Reducing Opioid Use

Reducing Opioid Use

By Eugene Curtin

When the National Institute on Drug Abuse reports that more than 130 Americans die every day from opioid overdose, and more than 1,000 are rushed to emergency rooms after opioid misuse, it’s easy to see the devastating impact these addictive painkillers can have.

For the anesthesiology group at CHI Health Creighton University Medical Center–Bergan Mercy, however, it’s a relatively old story about a war on addiction that its member physicians have waged for seven years.

“Around 2012 to 2013, our anesthesiology group decided to start changing how we take care of patients and how we manage their pain,” says Mark Reisbig, PhD’03, MD’08, associate professor in the School of Medicine’s Department of Anesthesiology.

“It used to be that we gave all these big-time opioid drugs that certainly took care of patient pain but also knocked them out and had a lot of bad side effects. We have now set up new protocols and are trying to move them out to other hospitals across the CHI system.”

The protocols de-emphasize common opioid painkillers such as morphine, fentanyl, hydromorphone and oxycodone and replace them with non-opioid pain relievers such as acetaminophen and ibuprofen administered consistently throughout the day.

Charles Youngblood, MD’02, MBA’15, chairman of the Department of Anesthesiology, says de-emphasizing opioids is part of a wider effort to reimagine pain management.

“We’re trying to treat acute pain better,” he says. “We’re doing better medicine, and using fewer opioids is a result of that. We’re addressing pain on multiple modalities versus just one, and so we’re using fewer and fewer opioids.

“If we can avoid them altogether, then all the better.”

The results, Reisbig says, have been encouraging as patients admitted for orthopedic surgery, abdominal cancers, colorectal surgery, hysterectomies, cardiothoracic and breast surgeries and even cesarean sections report satisfactory pain control from the application every few hours of non-opioid painkillers such as Tylenol and Advil. Other non-opioids used are gabapentin, lidocaine, ketorolac and ketamine, all prescription painkillers.

Reisbig refers to this mix of prescription and nonprescription painkillers, together with significantly reduced use of opioids such as morphine, as a “multimodal” approach under which a patient’s pain is monitored before, during and after surgery. Morphine is used during surgery, which grants about 24 hours of pain relief, followed thereafter by the application every few hours of non-opioids.

It began with Tom Connolly, MD’90, Reisbig says, a Creighton orthopedic surgeon who embraced the anesthesiologists’ desire to deploy alternative pain relief medications. The results, he says, were encouraging.

Patients reduced their pain estimates to two and three, down from seven and eight, on a scale of 1 to 10. Morphine consumption fell from 30 morphine equivalents to just one, and antiemetics used to control nausea fell from 67% to zero.

“Patients had less nausea, the pain was a lot better and we weren’t giving them a whole lot of intravenous opioids,” Reisbig says.

Thus encouraged, the anesthesiologists some two years later brought on board Brian Loggie, MD, chief of surgical oncology at the Bergan Mercy campus.

Loggie, Reisbig says, performs major surgeries on patients with advanced and even terminal abdominal cancers.

“Obviously, these are big surgeries that involve very large incisions and the insertion of tubes for hot chemotherapy after the abdomen is closed up,” Reisbig says. “So, there’s a lot of post-surgery pain management.”

The result, Reisbig says, was an almost 50% reduction in the number of patients receiving opioids and the application of just 250 micrograms of morphine down from the 30, 40 or 50 milligrams applied during a typical hospital stay.

Nevertheless, Reisbig says, opioids remain available and will be used if necessary.

“We’re giving what is indicated,” he says. “If people are experiencing a lot of pain, that’s what we’re going to use. But we’re not just giving it out.”

The gathering of data continues as the Creighton team continues to build the case that non-opioid pain management is effective. Data is the key to changing minds, Reisbig says, and the more non-opioid pain management is practiced, the more data there will be.

“It’s amazing to see these patients afterward,” he says. “They’re more alert, more awake, they don’t look like they’ve just had surgery where you had to wake them up. Now they’re sitting up, alert, eating. It’s exciting.”