5 Truths ENTs Need to Know about the Opioid Crisis

Between 100 and 150 Americans die every day from an opioid overdose; half of those deaths are related to prescription opioid use, according to the CDC. Opioids now account for more deaths than car crashes and gun homicides combined. Opioid usage has become so prevalent and so troublesome that the president of the United States declared the opioid crisis a national emergency in August 2017.

The crisis, some physicians say, has been a long time coming. In the 1990s, medical education and practice focused on alleviating pain. “The thought at the time was that we were undertreating patients with pain and that you could give patients significant amounts of opiates, and by and large, they’d be unlikely to develop dependence,” said Edward Damrose, MD, an otolaryngologist and vice chief of staff at Stanford Health Care in California.

Increasingly, however, clinicians and patients are recognizing that prescription opioid usage can lead to opioid addiction. Prescribing practices are starting to change, but slowly. “It’s like turning a huge cruise ship. For decades, we’ve been treating pain with narcotics, and the people at large, when they have pain, they expect a pill,” said Carl Stephenson, MD, an otolaryngologist in private practice in Alabama. “It’s going to take a long time to really change habits and thought processes.”

Here are six truths to keep in mind while caring for patients:

1. Your Patients May Already Be On Opioids

Otolaryngologists don’t write nearly as many opioid prescriptions as primary care providers, pain management specialists, or orthopedic physicians, but that doesn’t mean you can ignore the opioid crisis. A patient who walks into your office with sinus problems may also be taking an opioid for chronic back pain or an injury, and research suggests that up to 40% of people with head and neck cancer begin taking opioids before surgery (JAMA Otolaryngol Head Neck Surg. 2017;E1–E8). If you don’t ask about—and take into account—previous opioid usage, you could run into complications.

“If the patient needs surgery and you prescribe your usual amount of opioids for pain control, you may be massively underdosing them, and they may go through severe withdrawal,” said Babak Givi, MD, assistant professor in the department of otolaryngology–head and neck surgery at NYU Langone Health in New York City. “We cannot assume that a healthy-looking patient who comes to us for a minor procedure is not taking narcotics.”

Ask all patients about opioid use, emphasizing that you are asking because you want to provide them with the best possible care. Explain that previous opioid use can affect pain perception and the need for pain medication, and involve pain management specialists to collaborate on a pain control plan if the patient is using opioids.

“Incorporating surgical treatments for someone who already has pain management issues is tricky and requires an interdisciplinary approach,” said Jason Moche, MD, a facial plastic surgeon and assistant clinical professor of otolaryngology—head and neck surgery at Columbia University in New York City.

For decades, we’ve been treating pain with narcotics, and the people at large, when they have pain, they expect a pill. It’s going to take a long time to really change habits and thought processes. —Carl Stephenson, MD

2. The Number of Pills You Prescribe Matters

Currently, there isn’t a lot of uniformity regarding opioid prescribing practices, even within the same medical practice. One physician may write a script for 20 pain pills after a routine surgery; his colleague might regularly prescribe 14 pills to patients undergoing the same exact procedure.

The research, though, shows a clear link between the number of pills prescribed and the likelihood of patients developing dependence. A 2017 study published by the CDC found that patients who get a one-day supply of opioids have about a six percent chance of being on opioids for a year or longer. Patients who get a five-day supply have a 10% chance of using opioids a year after the initial prescription, and patients who receive a 10-day supply have a 20 percent chance of using opioids after a year (MMWR Morb Mortal Wkly Rep. 2017;66:265–269).

“If you give patients a two-week supply, most patients will not become addicted, but a significant number will,” said Andrew Kolodny, MD, co-director of Opioid Policy Research at the Heller School for Social Policy and Management at Brandeis University in Waltham, Mass., and executive director of Physicians for Responsible Opioid Prescribing.

Try to avoid prescribing extra narcotics “just in case,” or to avoid calls from patients over the weekend. According to the 2016 CDC Guideline for Prescribing Opioids for Chronic Pain, physicians “should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.”

3. You Can Probably Decrease the Amount of Opioids You Prescribe

A 2017 Dartmouth study that looked at opioid use after five common surgeries (partial mastectomy, partial mastectomy with sentinel lymph node biopsy, laparoscopic cholecystectomy, laparoscopic inguinal hernia repair, and open inguinal hernia repair) found that patients took just 28% of the opioids they were prescribed (Ann Surg. 2017;265:709–714).

Noting the data, Dartmouth provided physician education and recommended that surgeons encourage patients to use a nonsteroidal anti-inflammatory drug (NSAID) and acetaminophen before using opioids. A subsequent study found a 53 percent reduction in the number of pills prescribed for the same five surgeries, with adequate pain control maintained (Ann Surg. [Published online ahead of print March 6, 2017]).

Though the Dartmouth study didn’t include any otolaryngology surgeries, available evidence suggests that it’s safe—and prudent—to substitute NSAIDs for some opioids for post-surgical pain. Children undergoing tonsillectomy, for instance, used to routinely receive acetaminophen with codeine for pain control. Today, post-op pediatric tonsillectomy pain control typically involves plain acetaminophen and ibuprofen—sometimes combined with scheduled steroid doses and intermittent opioid use (a dose scheduled for the post-op day when pain is likely to be most intense).

“I think the message for otolaryngologists is that they really should avoid using opioids unless it’s absolutely necessary, and in many cases, it really isn’t necessary,” Dr. Kolodny said.

Be cautious even when prescribing opioids to people with cancer. A 2017 study published in Cancer found that opioid use is more common in cancer survivors, even those five and 10 years into remission, than in people without a history of cancer (Cancer. 2017;123:4286-4293), and a 2017 study of patients undergoing surgery for head and neck cancer found that nearly a quarter of patients who did not use opioids prior to surgery developed a chronic use pattern after surgery (JAMA Otolaryngol Head Neck Surg. 2017; E1–E8).

4. Patient Education Regarding Proper Use (and Disposal) of Opioids Is Necessary

Establishing realistic expectations regarding pain control is crucial. Patients need to know that some discomfort is normal, and that opioids can’t eliminate all post-operative discomfort. Post-surgical headaches, for instance, are often related to dehydration or caffeine withdrawal, and are better treated with a glass of water or cup of coffee.

It’s also important to discuss “peak intervals when the pain is going to be the worst,” Dr. Moche said. A patient who expects more pain on post-op day four compared to post-op day one is better equipped to deal with the pain, particularly if you also discuss a variety of pain control strategies, including the use of non-opioid medications.

Unused narcotics are a risk to children and the community, so be sure to talk about proper disposal. “Every patient you give an opioid to, instruct them how to dispose of excess ones,” said John Pang, MD, a head and neck surgery resident at UC San Diego Health and a coauthor of the JAMA Otolaryngology–Head & Neck Surgery paper regarding opioid use among patients with head and neck cancer. Your local pharmacist can help you and your patients figure out how to safely dispose of unneeded opioids.

5. Patients Who Want Refills Should Be Referred to Pain Management Specialists

A patient who continues to complain of pain and wants additional opioids after an initial prescription should be seen in the office. “Number one, you need to make sure that there are no complications that are causing pain,” Dr. Gavi said. “Do a good exam and listen to the patient.”

If no physical explanation for the continued pain can be found, Dr. Gavi has a conversation with the patient. “I say, ‘I can’t explain why you have this much pain; that’s unusual. I don’t have a good explanation for your pain, so I would rather you talk to a pain specialist,’” he said.

Consider involving a pain specialist in cases involving any patient who seems to have more pain than expected. “We don’t understand why some patients have more pain than others,” said Joshua Smith, MD. a chronic pain physician at Greenville Health System in South Carolina. “Maybe there is some drug-seeking behavior, but it’s not fair to our patients to chalk it all up to that.” A pain specialist can help identify and untangle factors that may be causing increased pain, and develop a multi-disciplinary treatment plan.

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Jennifer Fink is a freelance medical writer based in Wisconsin.