By Jim Lichauer, PharmD, BCPS, FASHP
At a recent business meeting, prior to the pandemic, I had breakfast with a man and we talked about work. When I explained my work helping hospitals and their physicians develop strategies to manage opioid prescription practices, he shared his story of struggling to stop taking opioids following a routine joint replacement surgery. He said he had taken the medication as prescribed, not more frequently, and for legitimate post-operative pain.
After taking the medication for several weeks, he said his body developed a physical dependence to the opioids. He then tried to wean himself off the drug. He had no training on how to do it, nor was he aware of the risks involved, and he soon found himself returning to the pharmacy for a refill. Each time he tried to stop taking the medication, he experienced withdrawal symptoms that would only go away with more opioids.
As we know, this is where his life could have gone horribly wrong. He could have begun soliciting refills until his doctor cut him off, started “doctor shopping” to get a fresh set of refills and then turned to illicit drugs as a last resort to stave off withdrawal. Fortunately, he paused to think about his future and decided against refilling his prescription. His reward for making the right decision was several difficult days of withdrawal, which often includes anxiety, restlessness, sweating, muscle aches, diarrhea and cramping. Other common symptoms such as dysphoria, insomnia and irritability can take longer to resolve. This man was brave in his choice and made it through the withdrawal. Many don’t. Even more important, his experience could have been minimized or prevented.
While providers have rightly been focused on the COVID-19 pandemic that is surging in our country, it’s also important not to lose sight of another significant public health issue that continues to take lives: opioid abuse. In 2018, 41 Americans died each day from overdoses involving prescription drugs.
Patients don’t know how to wean off opioids
Before the pandemic, almost 100 million surgical procedures were performed in the United States each year. As patients begin to return to elective procedures in some parts of the country, it’s worth examining the risks of post-operative opioid use. Although not all patients receive this prescription, the risk of continued opioid use for those who do is about 6%. Data published by the CDC also shows that use of prescription refills after a patient’s initial opioid prescription is associated with an increased incidence of persistent opioid use at one year.
In my work at Vizient leading our Opioid Stewardship Collaborative, a group that included pharmacists, nurses and physicians from 18 hospitals across the country, we realized the magnitude of this issue. Most patients are not appropriately educated on the potential to experience withdrawal symptoms or instructed how to taper their medications because physicians are not trained to provide this instruction.
And as an industry, we haven’t viewed the process of stopping opioid prescription refills as an issue. We now know that when some patients stop opioids abruptly after consistent use over several weeks, withdrawal symptoms may follow. And that’s how opioid dependency starts.
Since we know how habit-forming opioids can be, our stewardship must not only be focused on reducing prescription quantities and duration. It must also include education before the prescription is given to help patients and their family or caregiver understand the dangers of the drug as well as a process to teach them how to stop using them safely — and with as few withdrawal symptoms as possible — at the right time in their treatment.
How patients can take a more active role
Here are important steps for patients can take with their physician to help them minimize opioid-related risks and appropriately discontinue opioid use.
- Discuss your pain management history: Discuss your prior surgical experience(s) and your current pain management strategies. Make sure your physician understands what therapies have worked and their duration as well as what has not worked in the past.
- Discuss opioid alternatives: Do your research and ask your physician which non-opioid options, and nonpharmacological therapies they use to manage pain. They can discuss the many effective options to manage post-operative pain that may allow you to avoid or minimize the use of opioids.
- Start slow and go slow: If prescribed opioids, always use the lowest effective dose of pain medications for the shortest time possible.
- Be informed: Discuss how to appropriately and safely take your medication and make sure you understand when and how stop or wean off of your opioid medication.
Most importantly, be able to recognize warning signs and talk to your doctor if you have questions or concerns. Patients should be aware of the adverse effects of all medications they take but especially with opioids. Also make sure your family and caregivers know the warning signs and can help monitor your use of these medications. If you experience symptoms when you try to stop your opioid medications, you may be experiencing physical dependence. Contact your physician and ask for help in tapering off of the medication.
About Jim Lichauer, PharmD, BCPS, FASHP, Performance improvement Program Director for Pharmacy, Vizient
As performance improvement program director for pharmacy at Vizient, Jim Lichauer is primarily responsible for developing and leading collaborative programs focused on medication safety and adverse drug events.