Overcoming opioids
Hospitals seek alternatives to addictive drugs
BALTIMORE—A car crash shattered Stuart Anders’ thigh, leaving pieces of bone sticking through his skin. Yet Anders begged emergency room doctors not to give him powerful opioid painkillers— he’d been addicted once before and panicked at the thought of relapsing.
“I can’t lose what I worked for,” he said.
The nation’s opioid crisis is forcing hospitals to begin rolling out non-addictive alternatives to treatments that have long been the mainstay for the severe pain of trauma and surgery, so they don’t save patients’ lives or limbs only to have them fall under the grip of addiction.
Anders, 53, from Essex, Maryland, was lucky to land in a Baltimore emergency room offering an option that dramatically cut his need for opioids: An ultrasound-guided nerve block bathed a key nerve in local anesthetic, keeping his upper leg numb for several days.
“It has really changed the dynamics of how we care for these patients,” said trauma anesthesiologist Dr. Ron Samet, who treated Anders.
An estimated 2 million people in the U.S. are addicted to prescription opioids, and an average of 91 Americans die every day from an overdose of those painkillers or their illicit cousin, heroin.`
This grim spiral often starts in the hospital. A Harvard study published in the New England Journal of Medicine in February raised the troubling prospect that for every 48 patients newly prescribed an opioid in the emergency room, one will use the pills for at least six months over the next year. And the longer they’re used, the higher the risk for becoming dependent.
Doctors and hospitals around the country are searching for ways to relieve extreme pain while at the same time sharply limiting what was long considered their most effective tool. It’s a critical part of the effort to overcome the worst addiction crisis in U.S. history but, as Anders’ experience shows, their options are neither simple nor perfect.
Anders’ excruciating injury eventually did require a low opioid dose when the nerve block wore off but, Samet said, far less than normal.
“Provide them with good pain relief initially, for the first 24 to 48 hours after surgery, the pain that comes back after that isn’t necessarily as hard and as strong,” said Samet, an assistant anesthesiology professor at the University of Maryland School of Medicine.
And some doctors are discovering an added benefit of cutting back or even eliminating opioids. At the University of Pittsburgh Medical Center, a program called “enhanced recovery after surgery” is getting some patients home two to four days faster following major abdominal operations, using non-opioid painkillers that are gentler on the digestive tract.
“Our patients are very afraid of pain, especially the patients with a history of opioid addiction,” said Dr. Jennifer Holder-Murray, a UPMC colorectal surgeon who helped start the program. “When they come back to me and tell me they didn’t even fill their opioid prescription, that’s a remarkable experience.”
In trauma centers and surgery suites, there are no one-size-fits-all replacements for prescription opioids—narcotic painkillers that range from intravenous morphine and Dilaudid to pills including Percocet, Vicodin and OxyContin. They so rapidly dull severe pain that they’ve become a default in hospital care, to the point where it’s not uncommon for patients to have an opioid dripping through an IV before they wake from surgery, whether they’ll really need it or not.
Now, amid surging deaths from drug overdoses, some hospitals and emergency rooms are rethinking their own dependence on the painkillers,.
The new approach: Mixing a variety of different medications, along with techniques like nerve blocks, spinal anesthesia and numbing lidocaine, to attack pain from multiple directions, rather than depending solely on opioids to dampen brain signals that scream “ouch.” It’s known by the wonky name “multimodal analgesia.”
Consider colorectal surgery, so painful that standard practice is to administer IV opioids in the operating room and switch to a patient-activated morphine pump right afterward. The University of Pittsburgh program ended that opioid-first mentality. Instead, doctors choose from a wide mix of options including IV acetaminophen and prescription-strength anti-inflammatory painkillers known as NSAIDs, anti-seizure medications such as gabapentin that calm nerve pain, muscle-relaxing drugs, and others.