D

r. Phillip Chang’s emergency room epiphany started with a wreck.

A patient admitted to the trauma unit of the University of Kentucky Albert B. Chandler Hospital was prescribed opioid painkillers for injuries he sustained in a nasty car crash. Within days, the patient returned for more pills, the first of many trips to multiple doctors.“This guy was not a substance abuser before,” Chang said. “Because of the pain medicine, he became one. We asked ourselves: Were we responsible for it?”

The incident prompted the emergency department to issue new guidelines that opioids be prescribed only as a last resort. It has worked so well in the past two years that Chang, now UK HealthCare’s chief medical officer, is hoping to roll out the same protocols in 10 health systems across the state, which could change practices in dozens of hospitals.

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Similar changes are sweeping the nation. With heroin deaths now surpassing gun homicides, hospitals have been rewriting protocols and retraining staff to minimize prescriptions of narcotic painkillers.

Emergency departments, in particular, feel a heavy responsibility to take action: Collectively, they’re one of the top prescribers of opioids nationwide, behind family and internal medicine practices.

And so, this month in eastern Mississippi, Baptist Memorial Hospital-Golden Triangle began limiting opioid pain medication only to patients in the most acute pain. St. Joseph’s Regional Medical Center in New Jersey, which has one of the nation’s biggest emergency departments, is pushing to replace opioids whenever possible with less addictive treatments, like nerve blocks to dull pain. The center has even hired a harpist to fill the noisy halls with calmer notes.

It’s all part of a push “to stem the tide of the opioid epidemic,” said Dr. Jay Bhatt, chief medical officer of the American Hospital Association.

But it’s not always easy.

“Patients say, ‘Doc, I want the strongest thing you’ve got,’” said Dr. Daniel del Portal, an assistant professor of clinical emergency medicine at Temple University in Philadelphia. “But patients don’t always understand the risk the strongest pain medicine can create. Patients don’t appreciate that until it’s too late.”

At the UK hospital in Lexington, Ky., Chang said the philosophy used to be to give an opioid painkiller right off the bat. And then, he said, “we’d just give more of it.” Slowly, he got doctors, pharmacists, and nurses on board with using non-opioid pain relievers like Advil or Tylenol first, and trying multiple regimens before finally considering something stronger. He also trained them on how to explain the shift to patients.

“Sometimes it’s impossible to bring pain to zero,” Chang said. “But we’re trying to make it tolerable.”

Since 2014, Chang gathered data on 900 patients treated after the new policies were implemented. He was surprised at what he found.

The trauma unit managed to nearly halve the amount of opioids administered to patients who had no prior history of chronic opioid use. That might be helpful in a state that had the third-highest death rate from drug overdose in 2015.

However, the new guidelines had little impact on prescriptions for patients who were already chronic opioid users prior to admission. So UK has stepped up training to help emergency physicians, who are often focused on the immediate need to save a life, to think more for the long term. That might mean prescribing fewer opioids for drug-dependent patients and guiding them toward substance abuse treatment when they’re ready to be discharged.

Chang plans to roll out these new practices across other units of the hospital and then, if all goes well, take them to the statewide alliance of health care networks.

“Everyone of us needs to feel like we’re responsible,” he said. “The feeling of, ‘I’m not an addiction specialist; that’s not my problem’ has to go away.”

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  • So let me understand this. A stabbing patients shows up in the ED the knife is in the neck so I am called. I see that I am to spend the next 5 hours in the OR dissecting their neck to reclose stuff that is opened and reconnect stuff that is disconnected and yet when I am done I am supposed to prescribe Tylenol of worse some Cox-2 inhibitor that will then get me a lawsuit for cardiac issues or I am to write for an NSAID and get a call in 30 days from the ED that the guy is back with a gastric bleed and what do I want to do with him.
    Yes people are in pain and yes they deserve their proper pain meds and if they are so weak and intolerant that they prefer to be on meds rather then get off their sixes and get back to function then how is that medicine’s issue? The data suggests that most prescription narcotic patients do NOT in fact become heroine addicts so where is the connection. Yes prescription narcotic patients become addicted narcotic patients but that isn’t our issue. If they are in pain AND they want us to help then we do. If they can tolerate it then they don’t come to us to ask which is the REAL issue. Stop looking for pain relief and start look for pain reduction. If you have been in a car accident and have pain you are going to likely be in pain for a long time the question is do you want to risk the addiction or can you tolerate the pain? Either way it is the patient’s call. I can’t even imagine not prescribing for my patients who are in pain because the rules say I need to try lesser options until they run out
    I a surgical oncologist and my patients are not going to be helped by Aspirin and NSAIDs
    Dr D

    • Thank you doctor. Pain is very complex. You can’t just cookie-cutter patients into a one size fits all. It has gotten bad enough in Las Vegas, NV that my doctor pain management friend is getting referrals from oncologists because they are
      so afraid of the CDC Guidelines, the DEA, etc. In over 35 years, its never happened to him

  • I am concerned at the reach from heroin to prescribed pain medicines. The statistics show only a very small percentage of actual patients move from pain medicines to heroin. And the real problem here is HEROIN, not prescribed pain medicines. Yet the focus is on restricting prescribing??? what is going on here? can anyone not see the obvious lack of reasoning, problem solving skills, and logic? how are you going to reduce addicts using heroin by denying proper and adequate pain therapy to need pain patients??

  • So ER’s are just going to leave people writhing in pain? Great. That will save Trump some health care money …… at our expense again.

  • Here’s the big payoff after months of the ludicrous “opioid” panic: People in pain will be sent home from hospitals without prescriptions for main medication. Congratulations.

  • Thank you for making the change. We’ve been asking MDs not to make opioids a first choice for pain for years. My husband fractured 6 ribs from a fall and they wanted to give him morphine in the ER;he declined and did fine on po Tylenol. My pregnant daughter was told to accept morphine for her kidney stones , but declined and was pain free on IV Tylenol. This pregnancy, they suggested morphine at 29 weeks when she was having “uterine irritation”; she declined and stayed pregnant another 6 weeks without any problem.
    Unfortunately, my son was given Vicodin after his wisdom teeth were removed, then Percocet in the ER for a foot injury, and he paid the price. It took 10 years out of his life. Please think before you write a prescription. It could be your brother or son in a doctor’s hands one day.

  • Unbelievable. So because I’m in pain management I don’t deserve treatment for my pain if I show up with a broken leg, an appendicitis, or kidney stones. Instead I get a referral to rehab even though I’m not an addict. This anti-opioid b.s. has gone too far when doctors are patting themselves on the back for torturing their patients.

    • I totally agree. People in pain management don’t deserve to not be treated, turned away, and given a number for detox or rehab. What an insult on top of needing help.You doctors are making the heroin epidemic so much worse by making people in chronic pain look elsewhere for relief. Just wait, it’s going to get a hell of a lot worse.BECAUSE OF YOU!!!!! JUST WAIT!!!

    • Do you really believe that people with Chronic Pain have not tried every therapy,multiple times, before we were “DUMPED” on Pain Management Drs that do their best to make sure they do what they can for us. I don’t want to take opiates. I want a CURE!!!!!

    • No offense, but this is poor medical advice. And quite disrespectful to the pathologies, circumstances and real issue pain patients deal with. 1) most patients have tried some chiropractic care, and it has not been effective enough, nor has it been enough to completely replace prescribed pain medicines 2) in many cases, chiropractic care is contraindicated, making a delicate situation worse , even deadly 3) are you REALLY suggesting that people coming in from accidents, in pain, unable to move from ghastly pain leave the ER to go to a chiropractic care clinic instead? (this is the part most people would say “are you insane?”) I can only surmise that you actually dont KNOW enough ABOUT chiropractic care yourself to spout such a harmful and ignorant comment.

    • Concerned Pain Patient: You appear to be over-reacting. Obviously you are unaware that 30% of pain patients are taking opioids for chronic LBP, not acute as you suggest. While no treatment is a cure-all, research has proven spinal manipulation is the “treatment of choice” for 85-90% of such cases; plus if you were to read the guidelines, our track record is far superior to drugs, shots, and surgery, and a lot safer. And to ease your fears, I have been practicing chiropractic for 37 years and written a few articles/books on this issue that you can at The Medical War Against Chiropractic @ http://chiropractorsforfairjournalism.com/Books_by_JCS.html

    • Chiropractic care not covered by Medicare/Medicaid right? A LOT of
      insurers don’t cover chiropractic care. A lot of alternatives suggested by the
      CDC aren’t covered. I know I can’t afford chiropractic care.

    • Joe Benotz: In fact, chiropractic care is covered by Medicare and has been since the Nixon Administration. BCBS and most group health ins. also cover chiro care as well as many military bases, workers comp. and the VA. Even if they didn’t cover chiro care, research shows it is still the preferred treatment for LBP (excluding red flags). Plus, chiro care is perhaps the least expensive treatment when you consider opioids painkillers do not correct the underlying joint dysfunction; for the price of one ESI (which has not been approved by the FDA for LBP) you can get a month’s care in a chiro office; and consider 75% of fusions for DDD fail according to JT Anderson’s research. Just as dentistry isn’t covered by many insurance, people still find a way to afford it. I find the same mindset among many patients who realize nondrug, nonsurgical chiro care is the best buy compared to drugs, shots, and surgery. The bottom line: overcome any chirophobia and give chiro care a try. You might enjoy my article about The Quiet Epidemic @ http://chiropractorsforfairjournalism.com/The_Quiet_Epidemic.html

  • This was a fine article about our opioid problem:
    http://www.latimes.com/opinion/op-ed/la-oe-hari-prescription-drug-crisis-cause-20170112-story.html
    “There are two quite different stories about why there is a prescription drug crisis in the United States, and why opioid-related deaths have quadrupled since 1999. At some level, you are probably aware of both. …They clash, and imply the need for different solutions. Thousands of lives depend on which of these tales is correct. Although this is a coherent story, put forward by serious and thoughtful people, there are some key facts that don’t fit. …
    “Here’s the first story. It has been endorsed by some excellent journalists and broadcasters, from Sam Quinones to HBO’s John Oliver. It goes, in crude summary, like this: Starting in the late 1990s, a handful of pharmaceutical corporations promoted prescription opiates as the solution to America’s physical pain. Large numbers of people then started to take these drugs — and because Oxycontin and Percocet and the rest have such powerful chemical hooks, many found themselves addicted. …
    This narrative leads to a clear solution: Restrict prescription opiates and prevent addicts from taking them. Since the drug caused the problem, ending access to the drug humanely will end the problem….The second, clashing story goes, again, crudely, like this: Opiate use is climbing because people feel more distressed and disconnected, and are turning to anesthetics to cope with their psychological pain….We can’t solve the opioid crisis if we continue to simplistically blame the drugs, or the people who supply them. That’s a misunderstanding of what is really going wrong. “

  • This is such a bad idea. I’ve known of a couple of people who didn’t receive opioids for acute pain relief after trauma (because they looked like a “hippie” – the one I knew best was as “straight” a guy as you could imagine in reality), and it was really horrible. One I read about in a non-fiction book about car accidents thrashed around after a bad auto accident and re-injured his spine more because doctors decided he was a druggie as he asked for drugs and suffered damage.

    • I often leave appointments wishing the doctor could be in my body for just one hour! I’m so sick of worrying if I’m dressed right, have too much or too little make up on, if my hair should be up or down, glasses or not? Why should I have to worry about making the right impression when I’m in so much pain I can hardly dress myself. I’ve also found myself praying to get an older doctor with more experience than a young doctor who has been taught to go by the book rather than looking me in the eye and seeing what daily torture is! I’m not looking to be pain free, just reduced manageable pain so that I can take care of myself and my family.
      Doctors and the CDC now don’t want to be responsible for the epidemic they started. I had so much Oxycodone pushed on me 15 years ago that I have quite the tolerance today. I still have serious back pain, and now you want to restrict the amount I need? Making me feel like it’s my fault? Screw you doctors, CDC, DEA!!! By the way I’m at a much lower dose, and suffering every day, left with a failed back surgery that I was pressured into getting as nothing worked for pain like my pain meds.
      Now everything is worse! Thank you very much!!

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