I recently (here) blogged about the devastating rise in overdose deaths from prescription opioid medications. This is no longer a hidden danger in our society. President Obama has proposed $1.1 Billion to address this issue. Presidential candidates from both political parties have frequently mentioned the opioid epidemic in their stump speeches and even in their primary victories. The Centers for Disease Control have recognized this alarming epidemic as one that is largely self-induced by the medical and pharmaceutical industries. In 2012, health care providers wrote 259 million prescriptions for opioid drugs—enough for every American adult to have their own bottle of the pills! This has lead to drug overdose being the leading cause of injury death in 2013. Among people 25 to 64 years old, drug overdose caused more deaths than motor vehicle traffic crashes. Given that the number one reason for an opioid prescription is Low Back Pain we can only describe this is as an utterly epic failure.
What is our role in reversing this process as we go forward clinically? It is well established that PT First for Low Back Pain decreases opioid use. Our continued efforts across all fronts in getting this message out to consumers, payers, and the medical community at large remains a top priority. However, what about the patient sitting right in front of you today? During your intake exam do you currently see the Oxycodone (OxyContin and Percocet), Hydrocodone (Vicodin) or Fentanyl (Duragesic) as a red flag in your history? Given the current statistics on the likelihood of overdose or death from these drugs I would urge each of us to place these drugs into the category of a red flag.
Once we identify red flags we are left with a decision of what is the next action step. As a start point let’s focus on the patient with LBP and a relatively new prescription of these drugs (4 weeks or less). The most important thing is that you must first establish trust and credibility with your patient, which is gained by exceptional communication and true environment of caring and compassion. This is not that difficult! As a side note yesterday I had the most hilarious encounter with a middle-aged patient (with a persistent pain problem) and her husband. As I was nearing completion of the visit, the husband says to me, “You have the best listening skills of anyone we have ever encountered in medicine.” Then the wife commented, “Well in medicine, that isn’t saying much!” We all laughed so hard it hurt. It is funny how humor gets at the truth of what ails healthcare. Lets get back to our patient with LBP on opioids that you have established a reasonable therapeutic alliance with. It is now time to find out the details of how and when they are taking these drugs. Once that is established shift to the open ended questions on function and pleasure such as:
Are you doing more while you are on the medications?
What things are you not doing when you are on the medications?
Do you enjoy taking the medications or would you rather not take them?
Though patient and situation dependent this is usually the time to begin probing for understanding. That again is best done with questions.
Do you know how addictive these drugs can be?
Do you think you could get addicted to these?
Are you aware that prescription overdose deaths caused more deaths than motor vehicle crashes?
This is usually enough to get the conversation started and gain an understanding of the patient’s perspective on using these drugs for their LBP. The next step is to complete the history and physical examination. A detailed examination is in itself therapeutic and increases the therapeutic alliance. At this point placing the plan of care in the context of the red flag opioid use is critical. Open discussion and framing of the situation in terms of real risk is necessary. Your plan should be very clear that a key goal is immediate reduction followed by termination of opioid medication use. In closing, I have provided a quick educational video that might be helpful for you or your patients in understanding the drawbacks of these medications. We are at a critical juncture; please provide any comments or useful suggestions to help stem this epidemic.