Page 20 - Layout 1

OPIOID CRISIS

continued from page 18

aggressive treatment of severe pain and a TABLE 1
movement away from “opioidophobia.” (4)
Those recommendations, intended espe- should be aware of the syndromes they commonly treat and any rel-
cially for terminally ill or cancer patients, evant evidence-based recommendations by their professional soci-
became broadly applied to non-terminally eties (7).
ill patients as well. These patients had a Patient Education
much longer lifespan and thus longer op-
portunity to develop drug misuse problems Patients should be made aware of the typical course of the disor-
while on opioid therapy. Based on increas- der that is likely causing pain and the most beneficial initial measures
ing awareness of potential problems such that should be employed to manage the symptoms. This reduces the
as tolerance, abuse and addiction with pre- anxiety of uncertainty, which can feed into worsening pain experi-
scription pain medications, as well as unin- ences and potentially lead to an exhaustive search of more expensive
tended or intentional diversion of the medical care, where it may not be helpful. Coping skills should be
medications to others, the societies now assessed and actively augmented with counseling if they appear in-
recommend a new culture of risk assess- sufficient. For example, most acute low-back pain resolves in a mat-
ment, drug monitoring and continual re- ter of weeks to months, and opioids have less strong evidence for
evaluation (5) (Figure 1). The Centers for use in acute low-back pain than many other medications (7). If opi-
Disease Control and Prevention (CDC) has oids are used, patients should be fully informed of the long-term
generally recommended against long health consequences, as well as the possibility that their provider may
courses of opioid therapy if at all possible, remove the use of opioids if problems exceed benefit. Patients
recommending that opioids be prescribed should also receive education on maintenance of mobility and
no longer than three to seven days beyond proper motivational attitude following acute low-back pain.
initial surgery or injury. However, many Bringing all Tools to Bear (…Before Opioids)
pain societies have voiced concern for re-
strictions inherent in this recommendation. Somewhere in the mid- Non-pharmacologic therapies (including education) should be em-
dle, a balance must be found between potential benefit and harm. ployed prior to or in conjunction with pharmacologic management.

RATIONAL STRATEGY FOR OPIOID USE:
REDUCING OPIOID BURDEN UP FRONT

Opioids do have side effects such as respiratory depression and
constipation, and long-term health consequences including tolerance,
increased pain, abuse/addiction, sex hormone suppression, stress
hormone suppression and sleep cycle disruption (6). Physicians and
non-physician licensed providers will likely prescribe opioids even-
tually, so the unique properties and issues in opioids create a need
for organized and logical management to minimize patient harm, re-
duce liability and adhere to regional regulations and practice stan-
dards, while also providing analgesia to patients in need.

Establishing a diagnosis
Although pain is a disease process of itself, currently it is still

widely recognized as being secondary to a primary disease by both
insurance payers, clinicians and state medical boards. Use of perti-
nent history, physical exam and testing or imaging can support clini-
cian knowledge and recognition of painful conditions. The
importance of establishing a likely diagnosis for chronic pain will
aid in the prognosis of an expected recovery course and in the plan-
ning of specifically directed treatment, if applicable. Physicians

20 San Antonio Medicine • October 2017