By Melissa Patrick
Kentucky Health News
Kentucky has a new law restricting painkiller prescriptions to three days for acute pain, but an anecdotal story from one of the state’s leading doctors suggests that it has a ways to go: the child of a friend recently got wisdom teeth extracted and was given a 30-day supply of pain medicine.
“They don’t need that many. They may only need — zero!” said Dr. Philip Chang, chief medical officer at UK HealthCare. “I don’t know how well that [law] is followed, to be honest with you.”
Chang also discussed proven ways to reduce opioid use, and still relieve pain, during the “Alternatives to Opioids” panel at the Howard L. Bost Memorial Health Policy Forum held Sept. 24 in Lexington by the Foundation for a Healthy Kentucky. The meeting’s theme was “Kentucky’s Substance Use Epidemic: A Solutions Update.”
Comprehensive EAP photo
The law, passed in 2017, limits painkillers to a three-day supply if prescribed for acute pain, but doesn’t apply to chronic pain and has a long list of other exemptions — and allows a prescriber to override the new rule by documenting a justification.
At the end of the session, Dr. Mel Pohl, chief medical officer of Las Vegas Recovery Center, noted that Nevada doesn’t have this problem because its laws on opioid prescriptions are very strict.
“If people prescribe opioids for more than three days for a minor and seven days for a major surgical procedure, they will be brought before the medical board,” he said. “It’s too bad that we had to be punished and threatened into changing our behavior as prescribers, but we did. And now it’s happening and I think that the paradigm shift is in place.”
Chang said it was important for providers to get on board with the new law because opioids have adverse consequences. He pointed to research that shows a one-week prescription of opioids to patients who have never used pain pills before increases their risk of becoming addicted by 15 percent in one year, and a 30-day prescription increases that risk to 35 percent.
He also cited research that found a combination therapy of ibuprofen and acetaminophen is much more effective for treating pain than opioids. “This is the information we need to get out there, so they know that this doesn’t come without a costs,” he said. “The misconception that opioids are always better is not true.”
Chang, a trauma surgeon, also noted a pilot study that he led, which basically didn’t allow providers to prescribe any pain-medication prescriptions unless the patient had exhausted all other means of pain-control medications available to them, like ibuprofen, Tylenol and muscle relaxers.
He said that in just two years’ time, they were able to drop the overall opioid-prescribing rates for trauma patients 50 percent, with the best results in the “opioid naive” patients.
The pilot was so promising that the policy has been implemented hospital-wide, with results over the last two years showing a steady decline in the amount of daily morphine prescribed, resulting in 250,000 fewer pills per year, and no changes in patient-described pain scores. “None at all!” he said.
“We can do this,” Chang said. “We can get away from this trend of prescribing opioids and more opioids and more frequent and different kinds of opioids. We can get away from it.”
Dr. Danesh Mazloomdoost, medical director at Wellward Regenerative Medicine in Lexington, told the group that we need a culture change when it comes to pain management and that the question shouldn’t be how can we manage opioids more effectively, but to ask if they are even effective.
“That’s really the key to understanding how we’re going to fix this pain issue,” he said. “We’ve got to stop thinking that we can cure everything or symptom-manage everything with a pill, and start getting an understanding of what the physiology of our bodies is, how our bodies function and how we’re going to get healthy to feel better.”
Mona Carper, a physical therapist and professor at UK, said it is long past time for her profession to have a seat at the table when it comes to discussing pain management.
She said access to physical therapy within the first 14 days of injury is critical for decreasing the need for opioids and for decreasing the long-term cost of care.
Pohl, an addiction specialist who treats co-occurring pain and addictions with the goal of getting patients off opioids, said, “When we take people off opioids, guess what happens to their pain? It goes down.”
Pohl gave several suggestions for alternatives to opioids, including several specific types of therapy, including cognitive behavioral therapy, complementary alternative therapies like nutritional interventions and acupuncture, and mindfulness practices.
He spent much of his time talking about the benefits of practicing mindfulness daily, which he said is a type of meditation that involves focusing on an object, like breathing. He said the practice of mindfulness allows people to “detach from thoughts, feelings and physical sensations” and thus better tolerate or manage their pain.
Pohl noted two studies that spoke to the effectiveness of the practice, including a three-month study of adults 27 and older that found practicing mindfulness, or meditation, resulted in less pain, improved attention, enhanced well-being, and improved quality of life. The second one found that just four days of mindfulness training decreased pain and feelings of unpleasantness by half.
He added that results from his own clinic show a 20 percent reduction in pain scores among his patients who practice mindfulness. He said, “That is efficacious as most opioids.”