Striking a balance for patients in pain

"Opioids Killed Prince."

The statement on a mainstream news site struck me in large, bold lettering. The tragedy is another high-profile reminder of the dangers of one of the most commonly prescribed medications in our society.

Prince was found with fentanyl in his system. Fentanyl is typically used in IV form for surgical procedures and outpatient procedures, but it can also be used in patch form in an outpatient setting for chronic pain. For severe cancer pain, the medication is also available as an under-the-tongue spray or lozenge. High doses of the medication can be fatal, especially if mixed with other opioids or if it is escalated too rapidly.

The media seem to be portraying Prince as a victim of forces out of his control, and it appears he was seeking the treatment of an addiction specialist in the days before his death. However, as a pain medicine physician, I was concerned with how Prince ended up in the tragic situation.

Was Prince’s fate another example of physician negligence, or was this an example of a wealthy patient manipulating the health care system? No matter what the underlying cause, it is an important opportunity to discuss the role of opioids in health care and educate patients and other doctors on their appropriate use. 

In 2012, over 259 million prescriptions were written for opioids. From 1999 to 2014, more than 165,000 patients died from opioid overdose. In 2011, more than 420,000 emergency department visits were attributed to opioid misuse. All these reported numbers reflect the growing problem of opioids in our country.

The Centers for Disease Control and Prevention released a set of guidelines in early 2016 addressing the use of opioids in the outpatient setting and analyzing studies of opioids from the last several years to develop the set of recommendations. The most eye-opening results from the CDC document reveal that there are no studies that prove opioids reduce pain scores and improve patient function in the long term (more than one year).

Also, long-term use of opioids leads to the patient developing a physical and psychological dependence over time and can result in fatal side effects like difficulty breathing, leading to death. However, the CDC recognizes that opioids can be useful for certain patients in certain situations. Sometimes a patient has other medical conditions that prevent the use of other commonly prescribed medications for pain like anti-inflammatories, nerve modulating medications and muscle relaxants. In those situations, opioids may be an appropriate option if the patient and physician discuss the limitations and risks of the drugs.

There have been recent changes in South Carolina to improve physician awareness of how patients are using opioids and improve education for both physicians and patients. On June 6, 2014, South Carolina Governor Nikki Haley signed Senate Bill 840 into law. The new law requires all dispensers of opioids (pharmacies) to report prescription monitoring data daily. The data is reported in SCRIPTS, the South Carolina Reporting and Identification Prescription Tracking System.

The SCRIPTS database shows information for controlled substance prescriptions, including the prescriber and dispenser of the substances. SCRIPTS is available to all physicians who prescribe opioids, and the use of the system is recommended under the new CDC guidelines.

SCRIPTS allows physicians to monitor how many prescriptions a patient has received and monitor for patterns of misuse. The new law also requires physicians to obtain further education related to the prescription and monitoring of controlled substances. MUSC has hosted the new educational course and will continue to give physicians in our area the chance to advance their understanding of opioid medications.

In the pain clinic at MUSC, we continue to use opioids for selected patient populations. Each patient is assessed individually for candidacy for opioid prescription. Some pain disease states, like fibromyalgia, have been shown in the literature to not improve with opioid therapy, and we seek to educate patients with these diagnoses to try other avenues of treatment. 

If opioids are used, we provide the patient with a pain contract with clear agreements and guidelines for the prescription medication. We use urine drug screening to ensure the medications are being taken appropriately. We are following the new CDC guidelines and performing the necessary documentation to stay in compliance with the new South Carolina laws.

A difficult reality for some patients is the understanding that we cannot always completely cure their pain, and it may be necessary to live with some degree of pain. Opioids are dangerous medications, and the benefits of their use are sometimes outweighed by the magnitude of potential side effects, including difficulty breathing, sedation and even death.

Patients can be advocates in their care and be informed of the type of training their physician has received. We encourage patients to discuss with their physicians the goals of treatment with opioid medications as well as a plan of action when the dose exceeds levels recommended by the CDC. Patients may also request an evaluation by a pain medicine physician.

It is sometimes difficult for a patient to discern the appropriate type of physician to seek out among the deluge of misinformation regarding qualifications in the pain medicine specialty. There are multiple boards that grant certification to physicians in the field of pain medicine, including the American Board of Anesthesiology, the American Board of Interventional Pain Physicians and the American Board of Pain Medicine.

Each board requires a certain amount of experience in pain medicine and requires the physician to complete a written certification exam. The American Board of Anesthesiology additionally requires the physician to have completed an additional 12 months of training in an American College of Graduate Medical Education-accredited fellowship program prior to certification with a written exam.

Opioids can be beneficial medications if used appropriately with a clear understanding of their risks and limitations. Better communication between patients and their physicians will help to prevent tragedies like Prince’s death in the future. 

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Editor's note: Inside Track is a periodic column by MUSC faculty and staff about the intersection of health matters and our lives. Dr. Ryan Nobles is a chronic pain management physician at MUSC Health.