The move towards nonopioid pain management

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Matthew McGirt
Matthew McGirt

The high prevalence of opioid related adverse events and costly consequences to our society has prompted many to critically look at our practice of outpatient opioid prescription. As a result, multiple stakeholders in US healthcare are adopting non-narcotic pain management solutions, education, and awareness programmes. 

In the hospital setting, intravenous and oral narcotics remain the mainstay of acute pain management. When administered under nurse supervision or through patient-controlled anaesthetic devices, the historical assumption has been that narcotics offer the best balance between safety and effectiveness for acute pain control. Based on several recent and reproducible study results, this notion is now being challenged.

Recently, investigators sampling administrative Medicare records from 2010–2012 found that opioid related adverse events occur in up to one out of every eight patients undergoing spine surgery,1 whether it be cervical2 or low back surgery.3 Even when intravenous narcotics are administered through patient-controlled devices, specifically aimed at maximising safety of inpatient narcotic use, they appear to introduce greater safety concerns than previously recognised. In a recent analysis of 1998–2012 national Medicare records, our research team recently observed that patient-controlled anaesthetic use for pain control after low back surgery was associated with an increase in opioid-related adverse events independent of extent of surgery or patients’ comorbidities.4 Despite patient-controlled narcotic delivery in an observed hospital environment, almost one in ten patients experienced an opioid related adverse event.4

Over 50% of hospital admissions include the administration of narcotics.5 An estimated one third of all hospital adverse events are related to adverse drug events, affect approximately two million hospital stays annually, and prolong hospital length of stay by an average of two to five days.6 With close to a million preventable complications per year arising from in-patient narcotic prescription, one has to consider whether it is time for a large and rapid paradigm shift for hospital-based pain control, particularly within a US healthcare system that is currently operating with unsustainable cost increases. As recent studies are suggesting, inpatient narcotics are not only associated with preventable deaths and adverse events, they also increase length of stay, reduce mobilisation, increase cost of the episode of care, and lead to greater resource utilisation in the immediate post discharge period. Furthermore, narcotic use has recently been recognised as reducing the short and long-term benefits of musculoskeletal treatments, including spine surgery.7–8 

In a healthcare reform era aimed at improving the value (quality/cost) of services by increasing quality and reducing cost of that care, inpatient narcotic use contradicts the value-based reform movement as it reduces safety and healthcare quality while increasing utilisation and cost of care. Multi–modal, non-opioid pain management paradigms should be supported and implemented in the hospital setting to increase the value and efficiency of not only musculoskeletal care, but all hospital based care. As we begin to more critically look at US healthcare opportunities for quality improvement and its value-based evolution, our hospital-based narcotic practices represent low hanging fruit. No one stands to benefit more than our patients.  


Reference:

  1. Polly D, Ong K, Lovald S, et al. Study presented at the Annual Meeting of AANS/CNS Joint Spine Section 2015.
  2. Kurd M, Ong K, Lovald S, et al. Presented at the Annual Meeting of AANS/CNS Joint Spine Section 2015.
  3. Kurd M, Ong K, Lovald S, et al. Presented at the Annual Meeting of AANS/CNS Joint Spine Section 2015.
  4. McGirt MJ, Devin C, Lau E, et al. Prevalence of PCA device use for inpatient posterior lumbar spine fusion surgery and associated opioid-related complications and costs.
  5. Herzig SJ, Rothberg MB, Cheung M, et al. J Hosp Med. 2014; 9(2): 73–81.
  6. Draft National Action Plan for Adverse Drug Event (ADE) Prevention (2013). US Department of Health and Human Services.
  7. Lee D, Armaghani S, Archer KR, Bible J, et al. J Bone Joint Surg Am 2014 4; 96(11): e89.
  8. Armaghani SJ, Lee DS, Bible JE, et al. Spine (Phila Pa 1976) 2014 1; 39(25): E1524–30.

Matthew J McGirt is an adjunct associate professor at the University of North Carolina, USA

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