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Receptors in Addiction / Source: Wikimedia Commons and Depra P Davis

Pennsylvania’s Opioid Guidelines Have National Ortho Impact

Jessica Mehta • Fri, April 7th, 2017

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The Pennsylvania Orthopedic Society just updated its guidelines for opioid prescriptions. Nestled within is a lesson for doctors and patients around the country on how to better prescribe these powerful, but addictive medications.

Pennsylvania Governor Tom Wolf, announced the changes on St. Patrick’s Day, March 17, 2017. Standing with him and top doctors from around the state was Professional Football Hall of Famer and former Steelers running back Franco Harris. “This really is an important issue. I’m not sure there is anyone in Pennsylvania who hasn’t known someone with an opioid addiction,” Governor Wolf said at the University of Pittsburgh Medical Center (UPMC) Montefiore news conference.

If that statement sounds shocking, you’re probably not a Pennsylvanian. The Pocono Record reports that 3,505 Pennsylvanians died of drug overdose in 2015—that’s a sharp uptick from just under 2,500 in 2014. Physician General of Pennsylvania Rachel Levine, M.D. notes there were 414 overdoses in Allegheny County alone, where Pittsburgh is located, and although 2016 statistics aren’t available yet, she expects them to be even higher. For 2015, numbers are higher than those who died in a car crash.

Margaret Jarvis, M.D., Geisinger Marworth Treatment Center’s medical director, says, “Pennsylvania is in the midst of a full-fledged epidemic. The prescription opioid and heroin crisis is the most significant public health crisis facing our state today.” In the U.S., doctors prescribed 240 million opioid prescriptions in 2014 alone, usually for popular painkillers like oxycodone, hydromorphone, hydrocodone, propoxyphene and meperidine.

Suzette Song, M.D., orthopedic surgeon and vice president of Medical Affairs at OSS Health in York, Pennsylvania, was on the committee who drafted the new guidelines under the guidance of Dr. Levine. As an orthopedic surgeon, she’s seen the struggle to determine the “right size” of opioid prescriptions, saying:

“In our practice (at OSS Health) we set out to more accurately determine how long our patients were actually utilizing opioids after surgery or sports injury. It became clear that many of our patients were ending up with too many ‘extra’ pills. We, much like the majority of our extremely well intentioned colleagues, were intent on trying to avoid having our patients run out of these medications too early. What we were able to do by specifically researching, with the help of our patients, was to better ‘right size’ our initial prescriptions and educate our patients as to our expectations for them.”

Update for an Epidemic

The new guidelines have holistic leanings, encouraging acupuncture, non-opioid pain medication for chronic conditions, and more exercise. The Medical Director for the Waismann Method (an opioid detox facility), Michael Lowenstein, M.D., has been practicing pain management for over 25 years. He says, “I think the new guidelines will help…(they will) help emergency room (ER) doctors feel more comfortable prescribing opioid medication.” He also points to the “SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised) test, which only takes a few minutes” as a vital tool when prescribing opioids. Dr. Lowenstein lists three major potential perks of the new laws:

“I think the updates will enable physicians to identify patients who are at risk patients for opioid abuse or who are currently abusing opioid. Combining a risk assessment protocol with the required monitoring will improve patient safety and identify abusers at risk much earlier. Also, there is a potential cost savings for emergency rooms by curbing opioid abusers from even attempting to procure opioids from ERs. If an opioid abuser knows they can only get 7 days of medication with no refills and/or if they know an opioid prescription database will be queried, it may thwart ER visits by opioid abusers. Further I think this will make it easier for ER doctors to do their jobs, and say no to potential opioid abusers: ‘This is all I can do, this is the law’.”

Targeting Sports Medicine and Athletes

However, the biggest change of all (and why Franco Harris was at the announcement) concerns athletes. Opioids are now a no-go for treating athletes with chronic pain. They are still allowed opioids for acute pain, but on a short-term basis. Harris says in six months, two friends lost their children to drug overdoses. “I’m just in shock at that because I never would have thought it would affect these families…we all think this is far from us. This is affecting everyone everywhere, and all of us have to be concerned.”

Governor Wolf, along with the Department of Health and the Department of Drug and Alcohol Programs, manages the state’s Safe and Effective Prescribing Practices Task Force.

In 2016, Wolf secured $20.4 million for the 2016-17 budget to battle opioid abuse and heroin use in Pennsylvania. The new guidelines also state that if an athlete is injured badly enough that an opioid medication is an option, they’re not eligible to continue playing. This is especially highlighted for young and amateur athletes.

The updated guidelines are designed to lower overdose deaths and addiction to prescription painkillers. They’re specifically directed at orthopedic surgeons and dentists, the most common specialties to prescribe opioid painkillers, but they’re simply a strong encouragement—not a requirement.

With the Centers for Disease Control and Prevention (CDC) noting that 60% of overdose deaths in the country are caused by opioids, it’s time to take action. Ten people in Pennsylvania die each day from overdose. Even though the U.S. is only 4.4% of the global population, we use 80% of the world’s opioid supply. It’s sometimes found in overdoses for the person to have both a medical prescription and recreational opioids obtained from family, friends, or purchased illegally. The CDC says that number of opioids prescribed post-surgery is also increasing, up 18% from 2004 – 2012.

Orthopedic Opioid Prescription Guidelines

The new guidelines specific to orthopedic surgeons warn that up to 20% of adult orthopedic trauma patients “seek prescription analgesia after discharge from multiple providers. This can speak to both lingering pain of trauma, as well as the increased propensity toward opioid addiction.” To combat this trend, the updated guidelines for orthopedic surgeons recommend:

  • Discuss weaning opioid usage with patients before surgeries
  • Set realistic pain control expectations with patients before surgery, including the idea that some amount of pain is normal
  • Consider regional anesthetic peri-operatively to reduce/remove the potential for opioids post-operatively
  • Use indwelling catheters in spaces outside the joint (i.e., scalene catheter) to reduce/remove peri-operative narcotics
  • If opioids are prescribed post-operatively, limit them to seven days. Chronic opioid therapy can become present at day 14 of consecutive use according to the CDC.

Guidelines specifically for orthopedic sports medicine surgeons and physicians include:

  • “There is no need for sports medicine specialists to prescribe opioids for the treatment of chronic pain”
  • Avoid sustained-release opioids when possible
  • Physical therapy may increase acute pain and necessitate opioid usage, but should be limited to 7 – 10 days
  • Student athletes should be informed about the risk of opioids mixed with alcohol (particularly binge drinking)
  • Athletic programs should have a written opioids policy, as recommended by the National College Athletic Association (NCAA)
  • Physicians who travel with teams out of state should know the federal and state laws regarding opioid prescriptions based on where they’re practicing

A number of Pennsylvania orthopedic surgeons have spoken out in support of the new guidelines. One spine surgeon at UPMC St. Margaret and the president of the Pennsylvania Orthopedic Society Patrick Smith, M.D. says, “It’s vital to distinguish between chronic and acute pain. Orthopedic patients suffer acute pain … we want to do it (prescribe opioids) in a more thoughtful and thought-out way.”

Levine has rallied for an “opioid stewardship” amongst physicians. She agrees that opioids can be vital and helpful, but are easy to over-use. “There are too many people with minor injuries who are getting longer prescriptions.”

NFL Lawsuit

It’s no coincidence that these updates are nipping at the heels of a recent class action lawsuit filed by over 1,800 current and former National Football League (NFL) players against 23 NFL teams. The case is pending in northern California’s U.S. District Court. The plaintiffs allege they have long-term joint and organ damage from “improper and deceptive drug distribution practices by the NFL.”

Court filings show that team leaders and affiliates allegedly dispensed opioids and other painkillers, along with prescription-grade anti-inflammatory drugs, in very high numbers.

According to NFL medical advisor Lawrence Brown, M.D., M.P.H., in 2012, the average NFL team allegedly prescribed around 5,777 nonsteroidal anti-inflammatory drugs and 2,213 controlled medications to players. If those figures were averaged, each player would have received six or seven pain injections or pills every week during the NFL season—but it’s unlikely that the alleged doses were averaged.

The Washington Post, which reviewed the sealed documents, reports that there are “multiple instances [backed by testimony and documents] in which team and league officials were made aware of abuses, record-keeping problems and even violations of federal law and were either slow in responding or failed to comply.” The teams are accused of abusing opioids and other painkillers. One issue in the class action lawsuit are allegations that “traveling physicians” aren’t aware of and/or don’t follow local opioid and painkiller regulations—however the bigger issue is that trainers allegedly took on the role of “pharmacy dispensers.”

According to testimony by the Pittsburgh Steelers’ team doctor and former president of the NFL Physicians Society, Anthony Yates, M.D., “A majority of clubs as of 2010 had trainers controlling and handling prescription medications and controlled substances when they should not have.” A 2009 email from head trainer of the Cincinnati Bengals’ Paul Sparling included in the filings reads, “Can you have your office fax a copy of your DEA [Drug Enforcement Agency] to me? I need it for my records when the NFL ‘pill counters’ come to see if we are doing things right. Don’t worry, I’m pretty good at keeping them off my trail!”

An NFL spokesperson Brian McCarthy says the allegations have no merit.

The Average Patient

Associate vice president of strategy and innovation at Geisinger Health System Michael A. Evans, RPh, has noticed a shift to increased reliance on opioid prescriptions since the 1990s. The reason? One theory is that most insurance plans won’t pay for so-called alternative therapies like exercise and acupuncture—the exact recommendations in the latest guidelines. They will pay for prescribed pain medication.

There’s also a discrepancy in how doctors and patients see “pain-killers.” For patients, the name implies that the drugs will stop the pain entirely. Doctors generally consider pain killers to be synonymous with pain management, or a means of bringing pain levels to a manageable level. When patients still have pain, even with opioids, they’re more likely to seek out other means of supplementing their prescription, which can lead to addiction and overdose.

The Street Connection

Opioids and heroin are strikingly similar on a molecular level. However, heroin is cheaper and more accessible than opioids. Heroin gives users instant relief when injected. This “opioid alternative” brings with it all the risks of a street drug including risk of blood-borne diseases like HIV or Hepatitis C in addition to addiction and overdose risks.

One self-proclaimed opioid user, abuser, addict and former full-time street seller who goes by “Bianca” in Beaverton, Oregon, describes the current state of opioid street popularity and sales in the Portland, Oregon metro area:

“Since the demise of OxyContin, which resulted in a time release makeover that resembles squashed skittle if you try to tamper with its perfectly round shape forced users to take it only orally, the desired pill of choice is slightly smaller and less climactic: Oxycodone. Starting at 5mg, oxycodone allows its users to crush, snort, or smoke its contents…currently, street value in the Portland area ranges from $1 per mg - $1.25 per mg. The original formula of OxyContin that was replaced by a shell of impenetrable titanium, now known as Ops, retails on the street for about $0.50 per mg.”

Bianca also says that no matter the cost, “Users will still use. They will collect extra bottles…opioids will never die.”

Former U.S. Secretary of Health and Human Services in Washington, D.C. Sylvia Mathews Burwell says the epidemic won’t improve until there are better educational resources, updated guidelines, and training to help health professionals make more informed decisions when prescribing opioids. The Pennsylvania guidelines are a step in the right direction, and can be used by medical professionals around the nation and world.

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