In What Circumstances Are Opioids Appropriate?

| | Evidence Based Medicine, Physician Peer Review, Technology & Integration

Grapic For Dr Cortes August 2016 Opioid Article
At the 2016 WCI360 in Orlando, “Kill the Pain and Kill the Claim” was one of the more interesting breakout sessions. Held Aug. 24, at 11:00 a.m. in Crystal Ballroom C, the session featured the medical director for Hartford Insurance, Dr. Marcos A. Iglesias. Dr. Iglesias focused on the link between opioid therapy and the duration of a claimant’s disability. As you probably guessed, the more opioids consumed by a claimant the longer the claim duration.

This made me ask myself, “Are opioids ever appropriate?” Given the negative news over the past 3-5 years you may think that under no circumstances are opioids appropriate. In this article I share my thoughts on when I believe opioids are appropriate to use.

Obviously, there are negative associations with opioid use — overuse, addiction, abuse and death. However, there are circumstances in which opioids can be used properly, as long as they are prescribed for medically indicated conditions and under close supervision.

The first circumstance involves acute pain as a result of severe injuries. This can include polytrauma, fractures, dislocations, amputations, acute large disc herniations, large lacerations and crush injuries. In these scenarios, the level of acute severe pain is usually obvious. A medical provider can observe the patient who has great difficulty walking, moving an extremity, changing positions and who requires support or assistance. Other obvious symptoms are where the patient is diaphorectic (sweating profusely), moving slowly and cautiously, and showing facial expressions that are consistent with someone experiencing significant pain. In these clinical scenarios, an initial short course of opioids may be appropriate. Further need for the opioid would be taken into consideration upon re-evaluation.

In contrast, consider a situation in which the patient presents and specifically requests (or even demands) opioids. I’m always leery of this situation. Often a patient will describe 9/10 pain on the VAS pain scale without any noticeable corroborating signs of pain, including anything identified with diagnostic testing. It’s basically their word that they are experiencing severe pain. To me this is always a red flag.

Opioid use is also appropriate in the post-operative setting. Acute increased pain after surgery is expected. The level of pain varies depending on the procedure performed and on the individual. In my experience, educating the patient on the expected postoperative course and anticipated levels of pain helps to manage expectations as well as opioid use. Patients need to know that the opioids are expected to manage, not necessarily eliminate, the pain. Lastly, patients need to be advised in advance that they will be weaned off the medications at a certain time frame after the surgery.

Of all of the scenarios in which we see opioids prescribed, the most problematic is when a patient suffers from chronic pain. In my experience, chronic pain conditions are often difficult to treat. As medical practitioners, we try to limit chronic opioid use, but there are circumstances in which their chronic use can be appropriate.

Often, an injured worker successfully returns to work with a known chronic pain condition. For example, an injured worker has suffered a significant injury, such as a calcaneus (heel) fracture. These fractures can be life changing. They often result in limited motion, can inhibit the ability to bear prolonged weight, and produce chronic pain even when fully healed. If it has been documented that the patient is taking the opioid as instructed, is at stable doses, shows no signs of abuse, and there is documented improvement in pain and function, then continued use under close supervision is often appropriate. But again, the chronic use of opioids requires great scrutiny. This can include requiring the patient to sign an opioid contract, doing urine toxicology screens and checking state mandated databases to confirm the patient is not obtaining opioids from any other physicians.

Much of the bad press around opioid use is well deserved. But it’s also important to keep in mind the limited scenarios where opioids are appropriate. Granted, as medical technology advances, we may see opioids simply become obsolete – replaced by something that provides the same or better levels of pain reduction without the corresponding addiction or abuse problems. Like many medical practitioners, I would welcome the arrival of that technology.

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.