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Fighting Back: Broader approach to treating pain cuts opioid use by 25%

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Editor's note: "Fighting Back: The Opioid Crisis" is a three-part series in partnership with KTVL. In Part 1, four former addicts talk about how they overcame their demons and are now helping others. In Part 2, a mother takes to the streets with naloxone after losing a son to heroin overdose. See more during KTVL's 6 p.m. broadcast tonight.

Nurse Karey Westbrook vividly recalls a woman who regularly took opioids for chronic pain and then went in for surgery.

Westbrook was caring for her after the operation and was administering more opioids to try and combat the woman’s post-surgical pain. But the woman continued to experience high levels of suffering, describing her pain as a level 10 — the worst possible. Meanwhile, she was growing more and more sleepy from the drugs.

Opioids can have a sedative effect, suppressing people’s breathing to the point that they die.

“And I ended up giving her too much and we had to use a reversal agent,” Westbrook says. “And that changed my life.”

Although the medical team reversed the overdose, Westbrook was filled with guilt over what had happened. She saw firsthand the potentially deadly consequences of opioids — and the fact that they are not a silver bullet for pain.

“And she still didn’t have good pain control despite the fact that I was giving more and more of the medications, more and more of those opioids to try and get better pain control,” Westbrook says. “And we didn’t achieve it, but we did see the results of the adverse effects of opioids.”

She tells the story of that incident to new nurses at Asante.

“Because that is a day that I will never forget. I can see her face. She lived. We were able to pull her back out of it. But that was terribly devastating for her,” Westbrook says.

One year ago, Westbrook joined a newly formed pain team that is reassessing how the Asante hospital system addresses pain in patients at its Medford, Ashland and Grants Pass hospitals.

Asante formed the pain team as the Rogue Valley and the rest of the nation continues to grapple with widespread opioid addiction. Opioids include prescription painkillers like OxyContin as well as heroin.

Four out of five heroin users were first exposed to opioids through prescription painkillers, according to the Partnership for Drug-Free Kids.

With more Americans dying from overdoses than car wrecks, the federal Drug Enforcement Administration is clamping down on opioid pain pills.

The United States has more opioid prescriptions per capita than any nation — enough to provide every adult in the country with a bottle of pills, according to medical experts.

“We knew we had to be proactive because the Drug Enforcement Administration has put caps on how much can be produced,” says Mike Wyant, a pharmacist and the medication safety coordinator for Asante. “And we knew that at current levels of usage, we simply would probably run out of drug.

“So we needed a comprehensive plan to reduce the amount that we were using. And we’ve been largely successful. Over the last year, our overall usage has gone down approximately 25 percent.”

Wyant and Westbrook co-chair Asante’s interdisciplinary pain team, which includes doctors, nurses and pharmacists.

Asante is rethinking the traditional 0-10 pain scale in which patients self-report their own suffering from “no pain” to “worst possible pain.”

Instead, health care providers are looking at how to treat pain to allow a person to function and have a better quality of life.

They are also embracing the value of less dangerous pain treatment, including over-the-counter drugs such as ibuprofen, medication to ease nerve sensations, physical therapy, massage, lifestyle changes and more.

Westbrook said the approach is like using a whole toolbox — not about withholding opioids.

“That’s not what it’s about,” she says. “It’s about showing you other options that could help you just as well and would have less risk of hurting you. So it’s really about education. We’re up against years of misinformation and miseducation about opioids, and so we not only have to learn new ways, but teach new ways.”

A perfect storm

In 1996, the pharmaceutical company Purdue released the pain medication OxyContin, a major driver of the opioid epidemic. The company heavily marketed the drug, reassuring physicians it was safe, effective and carried little risk of addiction, according to staysafeoregon.com, a website devoted to opioid addiction and overdose prevention.

Purdue’s claims came even though Americans had become addicted to similar drugs like opium, morphine and heroin as far back as the 1800s.

The company was fined $600 million in 2007 for misrepresenting OxyContin’s risks, according to staysafeoregon.com.

As Purdue was promoting its new drug OxyContin in the 1990s, pain organizations, patients and families were raising alarms about the under treatment of pain.

A movement began to label pain as the “fifth vital sign.”

In 2001, the Joint Commission on Accreditation of Healthcare Organizations mandated that hospitals assess pain in all patients.

Doctors faced citations and were sometimes sued for not aggressively treating pain.

Wyant says doctors were put in a no-win situation. No matter their misgivings, they felt compelled to write more prescriptions for opioid pain medication.

“During the course of my career I have seen a literal explosion of opioid prescriptions and orders. It has gone up at least fourfold probably in the last 15 years,” says Wyant, who has been a pharmacist in both retail and hospital settings for 25 years.

He says he long has been concerned about opioid risks, which include unwanted side effects, addiction and overdose.

Wyant says doctors sometimes didn’t spend enough time talking to patients about those risks.

Dr. Scott Wilber, vice president of medical affairs at Asante Rogue Regional Medical Center in Medford, has been an emergency department physician for 25 years.

He says the medical community and patients put too much faith in opioid pain medication as a cure-all for pain.

“Over the last 25 years, the difference has been that there was a real focus on using opiates for treatment of pain and an idea that we could eliminate pain in patients,” Wilber says. “And I think both of those ideas led us down the path of focusing on opiates in high doses as the only modality to treat pain. And in reality, we can generally never make pain completely go away in someone that has an acute or a chronic pain condition. What we want to do is make the pain tolerable, improve the patient’s quality of life so that they can deal with the pain.”

A better toolbox

Wilber says opioids remain an important tool for acute, short-term pain, such as from a broken bone, and for certain patients, including those with terminal cancer.

But again and again, he says doctors have seen people with chronic pain coming to emergency departments with poor pain control even though they are taking opioids.

“We raised the red flag with patients that had extremely high prescriptions of medication and said, ‘This doesn’t seem like the right way to treat this. The patient’s still coming to the emergency department despite being on extremely high doses of oral pain medicines at home,’” he says.

Opioids aren’t effective for some types of pain, such as migraine headaches, he says.

They trigger rebound headaches, so other medication is a better choice, Wilber says.

Other types of treatment, such as physical therapy and the application of heat and cold, can help alleviate different types of pain, he says.

For people who still have nerve pain after a bout of shingles, non-opioid medications do a better job of easing sensations in the nerves, Wyant says.

Nurse Westbrook says some patients resist going off opioids or moving to a lower dose, especially if they haven’t tried other treatments.

“But what we need to do is introduce other ideas,” she says. “So, OK, maybe opioids have a place here, but let’s dial down the dose and add a few other things to it so that we’ve got like a tool box for your pain management — not just one thing.”

As Asante trims its opioid use, Wyant says the hospital system is in the midst of gathering data about patients’ pain perceptions.

“We certainly don’t want to go back to an era where people have to needlessly suffer,” he says.

So far, Wilber says he hasn’t seen a spike in pain complaints.

“I see patient complaints here, and since we’ve reduced our opiate use by 25 percent over the last year, I haven’t really seen an increase in patients complaining that their pain wasn’t treated,” he says.

Westbrook says Asante’s pain team has been in contact with similar teams forming at other hospitals across the nation. Pain team members are also consulting with groups like the American Pain Society to make sure patient suffering is never forgotten in the push to use fewer opioids.

Westbrook says Asante has taken what it’s learned so far on a road show awareness campaign, visiting rehabilitation centers, pharmacists and other health care providers.

“People are inspired. They’re enlightened,” she says.

Westbrook says reducing opioid addiction and overdose deaths will require the efforts of the whole community.

“Everyone knows we have to do better. We know if we team up on it, we can do it,” she says.

Reach Mail Tribune reporter Vickie Aldous at 541-776-4486 or valdous@rosebudmedia.com. Follow her at www.twitter.com/VickieAldous.

"We raised the red flag with patients that had extremely high prescriptions of medication and said, ‘This doesn’t seem like the right way to treat this.'"-- Dr. Scott Wilber, Asante vice president of medical affairs
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