opioids were used exclusively to help manage the pain of cancer, palliative care and end-of-life patients, not the litany of ailments they are often prescribed for today.
For C-sections, chronic pain, fractures, contusions, dental surgery, foot surgery and more, physicians typically used non-opioid alternatives to treat their patients.
In the late 1990s, the world changed dramatically as pain was officially recognized as the fifth vital sign. Many physicians became more comfortable prescribing opioids to a plethora of patients, and medical students and physicians were told that opioids were not addictive (i.e., the benefits outweighed the risk of addiction in chronic pain), largely driven by a surge in opioid marketing campaigns. By 2012, healthcare providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.
With over 52,000 Americans dying from drug overdoses in 2015, and approximately 63% of those deaths involving the use of opioids, the consequences of these practices have become much more real. It is important to take a harder look at non-opioid alternatives that could be used to help to reduce the chance that patients will become dependent or addicted to opioids.
|Survey-based screening tools
Screening tools for opioids have been around for decades. One of the most common tools in use is called the Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R). SOAP-R is a tool for clinicians to help determine how much monitoring a patient on long-term opioid therapy might require.
The survey questions can be filled out in less than 10 minutes by answering 24 questions such as: How often do you have mood swings? How often do you feel bored? How often have you felt a craving for medication? The tool is administered by clinicians to patients at their initial visit and various studies have shown the tool to be effective in carefully predicting substance misuse.
Another tool, the Opioid Risk Tool (OPT) invented by Lynn Webster, M.D., can be completed by a patient in less than five minutes. The OPT scores patients based on their gender and a series of five questions focused on whether the patient and the patient's family has a history of substance abuse, age being from 16-45, a history of preadolescent sexual abuse, and the existence of psychological diseases (e.g., attention deficit disorder, obsessive compulsive disorder, bipolar, schizophrenia and depression). The tool has been effective in pilot studies of correctly predicting which patients were at the highest and lowest risk of exhibiting aberrant, drug-related behaviors associated with abuse or addiction.
These tools, as well as the new opioid prescribing guidelines shared by the CDC and various states, offer good alternatives to prescribing opioids.
|Predictive models of tomorrow
It's not news that the use of advanced analytics has been on the rise across many industries, especially in the insurance industry. A number of companies are using predictive models and behavioral health screens to assess an individual's risk for dependency, and steering some injured workers to non-opioid alternatives.
A Deloitte Consulting LLP article focused on reversing the opioid epidemic. Opioid predictive models were described which focused on helping to prevent opioid dependency and addiction before the habits ever form. Utilizing data such as co-morbidities, job classes, injury causes, business characteristics and claim characteristics, the opioid prevention model is run at the three-point contact between the employer, injured worker and physician to predict the number of opioid supply days that an injured worker might consume.
Armed with the predicted supply days and reasons driving the highest scores, insurance companies can utilize prescribing guidelines and peer-to-peer contact between the insurance company physician and prescribing physician to help improve the care of the injured worker; this ultimately minimizes the chances that they will be long-term users of opioids.
As more and more patients become addicted to opioids for pain relief, physicians are looking for alternative options. (Photo: Shuttestock)
|Non-opioid alternatives
Medications
Americans have been using non-opioid medications, like ibuprofen, aspirin, pregablin and antidepressants, to treat pain for many years. In the CDC flyer, Nonopioid Treatments for Chronic Pain, CDC guidelines clearly state that “Opioids are not the first-line therapy for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Evidence suggests that non-opioid treatments, including non-opioid medication and nonpharmacological therapies can provide relief to those suffering from chronic pain, and are safer.” These guidelines list a number of effective approaches to managing chronic pain, the first on the list being the use of non-opioid therapies to the extent possible.
For lower back pain, the CDC recommended treatments include: 1) Self-care and education in all patients; advise patients to remain active and limit bed rest, 2) nonpharmacological treatments: exercise, cognitive behavioral therapy, interdisciplinary rehabilitation, and 3) medications — first line: acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), second line: serotonin and norepinephrine reuptake inhibitors (SRNIs)/tricyclic antidepressants (TCAs).
Acupuncture
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