EXPLORING OUR PATIENTS’ NON-OPIOID OPTIONS
MANAGING PAIN WITH FEWER OPTIONS
The shock wave of the 2017-18 opioid shortage has passed, yet the U.S. opioid overdose epidemic remains. Health care providers are grappling with a very real challenge: Opioids are a crucial resource in the toolkit for pain management, but given the opioid epidemic of addiction and abuse, we have to manage patients’ pain more thoughtfully. This can be achieved by incorporating non-pharmacologic and nonopioid medications early and establishing a team of interdisciplinary experts.
ACCORDING TO THE U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES, IN 2018:
- 10.3 million people misused prescription opioids
- 2 million people misused prescription opioids for the first time
- 2 million people had an opioid use disorder
- 130 people in the U.S. died every day from opioid-related drug overdoses
WHAT ARE OPIOIDS?
Opioids refer to a class of drugs that includes legal prescription pain medications as well as illicit drugs. Despite reassurances in the late 1990s from pharmaceutical companies, opioid pain relievers can be highly addictive. Common prescription opioids are codeine, hydrocodone, morphine and oxycodone. Fentanyl is a powerful, synthetic opioid; its illicit production and use has increased dramatically. Heroin is an illegal opioid.
BACKGROUND: THE CRISIS
States and communities across the nation are struggling with staggering opioid overdoses caused by the drugs’ past accessibility, physician prescribing habits and illicit drug abuse. In 2017, the U.S. Department of Health and Human Services declared the opioid epidemic a public health emergency.
Barriers to opioid access included increasingly stringent regulation steering production and usage. Then Hurricane Maria’s devastation in September 2017 stalled pharmaceutical manufacturing in Puerto Rico, a supply hub for prescription opioid drugs used in the U.S.
Our UF Health pharmacy and supply chain experts are prepared, agile and resourceful when handling supply crises. They guided us remarkably well through the subsequent opioid shortage as our clinical faculty, nursing and patient care teams responded and adapted. We turned more to non-intravenous opioid options as well as better use of non-opioid and non-pharmacologic alternatives to shift prescribing processes. These efforts turned an opioid shortage and potential crisis into a stewardship opportunity. Ongoing legislation now requires us to reconsider how we prescribe, order and administer Schedule II opioid drugs for anesthesia and pain management.
THE NATURE OF PAIN
Inpatient and outpatient pain management options differ, as does the nature of each individual’s pain.
Somatic pain: Dull, achy, throbbing and sore. It is usually well localized — for example in fractures, arthritis or injury — to deep musculoskeletal structures or superficial cutaneous tissues, or in bone and spine metastases.
Visceral pain: Squeezing pressure, cramping, deep, distension, stretching, bloated and diffuse. It originates deep in an organ and is often referred to dermatomes innervated by the same fibers and is often seen in post abdominal or thoracic surgery, bowel obstruction, venous occlusion, ischemia, liver metastasis, ascites or pancreatitis.
Neuropathic pain: Burning, shooting, numb, tingling, radiating “like a fire” or electrical shock like pins and needles. It is caused by nerve damage by tumor or injury, spinal cord compression, postherpetic neuralgia, diabetic neuropathy or neuropathies from tumor chemotherapy or radiation. Neuropathic pain can be related to dysesthesia — sensations of pain from non-painful stimuli.
Acute vs. Chronic:
Acute pain: Can be seen after surgery and teams may use opioid medications during procedures and postoperatively to keep patients comfortable.
Chronic pain: Specialists, like rheumatologists, are especially challenged to help patients suffering from chronic, long-term pain due to rheumatic and autoimmune diseases and may often rely on opioid medications when other treatments may not be considered as effective.
To heighten the complexity, each person’s pain threshold is different. And a patient’s mental state or mental illness can intensify their perception of pain. Social determinants of health such as mental illness, poverty and substance abuse can have a great impact on a patient’s pain and must be addressed early in the course of evaluation for pain to be successfully managed by an interdisciplinary team of experts in complex cases. As a prolonged stressor, chronic pain leads to sustained, elevated levels of the stress hormone cortisol. This decreases the size of the hippocampus and can affect learning, memory and emotion, all of which can produce or worsen behavioral health problems.
Ongoing pain can diminish quality of life and make normal activities challenging. Strong pain relievers like opioids have long been an immediate and convenient solution, but they may not be the best long-term solution in certain patients.
“Pain is a good thing: it keeps us safe,” said Sheri Kittelson, M.D., FAAFP, UF Health Shands Palliative Care chief. “Being in pain crisis or oversensitized to pain, however, is a bad thing. And our job as health care providers is to deliver safe treatment options to our patients that increase their quality of life and reduce their suffering.”
NEXT STEPS: REDUCING RELIANCE ON OPIOIDS
The multidisciplinary UF Health Pain Committee calls on physicians, nurses and pharmacists to reconsider opioid use when possible, in favor of promoting safer, more sustainable treatments for our patients. Nonpharmacologic and pharmacologic pain management therapies may be used independently or combined as alternatives to opioids. Here are the basics about some of these options and ways to connect your patients with them.
NON-OPIOID PHARMACOLOGIC THERAPIES:
- Anticonvulsant drugs (Gabapentin, Pregabalin, Topomax)
- Antidepressants (TCAs or SNRIs)
- Antispasmotics (Baclofen)
- Nerve block/local anesthetic (Ketamine, Lidocaine, Repivocaine)
- Corticosteroids and nonsteroidal anti-inflammatories, or NSAIDs (Dexamethasone, Toradol)
- Serotonin-norepinephrine reuptake inhibitors, or SNRIs (Cymbalta, Effexor XR)
- Topical analgesics (capsaicin, salicylates)
- Bisphosphonates and radiopharmaceuticals: for cancer-related bone pain
- Herbal supplements (turmeric, devil’s claw)
Consider expert consultation when needed for inpatient and outpatient services:
- Acute pain anesthesia (postoperative pain)
- Chronic pain anesthesia (blocks, ablations)
- Palliative care — life-limiting illness pain management
- Addiction medicine — addiction psychiatry
- Chronic pain — follow-up outpatient care
- UF Health Shands Arts in Medicine program
AIM offers creative arts experiences to promote well-being and healing with adult and pediatric patients. Activities with artists-in-residence and specially trained volunteers include coloring, crafts, music therapy and literary arts, as well as integrative therapies, including massage, meditation, relaxation, yoga, Tai Chi and Qigong. Call 352-733-0880 to request an artist-in-residence.
- UF Health Shands Child Life program
This program provides children with support, distractions and coping strategies that may assist in pain management. Child Life specialists are located on several units in the UF Health Shands Children’s Hospital and in the UF Health Shands Pediatric E.R. Place a consult order in Epic, page the unit-based specialist or call extension 46470.
- Infotainment system “distraction” channels
Our hospitals with built-in Sonifi™ infotainment systems offer inpatient TV channels featuring white noise or calming music and nature scenes to help distract patients from discomfort. These channels can also be used to complement a meditation or prayer practice.
Occupational and physical therapists visit patients to suggest appropriate therapeutic exercise, which can be as simple as sitting or moving between the chair and bed. Nursing and Patient Services staff help patients with these activities throughout the day
- Heating pads/ice packs
These are typically located in a unit’s stock room or can be ordered from the care team.
- UF Health Shands Pet Therapy program
Patients can request a pet therapy visit and, in some cases, arrange in advance to have their own pet brought to their room. Details are posted at UFHealth.org/Personal-Pet-Visitation or arranged through UF Health Shands Volunteer Services at 352-265-0360.
- Chaplain Services.
Spiritual pain: Chaplains support patients who are dealing with illness who have both existential and spiritual suffering that causes or may intensify the perception of physical pain. They are an integral part of the team for patients with spiritual needs.
Psychology consultation is available, on an inpatient or outpatient basis, for patients with emotional distress.
* Available on limited units:
- Aromatherapy, video games and board games
The UF Health Integrative Medicine practice, located at Springhill, offers a licensed acupuncturist.
The service is covered by some insurance plans and can complement other therapies. “Acupuncture is not a oneand-done deal. It’s part of a total health plan, including diet, stress management and mindfulness,” said Irene Estores, M.D., UF Health Integrative Medicine medical director. Patients can call 352-265-9355 for an appointment.
- Cognitive Behavioral Therapy
Psychologists at our UF Health Psychology practice at Springhill can help patients regulate emotions and develop coping strategies using CBT. This practice is especially useful for patients with behavioral health challenges. Patients can call 352-265-4357 for information.
- Interdisciplinary rehabilitation, occupational therapy and physical therapy
The UF Health Rehab Hospital, an affiliate of Select Medical, offers interventions to help patients perform everyday activities. Call 352-554-2100 to make an appointment.
Yoga offered by trained instructors is recommended for patients challenged by pain, with an emphasis on injury prevention. Gentle Yoga for Health holds weekly, hourlong free sessions at the UF Health Shands Cancer Hospital. Call 352-733-0881 for details.
- UF Health Integrative Medicine
Integrative medicine experts encourage patients to explore once-considered “alternative” medicine practices to foster the connection between the mind, body and spirit. Integrative medicine addresses a patient’s full range of physical, emotional, mental, social, spiritual and environmental influences that impact health. Visit UFHealth.org/integrativemedicine for details, including
helpful resources on wellness classes, meditation exercises, mind-body resources, movement recommendations and other options.
- Patient support groups
Visit UFHealth.org and type “Patient Support Groups” in the search bar to learn about the diverse support groups and classes available to patients and the community.
Nutrition and Anti-inflammatory diet
The body’s inflammation response to illness causes tissues to swell and can stimulate the nervous system to cause pain. Health care experts find that an antiinflammation diet can help patients with systemic inflammation and poses few risks as a dietary intervention. Foods to avoid include sugars, processed meats, trans fats, gluten and processed and fried foods.
- Chiropractic adjustments
- Exercise, ambulation or repositioning
- Heating pads/ice packs
- Video or board games
- Voluntary breath change, mindfulness-based stress reduction and meditation
Meditation and breathwork can adjust breathing patterns by shifting the body from the sympathetic nervous system, with its fight-or-flight connotations, to the parasympathetic nervous system, which prompts the “rest and digest” response. “Breath is free, portable and doesn’t require movement. It’s not invasive — it just takes commitment,” Estores said. Free mobile applications like Insight Timer, which Kittelson uses, can support these practices.