Non-Pharmacological Interventions on the Use of Opiod in Managing Pain

read the following paper from my college and response in one or more of the following ways:
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the paper
In the late 1990s, pharmaceutical companies assured the health care community that opioids would not cause addiction problems. This prompted healthcare providers to begin prescribing these medications at exponential rates. Increased prescriptions for opioid pain relievers resulted in misuse before it was known that they caused dependency issues. In 2019, 70,630 people died from overdose, and this last year 1.6 million people have been reported to have opioid use disorder and have misused opioids for the first time. In 2017, the US Department of Health and Human Services (HHS) declared the opioid crisis a public health emergency (U.S. Department of Health and Human Services. 2022). The HHS now supports community and science-based efforts used to improve the physical and mental health of individuals struggling with opioid addiction.
In the scenario that I am the primary care provider managing Randi’s back pain, multiple approaches would be taken to screen and assess Randi’s pain. I would start by listening to Randi’s self-reported pain. A patient’s report of their pain is generally the most reliable indicator of pain. Due to Randi’s history of going to the ER for pain medications, I would also assess pain using the PQRSTU Mnemonic. This would include gathering detailed information about when the pain started, alleviating factors, quality and region of pain, severity of pain on a 0-10 pain scale, pain patterns, and how Randi’s pain affects her quality of life. A multidimensional scale would be used to consider the location, pattern, and affective responses, in addition to Randi’s verbal report alone. I would evaluate Randi for signs and symptoms of anxiety and depression. Pain and depression are closely linked. Pain can cause depression, and depression can cause pain, often resulting in a vicious cycle. Chronic pain causes several issues that can lead to depression, such as trouble sleeping and stress (Hall-Flavin, 2019). All these factors can negatively impact the health of any patient. Addressing Randi’s comfort, including how to provide relief, ease, and transcendence, can improve the physical, psychospiritual, environmental, and social aspects of her life. This can often be done without the use of controlled pain medications, such as opioids. Management of depression may result in fewer or lower doses of opioids being prescribed.
To start, I would prescribe a non-opioid and schedule a follow up visit with Randi in a week to see how she is managing. If the pain is still not managed, Randi would be prescribed a low dose opioid such a 5/325 mg hydrocodone/acetaminophen, as needed. To monitor Randi’s response to her treatment, she would need multiple follow up office visits. Regular toxicology screens would need to be done to test her blood for the presence of additional or excessive opioids. Randi would be thoroughly assessed at each visit for signs of dependence and withdrawal. Higher doses of the opioid would not be prescribed without Randi seeing a pain management specialist first. Randi would be screened using the Opioid Risk Tool, which can help providers evaluate risk for opioid use based family and personal history, age, history of sexual abuse, and evaluation of psychological diseases (Arcangelo et al., 2022). If misuse was suspected, I would strongly encourage Randi to enroll in a treatment program, providing a referral, with the program information and phone number.
To prevent overdose, I would be sure Randi has a script for naloxone. I would ensure she knows how to use the drug, and I would also provide written instructs for the use of the naloxone. An observational study of nearly two thousand individuals who had received an opioid prescription over a two-year period found that those individuals who were co-prescribed naloxone along with their opioid analgesic prescription had 47% fewer visits to the emergency department in the 6 months after receiving the prescription and 63% fewer emergency department visits after 1 year (Carroll et al., 2022). Patient education topics I would be sure to discuss with Randi include the risks of opioid dependency, the dangers in opioid dependency, nonpharmaceutical pain control measure that can be implemented to help manage pain, and the emergency contact information which may be needed in the case of an overdose. I would be sure Randi understands proper administration of her medication, common side effects of opioids, and proper use of opioid reversal agents which Randi will also be prescribed. All these measures should improve compliance in medication use.
Once I determine that Randi’s back pain has resolved yet she has developed opioid use disorder, she would be referred to a pain management specialist and an addiction treatment program. I would start Randi on Buprenorphine once addiction treatment was started. This medication can help manage Randi’s addiction, while helping with pain. Buprenorphine is usually prescribed with naloxone. Buprenorphine and naloxone work together to control opioid cravings while lowering the risk of bothersome side effects that happen with withdrawal (Arcangelo et al., 2022). This plan will be implemented in hopes that Randi’s pain is properly managed, while treating her opioid dependence, resulting in long-term freedom from debilitating pain and addiction.
References
Arcangelo, V. P., Pearson, A. M., Wilbur, V., & Kang, T. M. (2022). Pharmacotherapeutics for advanced practice (5th ed.). Wolters Kluwer Health.
Carroll, J., Green, T., & Noonan, R. (2022, June 9). Evidence-based strategies for preventing opioid overdose: what’s working in the united states. Centers for Disease Control and Prevention. Retrieved February 5, 2023, from https://www(dot)cdc(dot)gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdfLinks to an external site.
Hall-Flavin, D. (2019, April 3). Pain and depression: Is there a link? Mayo Clinic. Retrieved February 1, 2023, from https://www(dot)mayoclinic(dot)org/diseases-conditions/depression/expert-answers/pain-and-depression/faq-20057823Links to an external site.
U.S. Department of Health & Human Services, Opioid facts and statistics. (2022, December 16). HHS.gov Retrieved February 5, 2023, from https://www(dot)hhs(dot)gov/opioids/statistics/index.htmlLinks to an external site.
Post Reply # 2
Thank you Mary for sharing your research findings and experiences with us. I strongly agree with you that opioids are over-prescribed and I can tell you from personal experience with back pain, primary care physicians seem eager and willing to prescribe them. I have even experienced doctors who offer pain medications to me without even asking me to rate my pain. You are justified in implementing a complete and thorough pain assessment for Randi before making decisions about analgesia. You have mentioned the importance of assessing her knowledge and use of adjuvant (non-pharmacological) therapies to help with the pain and I agree with this point. Research has shown that non-pharmacological interventions can help mitigate pain and the need for pharmaceuticals and they can reduce anxiety, which, as you have mentioned, can enhance the pain experience (Zhang et al., 2021).
It is challenging in this situation to implement an opioid risk assessment tool because it may make Randi feel as though you do not believe her or that you suspect she will abuse the opioids but you are correct in highlighting the need for this (Klimas et al., 2019). I would educate her about the tool, why we are using it, and normalize its use by saying something like “opioids can be highly addicting so we have a questionnaire that we like all patients to fill out before we can prescribe opioids” so that Randi does not feel as though she cannot be trusted or that she is being singled out.
Clarke et al., (2019) highlight the challenges we face as practitioners when managing pain safely using the lowest possible dose of opioids. As you have stated, all patients, regardless of whether or not they have a history of opioid addiction, should be treated with the lowest dose possible along with concurrent adjuvant therapies. Researchers cite that one reason for this is that providers fear undertreating patients and being reported to professional bodies (Clarke et al., 2019). While we need to ensure that analgesia is optimized, we have to balance the risk versus benefits ratio for each individual patient. One way this can be done is to employ the World Health Organization pain ladder in which the patient's subjective pain rating is used as the premise for treatment (i.e. pain from 1-3 would be treated with a non-opioid) (Yang et al., 2020). This can help standardize opioid prescriptions and ensure that people experiencing mild pain are not automatically given analgesics for severe pain.
Randi stated that when she first went to the Emergency Room for back pain, she would have likely been alright with ibuprofen, and this shows that her pain rating and a comprehensive assessment (including opioid risk assessment) were likely not done. She was given opioids right from the start rather than starting with a non-opioid and titrating upward based on subsequent follow-up appointments (Clarke et al., 2019).
You have mentioned that Randi would need education regarding opioid addiction and I strongly agree with you. While it may be uncomfortable to initiate this topic and discuss her past addiction, being transparent and honest with her will hopefully foster her ability to trust her healthcare team and be honest with them.
References
Clarke, H., Bao, J., Weinrib, A., Dubin, R. E., & Kahan, M. (2019). Canada's hidden opioid crisis: The health care system's inability to manage high-dose opioid patients: Fallout from the 2017 Canadian opioid guidelines. Canadian Family Physician, 65(9), 612-614
Klimas, J., Gorfinkel, L., Fairbairn, N., Amato, L., Ahamad, K., Nolan, S., Simel, D. L., & Wood, E. (2019). Strategies to identify patient risks of prescription opioid addiction when initiating opioids for pain: A systematic review. JAMA Network Open, 2(5), e193365. https://doi(dot)org/10.1001/jamanetworkopen.2019.3365
Yang, J., Bauer, B. A., Wahner-Roedler, D. L., Chon, T. Y., & Xiao, L. (2020). The modified WHO analgesic ladder: Is it appropriate for chronic non-cancer pain? Journal of Pain Research, 13, 411-417. https://doi(dot)org/10.2147/JPR.S244173
Zhang, X., Zhou, G., Chen, N., Zhang, Y., & Gu, Z. (2021). Effect of non-pharmacological interventions on anxiety, depression, sleep quality, and pain after orthopedic surgery: A protocol for systematic review and network meta-analysis. Medicine, 100(44), e27645. https://doi(dot)org/10.1097/MD.0000000000027645