The Opioid Crisis and What Memorial Hermann is Doing About It

Every day, more than 115 people in the U.S. die from opioid overdose.¹ The Centers for Disease Control and Prevention estimates that the total "economic burden" of prescription opioid misuse in the U.S. is nearly $80 billion a year, including the costs of health care, lost productivity, addiction treatment and criminal justice involvement.²

Opioid Abuse by the Numbers

The details of this public health crisis are disillusioning:

• Roughly 21% to 29% of patients prescribed opioids for chronic pain misuse them.³
• Between 8% and 12% develop an opioid use disorder.^4-6
• An estimated 4% to 6% who misuse prescription opioids transition to heroin.^4-6
• About 80% of people who use heroin first misused prescription opioids.⁴

Safely Managing Trauma Pain

Victims of traumatic injury are at greater than average risk for opioid misuse and related complications. Every year, the Memorial Hermann Health System sees over 10,000 trauma cases, including over 6,000 at Memorial Hermann-Texas Medical Center. Most often, these patients are victims of motor vehicle or motorcycle accidents, falls, assaults or burns, all of which involve severe pain.

While opioids, such as oxycodone and morphine, are effective at treating acute pain, they pose serious risks and cause myriad side effects. So, how can physicians effectively treat trauma patients’ pain without subjecting them to these risks and side effects?

Multimodal Pain Regimen

Memorial Hermann is at the forefront of a growing number of health care systems across the country that are managing trauma patients’ pain without – or with minimal use of – opioids.

Memorial Hermann affiliated orthopedic surgeon William Harvin, MD, explains, “We have had great success in managing our patients’ pain by employing a multimodal pain regimen that includes the use of multiple non-narcotic classes of drugs, less invasive surgical techniques and nerve blocks that provide targeted, versus systemic, pain relief. The level of pain that some of these trauma patients experience, however, still requires the use of narcotic pain medication. But we use it early on and very sparingly, then shift to one or more of the other drugs as quickly as possible.”

Brad Domonoske, PharmD, BCPS, a clinical pharmacist specializing in surgery, trauma and burn critical care at Memorial Hermann-TMC, adds, “Even though narcotics can have negative side effects, they provide great analgesia for surgical pain. But after we get the patient through the OR, it's the long-term pain from the multiple fractures, surgeries and injuries that pose the challenges.”

Domonoske continues, “If you use narcotics as your sole basis of analgesia, the narcotics have lots of adverse side effects. They impair your immune system. They alter your ability to sleep, which can lead to increasing delirium, which has long-term adverse consequences. They also cause side effects, such as constipation and tolerance. And all of this has a huge impact on both the patient’s hospital length of stay as well as their mental and physical health after they go home.”

Pharmaceutical Solutions

Domonoske says Memorial Hermann affiliated physicians prescribe pain medications from four different classes of pain medication, each affecting different pain receptors in the brain. These drugs are used either in lieu of narcotics or as an adjunct to narcotics to dramatically reduce the number of narcotics prescribed:

• Non-steroidals (ibuprofen, naproxen, celecoxib) – The most commonly prescribed class of pain relievers, non-steroidals work right at the point of injury to decrease inflammation. “It’s that inflammation that causes a lot of your nerve endings to send signals that you’re having pain,” says Domonoske. “These drugs help to relief inflammation. They work at the site of injury, but they also work inside the brain to help modulate your perception of pain. Unlike narcotics, they won’t change your mental capacity or inhibit sleep.”
• Acetaminophen (Tylenol) – These analgesics provide the feeling of pain relief but, unlike narcotics, do not alter a patient’s cognitive ability, negatively affect their GI tract (long-term), affect sleep or become addictive.
• Gabapentinoids, including gabapentin (Neurontin) and pregabalin (Lyrica) – This class of drug targets the nerves that transmit pain signals, affecting the transmission of pain signals, decreasing the perception of pain.
• Tramadol (Ultram) – These narcotics bind to receptors in the brain (narcotic or opioid receptors) that transmit the sensation of pain from throughout the body to the brain. They can be addictive but are considered less potent than other opioids.

In addition to these medications, lidocaine patches may be used to provide targeted pain relief – without the side effects, including gastrointestinal distress or mental impairment, caused by other medications.

“They play very nicely with each other.”

“We typically give all four of those groups of meds, or at least a representative from all four groups, to a patient. The drugs play very nicely with each other,” says Domonoske. “Then, if the patient has some additional pain, we go to the narcotics. But the great thing is, we can limit the amount of narcotics we have to give, and we can get the patient off narcotics so much faster and still provide pain relief. The patients stay awake so that they can participate in their care, which expedites healing and shortens their hospital stays. Then we send them home on these adjunctive agents, which don't really interfere with their activities of daily living.”

References

¹ CDC/NCHS,National Vital Statistics System, Mortality. CDC Wonder, Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://wonder.cdc.gov.

² Florence CS, Zhou C, Luo F, Xu L. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013. Med Care. 2016;54(10):901-906. doi:10.1097/MLR.0000000000000625.

³ Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156(4):569-576. doi:10.1097/01.j.pain.0000460357.01998.f1.

⁴ Muhuri PK, Gfroerer JC, Davies MC. Associations of Nonmedical Pain Reliever Use and Initiation of Heroin Use in the United States. CBHSQ Data Rev. August 2013.

⁵ Cicero TJ, Ellis MS, Surratt HL, Kurtz SP. The Changing Face of Heroin Use in the United States: A Retrospective Analysis of the Past 50 Years. JAMA Psychiatry. 2014;71(7):821-826. doi:10.1001/jamapsychiatry.2014.366.

⁶ Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134. doi:10.1016/j.drugalcdep.2015.12.026.