10 questions and answers with a Mayo Clinic anesthesiologist
Tracy E. Harrison, M.D., a pediatric anesthesiologist at Mayo Clinic's campus in Rochester, Minnesota, specializes in acute pain management, chronic pain rehabilitation, and hospice and palliative care.
How would you characterize the state of the opioid crisis in our country?
I think that even given the opioid issues we are having right now, it's still very important to appropriately and adequately address acute pain resulting from trauma. That may be with opioids and multimodal analgesia. I think paying attention to the injury mechanism's severity and treating the pain adequately, appropriately and having good expectations is important at the outset.
Where I think we get into trouble with the opioid issues we are having right now is using opioids in longer term situations where the evidence for opioid use is not as strong and adverse side effects result.
Is the U.S. using opioids more than in other countries?
Yes, we use the vast majority of opioids available. It's staggering looking at the United States' opioid use percentage compared with the rest of the world's. In other countries, it's challenging to obtain opioids, even for very legitimate uses.
Are opioids being used appropriately in medicine in our country?
Our current problem came about from physicians ultimately wanting to do the best for the patient, relieving pain. But pain is a complex experience, and not all pain needs to be addressed by using opioids. As physicians, we need to do a better job setting expectations for pain resolution after trauma.
Although each situation is different and treatment needs to be individualized, we might consider setting a limit for the duration a patient will be on opioids after trauma or a surgical procedure and making sure we use nonopioid medications as adjuncts, if opioids need to be used at all. For chronic pain, such as headache and abdominal pain, often we want pain resolution so badly that we prescribe an opioid, which in many cases has not been proved very helpful for decreasing pain and can result in worsening of functioning and additional side effects.
Is there a difference between physical dependence and addiction?
Yes. Physical dependence on an opioid occurs in humans and in lab animals. It happens when a patient has received opioids for approximately five days or more and develops withdrawal symptoms — such as tachycardia, goose flesh, diarrhea or diaphoresis — when the drug is withdrawn.
It is very different from addiction, which is drastic behavior an individual exhibits to obtain opioids, such as stealing medications, buying street drugs to treat pain or engaging in risky behavior in exchange for drugs.
How should the opioid crisis be addressed?
This crisis has to be addressed on a number of levels:
- In an acute setting, we have the responsibility to treat pain appropriately. For a patient undergoing surgery or who suffers significant trauma, opioids may be indicated initially. We need to be vigilant for side effects, such as respiratory depression, sedation, nausea, constipation and pruritus. At the same time, we need to consider nonopioid medications as adjuncts to treat pain via a different modality.
- We have to provide patients with appropriate expectations regarding the time frame with which opioids will be prescribed in every setting, as best we can. We need to educate patients that opioid discontinuation may be necessary prior to complete resolution of pain and encourage nonopioid analgesics — such as ibuprofen or acetaminophen — to treat pain, if appropriate.
- We need improved communication with our patients regarding the pain experience and focus on return to functioning, despite unresolved pain.
- We must communicate that nonpharmacologic treatments for pain, such as ice, heat, diaphragmatic breathing or meditation, can be effective and part of a thoughtful pain management plan.
What do you recommend to improve communication with patients about pain and set appropriate expectations?
Be clear on the goal in your own mind and communicate it to your patients confidently. We need to explain to our patients — and understand for ourselves as providers — that appropriately managed pain does not mean zero pain. Patients and their providers often have fear when pain does not resolve as quickly as expected. We need to communicate it may be very normal and assure the patient any ongoing reason for pain has been treated appropriately.
We also can ask patients, "What is your comfort goal?" This goal is the pain score on the Numeric Pain Rating Scale, where 0 is no pain at all and 10 is the worst pain imaginable, above which it would be difficult to be up and out of bed, sleep, eat, or visit with friends and family. Then we can attempt to get below that level with strategies described above. I think one of the most powerful strategies is informing patients that some ongoing pain may be normal and expected.
Tell patients what to expect regarding pain, while being reassuring. I tell my patients in the preoperative period, for example, "You could have pain after your procedure, but we will do everything possible to manage your pain using medications and other strategies, while attempting to avoid significant side effects." Also, you might say, "As you get up and start moving around, it's very normal to have pain, and your treatment team will do everything possible to ensure you regain your mobility, even if slight pain persists."
Remind patients function is key to recovery. We need to encourage patients that despite having pain, they need to function appropriately for the time. For example, if the surgeon expects the patient to be up and out of bed the day after surgery, this should be conveyed presurgically to the patient. The provider's responsibility is then to provide medications to reduce pain so the patient can accomplish this task, such as providing a pain medication dose 30 minutes prior to physical activity. And encouraging patients that mobility is important in their ability to heal after a surgical procedure or trauma is an important aspect of their rehabilitation.
Establish time limits before prescribing. We need to start talking to patients about expected opioid use duration after surgery or trauma. It is not beneficial to expect patients will take opioids until their pain resolves. There are so many factors playing a role in the pain experience that this practice, in part, may be responsible for the opioid crisis we are facing today.
What can be done on trauma services to avoid contributing to the opioid epidemic?
First, we should develop guidelines related to trauma mechanisms and opioid prescription. The trauma's nature often guides our expectations of pain intensity and opioid need. For example, an individual suffering a dog bite will have a different pain experience than someone involved in a motor vehicle accident. Often providers can use past patient experiences to guide their relative expectations of pain duration and standard length of time the average patient will take an opioid for pain.
Second, it is known that we as providers generally prescribe far more tablets than a patient will need, and this opioid medication surplus is a significant risk to society members. We should prescribe only the amount of opioid tablets that seems appropriate for the given problem and ask the patient to follow up if pain continues to be an issue. Often the patient is fearful that pain has not resolved completely, and a conversation and reassurance from a provider may be very effective.
How should opioids be given to patients? Do you have any thoughts on selection or dosage?
I recommend the World Health Organization ladder of analgesia strategy: For example, mild pain is treated with nonopioid analgesics such as acetaminophen or ibuprofen. Moderate pain is treated similarly but with the addition of an opioid, if appropriate. Nonpharmacologic treatment with ice, heat or diaphragmatic breathing is considered for mild pain to decrease medication amount and side effects. More-intense pain may be treated with a stronger opioid, and instead of p.r.n., providers should consider scheduled prescribing, especially for the first day. Providers then reassess pain scores and ability to be physically active, rest or other functions, and tailor plans to patients' responses.
And dose is important: Always start at the lowest pain medication dose possible, titrating upward as needed. Also, for opioid-naive patients, give short-acting, immediate-release opioids versus long-acting, sustained-release opioids or methadone.
What do you suggest for follow-up when an opioid is prescribed for a patient?
Patients do better and end up taking fewer opioids if they follow up with their physicians and understand opioid treatment expectations from the beginning. Encourage nonopioid medications and nonpharmacologic pain treatments, as well as some physical activity every day. Discourage patients from being inappropriately sedentary during the healing process.
When considering trauma centers in southern Minnesota, what other advice would you give physicians related to opioid use in their practices?
- Validate the patient's report of pain and the fact that it is real.
- Educate patients about side effects and how to minimize them, such as using stool softeners to prevent constipation, and when to report to their physicians.
- Set realistic limits for expected opioid treatment duration and how to taper off safely.
- If you are prescribing opioids, be sure any pain improvement corresponds to functional improvement.
Dr. Harrison is the medical director of Mayo Clinic's pediatric pain rehabilitation program. She also serves in Pain Medicine, Mayo Clinic Children's Center, and Anesthesiology and Perioperative Medicine.
For more information
WHO's cancer pain ladder for adults. World Health Organization.