Beating Back an Epidemic
The problem of opioid addiction now affects us all. For me, the biggest
shock came when one of my patients, former National Football League quarterback
Erik Kramer, tried to commit suicide after his 18-year-old son, a high
school quarterback, died of a heroin overdose.[1]
It's a vivid illustration of the way the ripples from drug abuse are
becoming a tsunami that destroys not only the addicted but everyone around
them. As sports physicians, we must do our part to beat back the waves,
beginning with our approach to controlling patients' pain.
The magnitude and complexity of the problem makes it truly daunting. In
the year ending July 2017, a total of 66,972 people died of drug overdoses
in the United States, a 14.4% increase over the previous year. That includes
more than 115 deaths from opioids per day.[2]
These overdoses are killing Americans at a faster rate than the AIDS epidemic
at its height. They are killing more than the number that die from traffic
accidents or suicides. More have died from opioids than were killed in
the entire Vietnam War.[3]
Paving the Road to Devastation
To understand how we can stop this epidemic, it helps to know how we got
here. In the 1990s, drug makers
convinced doctors' associations and government policy makers that new formulations of opioids such as OxyContin would not addict patients,
and that they were essential to control pain. Prescriptions soared.
But patients did become addicted. One study found that 8.2% of patients
who took opioids for the first time after total knee arthroplasty were
still using them 6 months later,[4] despite weak evidence that the drugs are effective for chronic pain management.[5] Not only does abuse of these prescriptions kill thousands, but for many
people, these medications serve as a bridge to illegal drugs.[6]
The amount of opioids prescribed in the United States peaked in 2010, but
doctors still wrote 70 opioid prescriptions for every 100 people in 2015,
three times more than in 1995 and four times more than in Europe.[7]
Protecting, Then Empowering, Patients
For the clinician, the phenomenon poses a complicated challenge. We cannot
ignore our patients' pain. But we usually can't tell which patients
are at risk for addiction. We also usually don't know when they are
suffering from other mental health problems.
To play our part in addressing this national problem, sports physicians
must start by recognizing the magnitude of it. I'd like to see addiction
come out of the closet. It should be a medical diagnosis like any other,
so that patients can freely discuss whether they have struggled with it
in the past, gone through rehabilitation, or are still misusing drugs.
As it stands, most people can't get coverage for addiction treatment,
and rehabilitation programs are relegated to the margins of medicine.
As physicians, we must attend to the psychological, emotional, and addictive
aspects of our patients' lives, even when the healthcare system does not.
Sometimes we can make a difference in surprising ways. When I was in medical
school at Washington University in St. Louis, Missouri, I trained to run
a marathon. Every day I ran to the hospital. One day I passed my patient
who was at the hospital for mental illness, and he asked me why I was
running. I told him it made me feel good.
"Would it make me feel good?" he asked.
"I bet it would," I answered. And after getting permission from
his head physician, I took him for a run. He could barely run a quarter
mile, but he came back saying how good it made him feel. So the next day
we ran again, and the next day after that.
I believe that exercise empowers people to discover that solutions are
within them. It would be naive to think that running is all that the average
patient needs to recover from addiction. But in combination with behavioral
modification and addiction medications such as methadone, it can provide
powerful benefits.
Identifying High-Risk Patients
I've found it essential in my practice to develop relationships with
rehabilitation programs to which I can refer my patients. I've referred
some to in-patient 30-day detoxification followed by outpatient rehabilitation.
Other patients come to me already enrolled in rehabilitation programs.
In Malibu, there are several programs that attract patients from around
the world. They come to me with sports medicine problems while they're
in town. It's very important to be aware of the complexity of these
patients and work closely with their other physicians to coordinate the
medical management with the addiction therapy, especially to know which
drugs to prescribe and which ones to avoid.
I've also treated patients who injured their knees because a drug abuse
problem led to a car crash. These patients may be enmeshed in legal problems
and enrolled in rehabilitation but are continuing to abuse drugs and are
unable to comply with my advice for recovering from surgery.
These very complex patients require careful management. I spend a lot of
time on communication when treating them, trying to preempt problems.
To provide such patients with the best possible care, I have worked closely
with rehabilitation programs, such as Beit T'Shuvah in Culver City,
California. With runners enrolled there, I've talked about the principles
of my book,
The Win Within, which shows readers how to modify their own behavior.
Non-opioid Pain Management
The second step we can take to prevent opioid abuse is to address our patients'
pain carefully and systematically so that they can manage without opioids.
My goal is always to create for my surgery patients an experience that
is devoid of pain. I follow the motto "No pain is your gain,"
because it's not just the best approach for my patients' health;
it's the best possible way to promote my practice.
A lot of surgeons routinely send patients home with prescriptions for 30
hydrocodone/acetaminophen or oxycodone tablets. I've moved away from
prescribing those drugs, along with codeine and most of the other opioids,
because of my concern about addiction.
Instead, I rely on preemptive blocks and long-acting liposomal local anesthetics.
Typically, I inject ketorolac into the area around the joint before, during,
and after the surgery. After surgery, I prescribe a variety of acetaminophen
and nonsteroidal anti-inflammatories. I recommend ice, compression, and
sometimes electrical stimulation. Only when these measures fail do I prescribe
tramadol, a synthetic opioid. It does have some addiction potential, but
much less than hydrocodone, codeine, or oxycodone.[8]
I also have a discussion upfront with the patient about my strategy to
create a pain-free experience for them. When patients ask for opioids,
I tell them I'm very effective at pain management and that my surgical
technique aims to avoid causing pain in the first place.
That works about 98% of the time. Over the years, a handful of patients
have tried to manipulate me for opioid prescriptions. For this reason,
I pay close attention to the reports I get from central databases that
track patients' prescriptions from one pharmacy to another.
The most dramatic report I ever received concerned not a patient but another
physician, who got the license and Drug Enforcement Agency numbers of
several of his colleagues. I got a report saying that I'd written
about 30 prescriptions for him in 1 year. Several of us spoke to him,
and he entered a rehabilitation program.
Success in managing patients' pain requires careful monitoring. I ask
patients to score their pain on a 1-10 visual analogue scale. Not only
does this help me analyze the situation of an individual patient, but
it allows me to evaluate my success across my practice by averaging the
scores of dozens of patients. And by participating in the Arthrex Surgical
Outcomes System, I can compare my results with those of other physicians.
I challenge all physicians to take on this level of pain management.
No Easy Fixes
Although I feel confident in my approach, I also think surgeons' options
are limited until our healthcare system finds a better approach to mental
illness. Many people become addicted to opioids not because they got prescriptions
after surgery, but because it's the only way they know to douse the
flames burning inside their heads.
So the problem is going to require attention from politicians as well as
doctors. The purple ribbons that some members of Congress wore at the
State of the Union Address in January provided a reminder of the problem,
but we need much more than that. As I write this, we don't even have
an administrator for the Drug Enforcement Agency.
All of us must work together to develop comprehensive solutions of prevention
and caring to bring an end to this crisis.
References
-
Associated Press. Griffen Kramer died of heroin overdose. ESPN.com.
http://www.espn.com/story/_/id/7383205/griffen-kramer-son-ex-nfl-qb-erik-kramer-died-heroin-overdoseAccessed February 18, 2018.
-
Provisional Drug Overdose Death Counts. Centers for Disease Control and
Prevention.
https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm Accessed February 19, 2018.
-
Welch A. Drug overdoses killed more Americans last year than the Vietnam
War. CBS News.
https://www.cbsnews.com/news/opioids-drug-overdose-killed-more-americans-last-year-than-the-vietnam-war/Accessed February 19, 2018.
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Goesling J, Moser SE, Zaidi B, et al. Trends and predictors of opioid use
after total knee and total hip arthroplasty. Pain. 2016;157:1259-1265.
Abstract
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Sehgal N, Colson J, Smith HS. Chronic pain treatment with opioid analgesics:
benefits versus harms of long-term therapy. Expert Rev Neurother. 2013;13:1201-1220.
Abstract
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Harocopos A, Allen B, Paone D. Circumstances and contexts of heroin initiation
following non-medical opioid analgesic use in New York City. Int J Drug
Policy. 2016;28:106-112.
Abstract
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Guy GP Jr., Zhang K, Bohm MK, et al. Vital Signs: Changes in opioid prescribing
in the United States, 2006–2015. MMWR Morb Mortal Wkly Rep. 2017;66:697-704.
Abstract
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Tramadol: Update Review Report. World Health Organization.
http://www.who.int/medicines/areas/quality_safety/6_1_Update.pdf Accessed February 19, 2018.
Medscape Orthopedics © 2018 WebMD, LLC
Any views expressed above are the author's own and do not necessarily
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Cite this article: Sports Medicine Can Do Without Opioids -
Medscape - Feb 27, 2018.