Hospitals scale back on opioids

CHICAGO — Zulidany Cortez went to an emergency room in Chicago when she could no longer endure the pain from a wrist she hurt moving furniture.

In years past, doctors likely would’ve given the 32-year-old a prescription for an opioid painkiller. But when Cortez met with Dr. Mark Livak, the subject didn’t even arise.

“I think Tylenol should be OK,” Livak said. “We’re going to put you in a splint, a piece of moldable fiberglass that goes in an ACE wrap. I think that’s going to give you some pain relief just by not moving it.”

So it goes in many emergency rooms and surgical suites in the U.S., where physicians are trying to overturn their profession’s long-standing dependence on opioids.

Drugs such as Vicodin, OxyContin and fentanyl diminish moderate to severe pain, but they also carry a significant risk of addiction. It’s not clear how many people swept up in the opioid crisis got started because of a trip to the hospital, but some experts believe the portion is sizable.

“The majority of overdoses come from [people who use opioids to treat] chronic pain, but that doesn’t tell you how their use began,” said Dr. Andrew Kolodny, a Brandeis University scientist who is executive director of Physicians for Responsible Opioid Prescribing.

“I can’t point to data, but I believe that for the vast majority of people who become stuck on opioids, their prescriptions began because of injury or surgery,” he said.

But it’s not just patients who are in danger from excessive opioid prescribing. People who receive large doses often end up with leftover pills that are taken by others: More than half of Americans who misuse opioids report getting them from a friend or relative, according to the National Survey on Drug Use and Health.

Many hospitals are now moving to alternative methods of treating pain. Some doctors say lesspotent medications can handle pain equally well — and that patients are coming to share that view.

In the past six months, Rush University Medical Center has given postsurgical patients Tylenol, Motrin and gabapentin, a medication used for nerve pain. A mild opioid is used for intermittent pain spikes.

Dr. Asokumar Buvanendran, a Rush pain specialist, said patients greeted the new protocol in a surprising way.

“We were concerned we would have a lot of complaints, but we have not seen any of that,” he said. “We have seen the reverse — patients are more satisfied.” SECOND THOUGHTS

Opioids, which encompass everything from codeine to heroin, block pain signals to the brain. That trait has made them a prized analgesic for thousands of years, but experts say their use exploded in the 1990s as doctors — swayed by shifting attitudes about treating pain and aggressive pharmaceutical company marketing — became more generous about prescribing them.

While most of the pills went to patients with chronic conditions, Kolodny said they also became the first choice for people visiting an emergency room or recovering from surgery.

“There’s a notion that the drug can’t cause addiction, that the abusers are the ones at fault,” he said. “[Doctors] don’t think they’re creating abusers. They don’t quite get that the drugs themselves are causing addiction.”

But as overdoses spiked and stories emerged of habits that began with a broken bone or a pill filched from a relative’s medicine cabinet, medical professionals began to rethink their use of the drugs.

The U.S. Centers for Disease Control and Prevention called for physicians to prescribe no more than three to seven days’ worth of take-home opioids for acute pain. Numerous professional groups also called for restraint.

“We were probably too liberal when we were responding to all this pressure [to prescribe the drugs], but that’s really tightened up,” said Dr. Mark Reiter, past president of the American Academy of Emergency Medicine.

The same reckoning has happened in operating rooms. At Northwestern Medicine’s hospitals, surgeons try to prescribe no more than a small amount of opioids after a procedure, though they don’t stick to a specific amount.

“The reality of treating acute pain is we’re often guessing how many pills a patient will need,” said Dr. Jonah Stulberg, a Northwestern surgeon who has led its opioid reforms. “Some people’s pain gets much better in 24 hours; others have significant pain for three to five days. We probably will never be able to exactly match the number of pills a patient needs with their pain.”

Instead, Northwestern tutors patients about the potential dangers of opioids and asks them to bring unused medication to follow-up meetings with their surgeons, where the drugs can be disposed of properly.

Lynn Adler, who recently underwent gastrointestinal surgery at Northwestern, said she appreciated that policy.

“I had never been asked that before,” said Adler, 70, who returned a bottle of tramadol. “I loved it because I had filled the prescription but never took any. I didn’t know what to do with them, so I was really happy when they told me to bring them in.”

Some hospitals are focusing on what happens before an operation to lessen the need for post-op pills.

NorthShore University HealthSystem tries to set patient expectations at a realistic level in advance. And for some procedures, doctors inject localized pain blockers before surgery to keep the area numb after the person wakes up.

Dr. Rebecca Blumenthal, a NorthShore anesthesiologist, said before the organization adopted this protocol in 2016, every patient who underwent these procedures received opioid prescriptions. Now only half do, she said, and most get just a few pills.

“It’s amazing,” she said. “Our patients are having these very large surgeries, and half of them require very low opiates.”

Pablo Michalewicz, a 61-year-old biology instructor at Triton College who suffers from diverticulitis, was given a local pain blocker before having a section of his colon removed at NorthShore Evanston Hospital earlier this month.

He said he felt little pain when he awoke and declined the offer of a take-home opioid, using only Tylenol, ibuprofen and gabapentin.

“I wasn’t even close to needing [opioids],” he said. “The first five or six days I was waiting — like, when is the pain coming? It never did.”

Hospitals are also taking extra measures to foil people who might be seeking narcotic drugs. All doctors in Illinois are required to sign up for a state database that monitors opioid prescriptions, and some hospitals have also developed in-house systems.

At Cook County’s Stroger Hospital, that information is now automatically included in a patient’s electronic medical records, allowing doctors to make better decisions, said emergency medicine physician Dr. Steven Aks.

He said he and his colleagues are prescribing fewer opioids, and to his surprise, patients who once demanded the drugs are accepting alternatives.

“Honestly, I’m not sure what it is,” he said. “Five years ago, there was a lot more resistance. I think people are getting it.”