How Can Spine Surgeons Protect Themselves in the Anti-Opioid Climate?

Highlight from the North American Spine Society 32nd Annual Meeting

In light of the current anti-opioid climate, spine care experts convened at the recent North American Spine Society 32nd Annual Meeting to re-examine the approach to managing pain in patients with spine conditions. At a session titled, The Opioid Predicament: Implications for Spine Physicians and Surgeons, the experts presented a balanced approach to the management of acute low back pain, perioperative and post-operative pain, and chronic pain that includes opioid and nonopioid analgesics. Strategies to reduce the use of opioids were emphasized, and legislation that may impact current practice was discussed.
Prescription bottle of Oxycodone, Pills Spilling From Fallen BottleLegislation has been passed in each state that impacts how opioids are prescribed; however, questions still remain on how to adhere to the rules.“How much do doctors contribute to the opioid epidemic?,” asked Mitchell F. Reiter, MD, in an introductory session at the meeting. Given the 15-year increase in overdose deaths involving prescription opioid pain relievers,1 “clearly we are on the hook for part of this problem,” said Dr. Reiter, who is Assistant Clinical Professor of Orthopaedic Surgery at Rutgers New Jersey Medical School, Newark, NJ.

Public opinion also points to physician prescribing as part of the current opioid epidemic. Dr. Reiter cited a recent survey of 1,011 adults in the United States, 34% of whom believe that physicians who inappropriately prescribe pain medications are mainly responsible for the growing problem of prescription painkiller abuse.2

Are Physicians to Blame for Opioid Crisis?
“If we are responsible, why are we responsible?,” Dr. Reiter said.

Pain became the 5th vital sign in the 1990s, because pain was found to be undertreated and not well controlled in many patients, Dr. Reiter explained. However, given the current opioid crisis, the American Medical Association (AMA) House of Delegates voted in 2016 to eliminate pain as the fifth vital sign from professional standards and usage.3

“I disagree with the AMA’s approach to that particular aspect of the problem,” Dr. Reiter said. “I don’t know if the best way to deal with the problem is to stop asking patients if they are in pain.”

“Providers are caught in the middle. We are judged and sometimes paid based on patient reported outcomes scores,” Dr. Reiter said. “We feel the pressure to make our patients happy and comfortable.”

In addition, physicians are “an easy target for authorities” compared to drug dealers, Dr. Reiter said. “For right or wrong, patients can abdicate personal responsibility with terms such as ‘they are pumping me full of pills’ or ‘they never told me [opioids] were addictive,’” Dr. Reiter said.

Adapting to the Anti-Opioid Climate
“We are clearly in an anti-opioid climate, and the question is, how are we going to deal with this problem and adapt to this new reality?,” Dr. Reiter said. In an effort to adapting to this new reality, Dr. Reiter noted that be began educating himself on opioids and became stricter in how he prescribed these medications as well as more careful with documentation.

However, Dr. Reiter said he started encountering patients with poorly controlled pain because, for example, they were not given adequate analgesia for acute severe radiculopathy by their treating physician. In addition, he saw chronic pain patients who were once well managed on opioids suddenly abandoned because their physician retired or left practice.

“We want to make sure whatever we do is evidence-based, compassionate, and patient-centric, and that we avoid knee jerk or hysterical reactions,” Dr. Reiter said. While the providers who have had major legal problems with opioid prescribing are typically “bad doctors in general” and probably operate “pill mills," providers should educate themselves on the proper use of opioids or risk losing their medical license, he said.

Legislation has been passed in each state that impacts how opioids are prescribed; however, questions still remain on how to adhere to the rules. For example, Dr. Reiter said that prescription monitoring programs are helpful, but said it is unclear how often physicians should check these resources. In addition, he wondered when controlled substance contracts and consents should be used among spine care professionals, pointing out that spine surgeons typically don’t use these tools for every patient, but are starting to use them more often.

Also, Dr. Reiter questioned whether spine surgeons are responsible for urine testing and how often this testing should be conducted. Finally, he noted that documentation rules vary from state to state and spine surgeons should become aware of those that apply to their field.

Dr. Reiter said almost all patients undergoing spinal surgery will require opioid analgesia, and that surgeons should keep in mind that not all patients taking opioids are addicts, abusers, or drug seekers.

Re-Examining Opioid Use in Spine Surgery
“We do need to re-examine how we use opioids,” Dr. Reiter concluded. “We need to minimize the use of opioids while still trying to control patients’ pain, and that means we need to know our treatment options and, more importantly, we need to know their efficacy.”

View the other presentations in this symposium:

Disclosure
Dr. Reiter disclosed private investment with CreOsso LLC, and is on the NASS Board of Directors.

Updated on: 12/07/17
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