By Karen Dandurant
Posted Jan 16, 2020 at 12:46 PM
Updated Jan 16, 2020 at 12:46 PM
PORTSMOUTH -- As New Hampshire struggles with the opioid crisis, members of the medical community are also struggling to find ways to reduce the amount of unused opioids sitting in medicine cabinets.
One recommendation is for doctors and hospitals to prescribe smaller amounts per prescription. Another is to find alternate ways to deal with pain that does not involve the use of narcotics.
Dr. Thomas Wold, chief medical officer at Portsmouth Regional Hospital, said prescribing habits are reviewed regularly.
“We are definitely prescribing less,” said Wold. “We look at how we are prescribing in the emergency department a lot because that is such a fast-paced environment, but we also closely watch in all departments.”
Wold said in 2019 only 11% of patients were prescribed an opioid while in the hospital, and only 5.8% left with a prescription. If they did, Wold said it was likely only three pills.
“In 2016, the state recommendation was for no more than three days of prescription when leaving the ER,” said Wold. “We saw a 20% reduction in opioids leaving the hospital.”
In the surgical department, Wold said they use Enhanced Surgical Recovery, an evidence-based program that carries through all phases of a patient experience, from pre-operative through discharge.
“Days before surgery, we use nerve agents like Neurontin, nerve blocks to help prevent pain,” said Wold. “Post-operative, we get patients out of bed as soon as possible and that helps with pain management. The more ambulatory they can be, the less pain. We followed a cohort of 277 patients and saw a 22% reduction in opioid use. We saw patients meeting their pain goals.”
Whenever opioids will be prescribed, Wold said there is an informed consent process used.
“We talk with our patients about the real risk of addiction,” said Wold. “In a person who might more susceptible, we will give as little as three doses.”
Dr. Thomas McGovern, an orthopedic surgeon at Core Orthopedics at Exeter Hospital, said doctors have learned a lot about opioids over the past several years.
“We now know that any level of prior exposure to opioids at any level means the patient would require more during surgery than if they never had any in their life,” said McGovern. “We all contributed to this. When a person sprained their ankle, had tennis elbow from playing racquetball, we didn’t want them to have pain, so we prescribed Vicodin. We treated activity level pain with opioids. Then the person had a back pain and a few left in the medicine cabinet, so he took a few. When it came time for joint surgery, they needed higher levels of pain medication, so we prescribed more.”
The philosophy has changed. McGovern said doctors no longer are prescribing opioids for routine aches and pains.
“We used to think about the pain scale, one to ten,” said McGovern. “We thought 3 to 4 was too much pain. Now, say in joint replacement, the initial pain might be 8-10. We tell them yes, we know, but it will improve, so we will not use as much opioids. When we know pain is going to get better, we do this. It is not like treating a chronic illness with pain.”
By doing this, McGovern said they have reduced their prescribing by 50% to 75%.
Nicole Carrier, RN, of Core Orthopedics, is the nurse coordinator for Exeter Hospital’s joint replacement program.
“We have done a lot to reduce the opioids leaving from our offices and also to help people rid themselves of any leftover medications they may have at home,” said Carrier. “We have cut our post-operative prescribing in half. We use e-prescribing directly to pharmacies when necessary. We also do a lot more with Tylenol, and other non-narcotic medications.”
When Core Ortho prescribes an opioid, the number of pills is smaller, and they have a detailed discussion with the patient.
“We give them exact information about the drug,” said Carrier. “We talk about the side effects and we give up front information about the risks of addiction. We counsel them on the use and interactions with other substances like alcohol. We provide our patients with Deterra bags and work closely with Jim and Jeanne Mosher and the Zero Left program.
We talk about how important it is to dispose of leftover medications, so they are not sitting in a medicine cabinet for someone else to find.”
Wold said they also refer their patients to the Deterra bags, and to local safe stations where drugs can be brought for disposal.
Carrier said they recently began a mindfulness meditation program, as an alternate way to teach their patients to manage pain.
“Every patient here is offered a chance to use that program,” said Carrier. “It has significantly reduced their need for opioids. We are definitely seeing this work and it’s amazing.”
Brittany St. Martin, PT and yoga instructor, runs the new meditation program, which meets once a month for a 45-minute class.
“For the first half of class, we talk about the science behind pain,” said
St. Martin. “People in pain become stressed, which causes more pain. It’s a vicious cycle. We talk about how to manage the pain response. In the second part, we practice mindfulness and learn the techniques. I lead them through their body’s processes and they assess each one. It’s part- physical therapy and part-neurobiology. We center ourselves in mind and body, and tap into the parasympathetic system. That means really being there and not planning your grocery list.”
The result, said St. Martin, are people who feel better, sleep better and feel less pain.
Another thing Carrier said they are seeing is a new awareness in their patients.
“For the most part, they’re good with being prescribed less pills,” said Carrier. “Almost all of them have some experience with a person they know, or they have learned enough to be cautious. Some of the patients are afraid to take even one and say they would prefer not to.”
Wold said PRH uses alternative pain management techniques.
“We have a program called ALTO, which stands for alternatives to opioids,” said Wold. “We have options for the typical conditions such as headache and migraines, musculoskeletal, rehabilitation and chronic abdominal pain. Some of that can involve topical lidocaine injections to the pain trigger points, or the use of ketamine, a general anesthetic that uses lower doses than narcotics. We use antispasmodics for abdominal pain.”
Nitrous oxide, more commonly known as laughing gas, is being used again.
“We are finding nitrous oxide very useful when there is a fracture or dislocation that needs to be aligned,” sad Wold. “Also, we use Tylenol and Nsaids (aspirin and ibuprofen) a lot more, often together with great results.”
Wold said he is encouraged by the statistics starting to be seen regarding the successes of using less opioids.
“I am hoping we will begin to see a substantial decrease in the overdose death statistics next,” said Wold.