Anesthesiologists Urged to Reduce Opioid Prescribing

Anesthesiologists Urged to Reduce Opioid Prescribing

One of the nation’s largest groups of anesthesiologists has joined a growing list of medical organizations in urging its members to reduce the prescribing of opioid painkillers.

bigstock-Asian-American-male-doctor-exp-12827732The American Society of Anesthesiologists (ASA), which has over 52,000 members, says opioids should not be prescribed as “first-line therapy” to treat non-cancer pain.

The recommendation is one of five adopted by the society as part of the Choosing Wisely campaign, which encourages physicians and patients not to use medical tests and procedures that are overused or inappropriate.

“There has been a far greater use of opioid medications than the evidence suggests there should be.  In most cases, pain management should be built on a foundation that does not include opioids, especially in the setting of chronic pain,” said ASA President Jane C. K. Fitch, MD.

“In many situations, the risks of chronic opioid use are far greater than the degree of relief obtained by the patient.  In most instances, physician anesthesiologists should use other therapies to help with pain management before resorting to opioids.”

Fitch and the ASA believe non-drug treatments, such as behavioral and physical therapy, should be tried before analgesic medication is used to relieve pain. If the non-drug treatments don’t work, physicians should then try non-opioid pain relievers, such as non-steroidal anti-inflammatory drugs (NSAIDs) or anticonvulsants, before resorting to opioids.

“We want to make sure physicians are considering all options before prescribing opioids, and only doing so when it is absolutely necessary and the desired outcome will be achieved. Even then, the significant risks of chronic opioid use must be discussed with the patient,” Fitch said in an email to National Pain Report.

“Not only is the evidence lacking that patient outcomes are improved with chronic opioid use, but there are many side effects. These include drowsiness, lethargy, constipation and endocrine effects to name a few. In addition, there is a far greater risk of misuse, abuse and addiction than previously suspected.”

In addition to only prescribing opioids as a last resort, the ASA also recommends the following:

  • Physicians and pain patients should sign written agreements that identify the responsibilities of each party (such as urine drug testing) and the consequences of non-compliance with the agreement.
  • Avoid imaging studies (MRIs, cat scans or X-rays) for acute low-back pain in the first six weeks of treatment. Most low back pain does not need imaging.
  • Avoid irreversible interventions for non-cancer pain, such as peripheral chemical neurolytic blocks or peripheral radiofrequency ablation, which have significant long-term risks of weakness, numbness or increased pain.
  • Avoid intravenous sedation for diagnostic and therapeutic nerve blocks, as well as joint injections, spinal injections and epidural steroid injections as a standard practice.

“In the past few years, there have been increases in the use of spinal injections, leaving some concerned about the risks of these procedures,” said Fitch.

“There are excellent guidelines available for treating low back pain as well as low back pain with radiculopathy that show positive outcomes with conservative treatment alone, such as physical therapy, exercise, and medication. However, if pain persists and injections are warranted, physician anesthesiologists should continue to use them when they are necessary and appropriate as part of an overall comprehensive treatment plan.”

Doctors prepare to make anesthesia“This is definitely a step in the right direction,” says Dawn Gonzalez, whose spine was damaged by an epidural during child birth. She now suffers from arachnoiditis and is an advocate for Arachnoiditis Society for Awareness and Prevention (ASAP).

“The more and more interventional procedures are used, namely steroid injections, the number of injured and disabled patients climbs at an extreme rate. I have been disabled for life from having needles in my spine. ESI’s (epidural steroid injections) as a first or even second line of defense needs to closely evaluated,” Gonzalez said.

ESI’s are increasingly being used to treat back pain of all kinds, with nearly 9 million spinal injections in the U.S. in 2011. Several studies have found that steroid injections increase the risk of spinal fracture and do little to relieve back pain.

“Steroid injections have been shown no more effective long term than placebo, or nothing at all. Not to mention the risks of bone fractures and tissue and bone degradation they bring on. It’s a sure fire way to make a surgical intervention necessary,” adds Gonzalez.

The ASA may have its work cut out for it in persuading physicians to adopt more conservative treatment options. A recent study published in JAMA Internal Medicine found that doctors who treat back pain are prescribing more narcotic painkillers, not less, and ordering too many unnecessary diagnostic tests,

“Despite numerous published national guidelines, management of routine back pain increasingly has relied on advanced diagnostic imaging, referrals to other physicians, and use of narcotics, with a concomitant decrease in NSAID or acetaminophen use,” said lead author John Mafi, MD, of Harvard Medical School.

Authored by: Pat Anson, Editor

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Henry Madison

Dave says:
January 25, 2014 at 5:32 pm
Lorimer Moseley is a neurocentric practitioner and Sarno, like Moseley is a reductionist, as well. Amazing how modern medicine made fun of medicine in the 1800′s for its “snake oil”- only to replace it with modern reductionistic “snake oil”. Pain is not so easily reduced to simple formulas of Moseley or Sarno or the “pain specialists” or those with poisononous enthusiasm for “silver bullets”.

OK Dave. Please explain to me then the pathophysiology of chronic pain that makes as much or more sense than what Moseley says. I’m willing to learn. Thanks.

Dave

Its obvious the anesthesiologists- who mistakenly view themselves as champions of pain care encourage more of the same suboptimal pharmacological treatment of pain- and are deluded by exaggerating the power of drugging painfull conditions instead of looking for causes and cures. My don’t they just love to retard the cure to augment the profits. Despite some technological progress in pain care- there has been little moral progress and anesthesiologists- like other members of “the house of medicine” still care and do little for people in pain beyond focus on quick profits.

One more thing: I am happy that the article admitted the risks and dangers that go along with epidural steroid injections. I have 5 neuropathic pain syndromes that are intractable and 3 out of 5 were a direct result of epidural steroid injections. BUT the important thing to note, especially in light of the subject of this article: The epidural steroid injections were many and were “forced” because the worker’s comp carrier wanted to avoid “narcotics.” Even my spinal surgeons advised against the injections recommending “lifetime pain management regimen including long term opioids.” Because of the avoidance, I now have a spinal cord encased in nearly 5 inches of scar tissue, tearing with every move I make for the rest of my life. NOW what do you think are the “dangerous drugs?”

When I saw the headline of this article show up in my Twitter feed, my blood began to simmer as I thought, “Here we go again!” I knew I would have to come read the entire article now and take the time to comment because the article would most likely be based on some practitioner’s favorite research: the practice of fear and no real UP-TO-DATE science. Do you want to know how I could assume this? For one thing, the report from the Institute of Medicine (IOM) states as much in their 20111 report entitled, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research” (that link is as follows) http://bit.ly/OK0o3q. This report was groundbreaking and stated in the summation that, ” Better data are needed to help shape efforts, especially on the groups of people [in pain] currently under diagnosed and undertreated, and the IOM encourages federal and state agencies and private organizations to accelerate the collection of data on pain incidence, prevalence, and treatments. Because pain varies from patient to patient, healthcare providers should increasingly aim at tailoring pain care to each person’s experience.” Nothing in this article showed me that these IOM recommendations were driving the request, no, the “urging” that the ASA is giving their members. The anesthesiologists are to roll back a treatment with no thought to “tailoring pain care to each person’s experience.” Isn’t that correct? Yeah, that’s BAD for the patients, Docs. The IOM goes on in the summation to confirm that, “there are major gaps in knowledge about pain across health care and society alike.” Thus we still have to deal with the ASA and critics like Henry Madison above, who spouted forth every argument that the anti-opioid crowd gives. Unfortunately, even if they are well meaning the objections are NOT weighed with all of the other evidence like that of the IOM report and many other independent thinkers have brought to the surface over the past few years. An article by reporter Radly Balko is the second reason I could assume fear based reasoning for the ASA request. Mr. Balko soundly rebuked knee jerk bias in opioid discussions in his report. “The new Panic over Prescription Pain Killers” http://huff.to/NvsZ7Y. I strongly suggest that the ASA and critics such as Henry Madison and others who blindly flail at any use of opioids -read the BOTH of these mentioned reports for different facts than the ones you know right now. Also look at the 10 and 20 year studies of people on opioids in the Journal Practical Pain Management. All in the study had been on opioids for with chronic pain, most neuropathic in nature to which opioids were a good treatment, helping with other areas of health as well. Nothing is gained by blindly reducing the use of opioids which – as many with pain AND KNOWLEDGE stated here earlier – are much safer drugs than Acetaminophen or many NSAIDs. (Also addiction in pain patients with moderate to severe… Read more »

Ryan Lankford

“If the non-drug treatments don’t work, physicians should then try non-opioid pain relievers, such as non-steroidal anti-inflammatory drugs (NSAIDs) or anticonvulsants, before resorting to opioids.”

So patient should be taking more dangerous medications before physicians prescribe the safer medications. Brilliant.

Dave

Lorimer Moseley is a neurocentric practitioner and Sarno, like Moseley is a reductionist, as well. Amazing how modern medicine made fun of medicine in the 1800’s for its “snake oil”- only to replace it with modern reductionistic “snake oil”. Pain is not so easily reduced to simple formulas of Moseley or Sarno or the “pain specialists” or those with poisononous enthusiasm for “silver bullets”.

Andrew Jarvis

If conservatives treatments worked we would all use them!

6% of people with chronic pain who use strong opiates become addicted. What would you have the other 96% do?

The fact the author uses obviously weak arguments, like about the side effects of opiates — other than addiction they have a minor Side effects — show that she has some agenda. I don’t believe she wrote this to further the interests of those with chronic pain.

This article runs totally in the opposite direction of the interests of those with chronic pain and for the interests of the ASA. I have chronic pain and I thought this website was meant to work for me?

Mikal

This is from the article H. Madison posted:

I quote from the article below. it doesn’t say that people are dying due to taking the pills or medications for serious chronic pain!
It just points to those who are abusing the medications.

Live and walk in our shoes before you say we are unable to cope, and should not be on pain medicines.

Quoted from the LA Times which Mr. Madison feels gives a “good” reason to have those of us in chronic pain, taken off of pain medication.

” Such drugs now cause more deaths than heroin and cocaine combined.

“The problem is right here under our noses in our medicine cabinets,” said Laz Salinas, a sheriff’s commander in Santa Barbara, which has seen a dramatic rise in prescription drug deaths in recent years.

Overdose victims range in age and circumstance from teenagers who pop pills to get a heroin-like high to middle-aged working men and women who take medications prescribed for strained backs and bum knees and become addicted.

A review of hundreds of autopsy reports in Southern California reveals one tragic demise after another: A 19-year-old Army recruit, who had just passed his military physical, took a handful of Xanax and painkillers while partying with friends. A groom, anxious over his upcoming wedding, overdosed on a cocktail of prescription drugs. A teenage honors student overdosed on painkillers her father left in his medicine cabinet from a surgery years earlier. A toddler was orphaned after both parents overdosed on prescription drugs months apart. A grandmother suffering from chronic back pain apparently forgot she’d already taken her daily regimen of pills and ended up double dosing.”

These examples do not support the assumption that chronic pain patients should be taken off of their medications.
These are people abusing the medications, not chronic pain patients. (except the “grandmother” who double dosed. There are ways this could have been avoided.)

Mikal

Just because we use more drugs to help our pain, doesn’t rule out that we are wimps. Do you not think that these other people would use them also if they could? Do you really think people enjoy being in pain? Does the concept of coping, due to not having decent medications to help, point to the idea that we are over using them?
I will admit that there are many people who abuse the pills. There are many people who are not really in pain who take them. But to deny pain patients that need help because they are wimps, just is not a good point.

Henry Madison

http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918

These drugs are dangerous. There are no good long term studies showing any benefit from these medications. There are lots of reasons not to take these medications. Google “opioids” and look at the “news” and you’ll see what I mean. We have 5% of the worlds population and consume 80% + of the narcotics (90% of the worlds hydrocodone). We have absolutely no coping skills and will take a pill for just about anything. Check out http://www.supportprop.org and listen and read. Also read anything written by Robert J Barth…..here is a good article:
http://www.wci360.com/files/uploads/June_2012_WCI_News.pdf
If you have acute pain the narcotics may be indicated short term only. With chronic pain there is pain after tissue has healed so narcotics should not be used. Instead try taking the advice of Lorimer Moseley. He explains pain and the best way to treat it. Educate yourself as to “why” you have chronic pain and you will see that narcotics are not the answer.
Read the works by John Sarno while you are at it.
All these references could change your life if you educate yourself. We need to get away from the narcotics.

Dave

Like I told Mr. Anson before- to see without a vision is a terrible thing- and we are witness to and victims of the lack of vision in medicine when it comes to pain care. Modernist medicine is, of course, capitalistic-and not humanistic. And since the focus is on profit, and not people, essentially there is no vision in pain care worth considering. Like the age of decadence in the late 19th century- modern medicine is demoralized and demoralizing. As we slouch toward the postmodern and posthuman future- we can only expect more of the same lame visionless pain care. Long live pain care!

Multidisciplinary approach is preferred.. presuming that the pt has the insurance or finances to afford this.. Using a “step therapy” – trying one thing at a time.. will not only prolong a pt’s pain.. but may cause what may otherwise be acute pain to become engrained in the nerve path and become chronic. How you even begin to address the cause of the pain.. if you don’t aggressively treat the pt’s pain from the get-go.

Why should anesthesiologists give people opioids as a first line of treatment? There’s Expensive testing that can be done, usually by the time you’re at the pain doctor (anesthesiologist), your diagnoses and treatments are well documented, including numerous tests. Then there’s literally a score of brand name drugs that can be tried, off-label, I might add, to make sure none of them help you.

Let’s not forget physical therapy, a wonderfully successful undertaking. I have found two specific things about having attended numerous physical therapy sessions for multiple maladies over the years:

1) The treatments help while you’re going, not so much after you’ve completed the regimen.
2) Insurance sticks you with much of the bill, to the point where many sessions can see you hundreds of dollars in the red. Hard bills to pay when therapy is over and do are the results

Now that we’ve put you through all of that, we wouldn’t really be anesthesiologists if we didn’t offer, no extort, you into dangerous, ineffective epidural steroid injections. I say extort because patients are made to understand by many pain facilities, there will be no pain medication unless you agree to do a series of epidurals. These “treatments” are controversial to say the least. Not approved by the FDA, many patients see temporary, if any relief. Some patients suffer terribly painful, lifelong side effects called arachnoiditis caused directly by this procedure. It pays well to the anesthesiologists’ offices though.

How about some ten dollar a month oxycodone, doc?

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ginbug

People are being misled about pain meds! ALL meds have side effects and can cause harm, however some are worse than others. One major drawback about the use of opioids like oxycodone is that you can become tolerant and will have to have more the longer you are on it. Why do you think that is? It is because the endorphins that our body makes is essentially the same thing, so our bodies know how to deal with it already and therefore will adapt to it. This is also why it is “filtered” through your kidneys & especially your liver very easy and will not cause the damage all other meds. both rx & otc will cause. If taken as directed for real chronic pain, there is VERY little danger of od. The guidelines that are being used to determine the stats on od is very lax as anyone that dies with these drugs in their body and do not have a terminal disease like cancer, then they are counted whether it was an od of pain meds or not. 99% of the time when a patient od’s on drugs, it is either someone that was NOT prescribed and just looking to get high and took a large dose or most of the time it is people that are abusing it and was mixing it w/ other drugs and/or alcohol. The most common being benzos, which when mixed w/ opioids, turns lethal. The other common risk is methadone. While it can be used in treating chronic pain w/ great results, it needs to be used w/ caution as what makes it great is also what makes it dangerous and that is the fact that it stays in your body for a longtime and by taking it everyday, it can build up a large amount. Also because it is being used as way to get addicts off other drugs( The most stupid thing that has ever been done!!), many believe it is exactly the same as other opioids and if they were taking 160mg of oxy. then they think that it is ok to take that large amount of methadone and sadly, they are deadly wrong. Bottom line is that people need to be educated & learn the truth about these drugs & treatments available and the fact that chronic pain is completely different than acute & post op pain. While I do believe that other things should be tried before deciding to go on high dose opioids long term and believe that methadone should only be used on those that will never have to come off of them, I also believe that we should all have the right and freedom to decide what treatments we want to have on our own bodies and not forced into treatments or surgery that we do not want or lose what little meds docs are willing to give! What is next? will they just start taking us out back and shoot us like a… Read more »

dave

Dr Fitch and anesthesiologists should learn the many treatments for pain. In Germany 60X times more doctors, as a percentage, practice acupuncture. American doctors are morally and mentally lazy and addicted to using quick and suboptimal treatments for pain like pharmaceuticals. Its time doctors overcome their laziness toward people in pain and utilize the vast array of treatments for pain.

trudy myers

yeah sure-just let us patients in extreme pain sit around and do nothing to control our pain. You will see more and more suicides when patients cant get any relief

I’m sorry but I have more than just pain I have had back surgery nerves burned and I have the worst pain ever and for you to tell the true in pain ppl not the drug attics the actual people that live with like my self osteoporosis and osteoarthritis and migraines and lupus and bulging discuss and bone spurs in my bank and have my cartlidge in my knees getting bad and I have fibro on top of my other health issues i have thyroid and I had a heart attack and I’m only 42 so I didn’t ask for all the car accidents I got into and we’re not my fault and I didn’t ask for all this pain and depression on top of it. WHY DON’T YOU GUYS WALK IN OUR SHOES YOU DEFINITELY WOULDN’T HANDLE IT WITH LITTLE PAIN MEDICATION AND I USE TO WALK EVERY DAY UNTIL MY KNEES KEEP GIVEN OUT THEN I DO MY BEST JUST TO EVEN GET UP AND GO TO THE STORE WHICH IS NOT OFTEN TRUST ME IT’S NOT EASY TO LIVE AND WAKE UP WONDER ING AND PRAYING THAT I CAN GET A LOAD OF LAUNDRY DONE OR EVEN GET IN THE SHOWER. IM TELLING YOU THAT YOU GUYS HAVE NO RIGHT TO JUDGE. THERE IS ONLY ONE JUDGE AND HE SEES WHAT’S GOING ON AND HE KNOWS THE TRUTH AND WHAT IS SAD IS THAT THESE DRUG ATTICKS OUT HERE SHOULDN’T MAKE IT TO WE’RE YOU ARE TRYING TO CONTROL US WE ARE HUMAN BEINGS AND IT’S ONLY GOING TO GET WORSE BECAUSE OF WHAT EVERYONE IS TRYING TO DO I DO KNOW THIS WORLD IS COMING TO THE END AND IF YOU DOCTORS AND ANTISECIOLOGIST KEEP DOING WHAT YOU’RE DOING AND WHO EVER ELSE IS IT’S GOING TO GET BAD SO USE OUR TAX PAYERS MONEY TO BUST THE HERION AND SNIFFING AND WHATEVER ELSE THEY DO TRY BUSTING THEM. IT SEEMS TO ME THAT YOU GUYS WANT TO DIE US OFF THE EARTH BECAUSE OF WHAT US REAL AND TRUE PPL THAT DON’T ASK FOR PAIN AND HAVE TO SUFFER BECAUSE I WONT TAKE ANYTHING ELSE THAT I AM ON NOW AND I STILL DEAL WITH PAIN BUT NOT AS BAD I TAKE THE SAME AS I HAVE WHEN MY SURGERY STARTED QUIT TRYING TO CONTROL US AND CONTROL WHAT IS ON THE STREETS. WHY DO WE HAVE TO SUFFER FOR OTHERS WRONG DECISION. ITS AWFUL AND I CAN’T EXPRESS ENOUGH BUT SOMEONE NEEDS TO TAKE US FOR REAL AND NOT PEOPLE THAT ARE ON DRUGS I TAKE DRUG TEST ALL THE TIME AND IM GLAD TO.

nan

No sedation for ESI’s???? What barbarian came up with that brilliant idea?? I had steroid and marcaine injection into arthritic facet joints. My pain doc at the time would not do them without adequate sedation. Concurrently, I was getting physical therapy of the facet joints, which was the most painful thing I ever had done. During the 20 min pt therapy, there were no other patients allowed in or nesr the treatment area. I tried so hard not to cry or scream, but I couldn’t help it. Most of the time my therapist ended up in tears

Mikal

I can understand that using medications that have difficult side effects can be dangerous, but It seems as if it is less dangerous to use some pain killers, rather than risk constant use of advil and that whole group. They have horrible side effects, and they too can cause long term damage, and death.
It really must be up to the doctor and the patient and how the patient reacts to any given treatment.
Maybe there is an increase in dosing of opiods since so few other options are even available. They took some of the most helpful anti-inflammatory drugs off market due to dangers…and now what is left? Yes, some times physical therapy may help, but there are cases where nothing seems to touch the pain. To disregard how much pain non-cancer patients are in is to disregard a whole group of pain. Why do these new advocates think that only cancer patients are in horrid pain????
I dealt with cancer, I am 1+ years out, and no pain. I have more pain via my chronic aliments than I ever had with my cancer. I hope I will never have to have cancer that is more painful then the problems I live with now, and have lived with and have totally ruined my life! I am just starting to renew my life, and it is due to a caring and cautious doctor who is willing to help me with what ever is needed.
This whole debate and new laws are dangerous and will only cause more “normal” people who are in non-cancer pain to seek out illegal ways to gain medications which can help them, since you are gong to make them impossible to use.

Dennis Kinch

Can we please see some reports with numbers on them? I am sick of these people protecting us from ourselves, passing rules based on the small minority of “bad people.” Funny, I’ve never met anyone in chronic pain who was prescribed opioids as a first line defense against pain. I remember the 2 years of trying everything else until I was able to get on a program, then off of it because my insurance wouldn’t cover it, then on it because we fought for it, then off it because someone else wanted to “help” me, now back on it because we fought for it. I believe the numbers will prove that the majority of us, by a long shot, were put on opioids after many trials of other meds, that we always follow our doctor’s directives and we would rather be on “skittles”, if it would help the pain and give us quality back in our lives. Try to remember…WE are stuck with pain for the rest of our lives! I’ll say this again, ” If I die tomorrow from opioids, at least I’ve had 4 years of happiness and production.” I’ll take that any day over the safety net these rules are trying to achieve, causing pain that will disable me completely. And I’m not alone!