Addressing the Opioid Crisis

Published December 13, 2017

The opioid epidemic is a national crisis and a national tragedy. In 2015, two million Americans suffered from drug abuse or dependence on prescription opioids.

As an orthopaedic provider, we are taking the crisis – and our responsibility to help patients safely and effectively manage pain – seriously. Our doctors are taking the lead by leveraging alternative pain management therapies and techniques, conducting new research, lecturing at national conferences and prioritizing patient education and support.

Although many substance abuse disorders begin with medically prescribed opioids, the prescription isn’t often abused by the patient. Research by the Substance Abuse and Mental Health Services Administration found that over 65 percent of opioid abusers obtained the drugs for free from a friend or family member. And nearly 80 percent of those friends or relatives had been prescribed the medication by one doctor. They simply had leftovers available.

“The biggest problem is that doctors give people too much medicine,” said Dr. Haley Merrill, a foot and ankle specialist at our Orthopaedic Foot & Ankle care center in Arlington and Falls Church, Virginia. “They don’t consume it all, which is great – if they don’t need it, we don’t want them to take it. But when patients take the medication for a few days and put the rest in a medicine cabinet, it’s available in the future to them and anyone else who comes into their homes. This makes these strong and potentially dangerous medicines accessible for misuse or abuse.”

And studies show that abused prescription opioids, once obtained from a friend or relative, can lead to abusing harder or illicit drugs. Between 2008 and 2010, research by CM Jones found that over 77 percent of heroin users had first abused opioid pain relievers.

“It’s a huge problem that we’re giving out too much medicine in the community. It’s not everyone, but certainly some people do develop addictions and move from prescription opioids like oxycodone to heroin and other drugs, where they’re more likely to overdose,” said Dr. Merrill. “If we can decrease the amount of opioids prescribed and readily available, we can decrease the amount of addiction to other drugs as well.”

“Opioids are used sometimes as the first line of treatment, especially in the ER,” said Dr. Lisa Grant, a non-operative interventional spine care specialist at our OrthoMaryland care center in Baltimore, Lutherville and Owings Mills, Maryland. “The important thing is to educate the patient that it’s only a short-term solution to the pain. And we won’t start by prescribing Percocet for pain, for example – it has terrible side effects and can be addictive. Orthopaedists are getting better about being very careful when they introduce narcotics.”

CAO, and orthopaedic practices around the country, are working to manage the crisis in in three main ways: Adjusting the number of pills prescribed, leveraging alternative options for pain management and identifying at-risk patients to provide tailored support.

Adjusting Prescription Amounts

Several studies, including research conducted by CAO’s Dr. Merrill, has measured the typical amount of prescription pain medication that patients take for straightforward procedures. And they are often taking far less than prescribed, leaving excess medication at the end of recovery.

“Doctors might prescribe 50 tablets, for example, just because it’s a good number and we know the patient won’t need a refill,” said Dr. Merrill. “But are they taking 20 pills and putting the other 30 in the medicine cabinets? For many standard surgeries, we can figure out what patients generally need and prescribe a limited amount. If the patients need a refill, we can see them again and prescribe more if appropriate.”

Research found that physicians could decrease the amount of medication prescribed by 43 percent and still cover the medication requirements of 80 percent of patients. Dr. Merrill’s research also found that 63 percent of patients with leftover medication were willing to return it to a designated disposal site. By limiting the initial number of pills prescribed and educating patients about the need for safe and immediate disposal, doctors and patients can work together to dramatically reduce the amount of opioids available in community medicine cabinets.

Leveraging Alternative Options for Pain Management

With expertise in interventional pain management, physical medicine and rehabilitation, Dr. Grant uses a variety of approaches to help patients suffering from spinal pain or neck and back arthritis.

“I have a very conservative practice, and I recommend alternative medications and therapies, including weight loss, exercise and interventional workshops to help control pain. I’ll also educate my patients about the medication they are taking, to ensure it is used appropriately, judiciously and with good outcomes.”

As appropriate, Dr. Grant uses tramadol for power pain relief, as it’s a pseudo opioid controlled substance with lesser potential side effects. She has also found that specific anti-depressants can be highly effective for pain management, when used carefully, and often combines several medications at lower doses for superior results and better control.

Patient Screenings & Custom Support

Research estimates that nearly eight percent of patients may still use opioids a year after their own treatment and prescribed pain relief. To reduce this figure and provide better care to at-risk patients, Dr. Merrill recommends a standard screening procedure and follow-up support.

Several research studies have already established ways to identify patients who may need more pain pills than usual or may have risk factors for future opioid misuse or abuse. Dr. Merrill says that administering a quick screening quiz to anyone receiving prescription opioids, and following that up with custom support, has shown to be helpful in decreasing patients’ risk for addiction.

“If we utilize these tools, we can cut down the amount of medication we’re prescribing while still adequately controlling pain and supporting patients who may be at risk for greater pain or potential abuse,” Dr. Merrill said. “As part of a standard practice, if the screening determines a patient may be at risk, we can make sure they’re set up with a support person to give them help and guidance tailored to their needs.”

Lisa Grant, M.D., specializes in Non-Operative Interventional Spine Care at the OrthoMaryland care center. Her expertise includes physical medicine and rehabilitation as well as interventional pain management. She has been honored as a Top Doctor in Baltimore Magazine four times, and received several awards for excellence and leadership during her fellowship in pain management at Virginia Commonwealth University/Medical College of Virginia School of Medicine (VCU/MCV). Dr. Grant also received her medical degree and completed her residency at VCU/MCV. Outside of medicine, her interests include sailing, hiking, kayaking, cycling, rock climbing and traveling.

Haley Merrill, M.D., specializes in Foot and Ankle Surgery at the Orthopaedic Foot & Ankle care center in Falls Church and Arlington, Virginia. Dr. Merrill joined the practice after completing her fellowship at the care center. She earned her medical degree from the Medical University of South Carolina, and completed an orthopaedic surgery residency at the University of Missouri, Kansas City, where she graduated with awards in humanism and meritous performance. Dr. Merrill is also interested in sports medicine and fracture care, and she has researched and presented on narcotic prescription practices among orthopaedic surgeons.