New Hampshire hospitals are changing how they manage their patients’ pain, in response to an opioid epidemic that is widely blamed on overprescribing of legal painkillers.
Among those leading the way is Dr. Richard Barth, chief of surgery at Dartmouth-Hitchcock Medical Center in Lebanon. His research has shown that post-surgery patients need far less pain medication than typically prescribed.
It’s natural, Barth said, for surgeons to want to minimize the amount of discomfort their patients have post-surgery. “I think that’s a natural and a good thing,” he said. “We still want to do that.”
“What we have to realize is that we have a lot of different methods that are at our disposal to try to minimize people’s pain after surgery, but we’ve been overusing opioids to try to fix that problem.”
Barth recalls when he was in medical school in the 1980s, “We were taught that basically patients cannot get addicted to opioids if you give them opioids for acute pain.”
But that wasn’t true.
Large-scale studies have shown that 5 to 10 percent of surgical patients who had never used opioids before — they’re called “opioid naive” — who are prescribed the drugs “will still be on opioids six months or a year after the surgery,” Barth said.
While the reasons aren’t entirely clear, he said, there appear to be both genetic and behavioral factors that predispose some patients to becoming long-term users. And studies show that the duration of time that patients take painkillers predicts the likelihood that they’ll become long-term users, Barth said.
“So our goal has been to say: let’s try to give people the right amount of opioids to take care of the pain in that initial episode and not have a whole lot of opioids sitting around that can get diverted to others or might potentially lead them to have a higher chance of using it at six months or a year,” he said.
One of Barth’s studies showed that doctors could reduce by half the amount of opioids prescribed and still manage their patients’ post-surgery pain. And when they checked in later with patients, he said, “They still were only using 34 percent of the pills that we prescribed, even when we cut the number in half.”
It meant that doctors were still overprescribing. And in the midst of an epidemic that started with diversion of prescription drugs, the implications are enormous. “These extra pills are presenting a risk to patients becoming long-term users, and presenting a risk to others because they can get diverted,” Barth said.
In many cases, Barth said, patients don’t even need such drugs. Recent studies show that a combination of ibuprofen and acetaminophen “is even better than opioids for treating acute pain.”
And Barth’s research found these guidelines work just as well in the inpatient general surgical setting.
Dr. William Goodman became chief medical officer at Catholic Medical Center in Manchester in 2015, just as fentanyl was replacing heroin as the leading cause of overdose deaths in the state.
Goodman said there is data that shows that just having surgery creates an increased risk for becoming opioid dependent in the subsequent year. “The problem now is a lot of the people affected, their risk factor is that they do have access to health care,” he said. “It’s backwards.”
Goodman became then-Gov. Maggie Hassan’s representative on a committee that devised new state rules for prescribing opioids. And CMC has developed new protocols “that guide people to judiciously use opioids and alternatives to opioids for pain control,” he said.
It’s important to recognize the role that prescription drugs have played in creating the current epidemic, Goodman said.
Start with false claims by drugmakers that their drugs weren’t addictive. Meanwhile, care teams began monitoring pain as a “fifth vital sign,” and pain management was included in the patient satisfaction scores for doctors, which put pressure on them to keep their patients pain-free. It all contributed to a sharp spike in how many opioids doctors were prescribing.
“There’s no question that the prescription pad played a role,” Goodman said. “And it should have a role in helping to reverse this.”
In one study, Barth’s team found that the amount of opioids that patients were taking the day before discharge “was an incredibly good predictor” of how many pills should be prescribed at home.
Barth said his findings can be applied to family physicians and other practitioners as well; the goal is prevention. “We want to prevent people from becoming long-term opioid users who will then go on to overdose and die from it,” he said.
Goodman said he is optimistic that things are changing. Overdose deaths in New Hampshire have plateaued even as they continue to rise in other states, he said. CMC’s internal records show a 21 percent drop in opioids administered in the hospital from 2015 to 2017.
There are also implications for providers who treat patients outside the hospital. The new opioid prescribing rules adopted by the state Board of Medicine in 2016 call for emergency departments, urgent care settings and walk-in clinics to prescribe only “the minimum amount of opioids medically necessary to treat the patient’s medical condition.”
“In most cases, an opioid prescription of 3 or fewer days is sufficient, but a licensee shall not prescribe for more than 7 days,” the rules state.
Barth contends that such guidelines are “well intentioned” but too vague. “It doesn’t tell you exactly how many you’re taking and the time period to take those,” he said. Taking two pills every four hours for seven days, for example, would equal 84 pills; one pill every six hours while awake would be only 21. But, Barth said, “Either one is a ‘7-day supply.’”
Goodman said Barth “makes a good point.” He said he wanted the rules for urgent-care settings to limit prescriptions to three days, but compromised with the “sufficient” language. Dosing and frequency can vary from one medication to another, he said, and the committee questioned whether it’s the state’s job to “legislate medicine.”
And in the end, he said, they agreed that there has to be a level of trust “that the person who’s prescribing is doing the right thing.”
Barth said he’s hopeful that things are changing: “We’ve already seen marked decreases in the number of opioids that are being prescribed,” he said.
And as more doctors incorporate new prescribing guidelines into their practice, he said, “I think it’s likely to decrease the amount of pills that are available for diversion to others, and it’s also likely that patients aren’t going to be at high risk for becoming long-term users in the future.”
Goodman said the stigma around addiction is also changing. “It could happen to anybody,” he said. “It’s what you get exposed to; it’s not who you are. That’s a very important message.”
He recalled that former U.S. Surgeon General C. Everett Koop sent a mailing to every household in the country during the AIDS crisis with the message: “It’s not who you are, it’s what you do that gives you HIV.” It was a powerful message and one he believes resonates in this new crisis.
Goodman said what drives him to address the issue is the knowledge “that I know it could happen to anybody; it could happen to me, to my family.”
“It’s an unintended consequence of a well-intended action of prescribing medications,” he said. “And I think that as a member of the profession, we should do everything we can do reverse this.”
“Maybe there’s a little sense of responsibility since the prescription pad was so involved, but also because we do have an opportunity to make a difference,” Goodman said.
Barth, too, said he felt compelled to respond. “I just saw all the people dying of this, and that New Hampshire was leading the nation as one of the highest per-capita states for opioid overdose deaths,” he said. “I saw all the young kids that are dying of this.”
“As a surgeon, I prescribe opioids,” he said. “I have to do my part to try to help with this.”
Beyond the Stigma, sponsored by the New Hampshire Solutions Journalism Lab at the Nackey S. Loeb School of Communications, is funded by the New Hampshire Charitable Foundation, Dartmouth-Hitchcock Medical Center, NAMI New Hampshire, and private individuals.