Dr. Amir H. Fathi, an assistant clinical professor of surgery at UC San Francisco-Fresno, writes how some Fresno-area hospitals are working to reduce use of the powerful painkillers.
What is going on?
Opioids are a large family of medications that include a wide variety of drugs, including popular prescription pain relievers such as oxycodone, hydrocodone and morphine. These drugs result in pain relief and euphoria but can lead to dependence and, when misused, overdose and death. According to the National Institutes of Health, in 2015 more than 33,000 Americans died as a result of an opioid overdose, including those legally prescribed. Essentially, over 90 Americans die as a result of opioid overdose on a daily basis.
How did this happen?
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The opioid abuse and overdose rates began to increase following misinformation with regard to treatment of chronic noncancer pain. Aggressive marketing of newer, longer-acting opioids in the management of pain led to a quadrupling of sales of prescription painkillers from 1999 to 2013. Between 2009 and 2013, there were 280 deaths related to opioid pharmaceuticals in Fresno County.
Can’t we just stop prescribing opioids?
Opioids have improved the quality of life for millions of people, particularly cancer patients, or patients with acute pain following surgery. In some specific cases, opioids are an essential component of a patient’s personalized care plan.
What can our Valley doctors do?
Opioid overprescription is not a specific problem related to one specialty of medicine. It is a healthcare cultural maladjustment that can be divided into two main misuse categories: acute pain and chronic pain situations. There has been a dogma in acute pain situations, such as post-surgery, that patients need the most potent available drug to alleviate immediate pain. The answer has been opioids in large quantities for post-surgical pain control. The other group includes patients with a history of long time opioid use for their chronic pain/disability condition.
Surgeons prescribe approximately 10 percent of the 280 million opioid prescriptions written every year. Interestingly enough, patients report taking only 20-30 percent of their prescribed opioid pills. A large amount of these drugs unfortunately become diverted to nonpatients, contributing to the opioid epidemic.
Locally there has been a system-wide effort in the Community Medical Centers to improve the surgical outcomes. As the largest health system in the Valley, which covers a population over 2.7 million, these quality improvement programs can significantly affect the state of health in the Valley. All three hospitals – Fresno Heart and Surgical Hospital, Community Regional Medical Center and Clovis Community Medical Center – have embarked on a national quality initiative called Enhanced Recovery After Surgery. ERAS refers to patient-centered, evidence-based, multidisciplinary surgical pathways to reduce the patient’s surgical stress response, optimize their physiologic function and facilitate recovery.
One of the most important components of this program is minimizing the use of opioids while replacing them with nonopioid medications. Minimally invasive and bariatric surgery programs at Fresno Heart and Surgical Hospital have successfully eliminated the opioid usage for all of their bariatric surgery patients. At CRMC, a large number of cancer and trauma surgery patients are being treated with multimodality nonopioid pain control pathways to minimize opioid usage. Clovis Community’s surgery department is also adopting the protocols. In our surgical programs, this systemwide paradigm shift has made a big difference in the amount of pain medication patients require after surgery.
What can you do?
Sir Francis Bacon once said “The knowledge is power.” We must educate ourselves about opioids, continuously raise awareness about the misuse of painkillers and actively limit their utilization. It is our job to work hand-in-hand with our healthcare providers to save our Valley.
Amir H. Fathi M.D., is an assistant clinical professor of surgery at UCSF Fresno. He is the director of liver-pancreas-biliary surgery program. He is also the surgeon champion for Enhanced Recovery After Surgery (ERAS) and National Surgical Quality Improvement Project (NSQIP) for Community Regional Medical Center.