Recently, the U.S. Food and Drug Administration approved Targiniq, yet another abuse-deterrent narcotic pain pill, as part of its ongoing effort to curb the growing epidemic of prescription drug abuse and overdose. In response, Dr. Andrew Kolodny, president of Physicians for Responsible Opioid Prescribing, aptly noted, "If we really want to turn this epidemic around, the most important thing is to stop creating new cases of addiction."
But how? The traditional approaches of limiting access, policing use and persecuting misuse, have proven largely ineffective in preventing long-term dependency and keeping prescription opioids off the street.
Despite well-documented health risks, including mortality, opioids remain the mainstay of pain management today, especially in the acute post-operative setting. Complications associated with opioid use are viewed as the unavoidable cost of providing incomparable pain relief to patients. And herein lies the problem: Opioids are perceived as the first and best line of defense against pain, regardless of patient history, pain-relief needs or the availability of better-suited alternatives. As a result, more patients are being exposed to opioids than is necessary, which in turn increases the risk of misuse and abuse.
Logically, one could argue that minimizing patient exposure to opioids by flipping the decades-old "opioids first" treatment algorithm on its head, could be a practical, actionable solution to reducing avoidable complications and long-term risks of overdose, dependency and abuse.
The good news is that hospitals across the country including California Pacific Medical Center and St. Mary's in the Bay Area, have started moving away from the traditional opioid-centric pain management model towards an opioid-sparing approach. The new model of care, known as a multimodal pain regimen, uses a combination of non-narcotic pain medicines, and reserves the use of opioids for severe breakthrough pain.
The success of the multimodal regimen is owed to a new local analgesic called Exparel, which is injected into the surgical site during a patient's procedure, and controls pain with a numbing medication for up to three days. The immediate and long-acting effects of this pain reliever largely eliminate the need for opioids after surgery, when pain is at its peak. Hospitals that have successfully adopted a low-narcotic multimodal approach report significantly lower opioid requirements and subsequent reduction in opioid-related side effects.
This bold move by hospitals is just the first, albeit an important, step in changing physician and public perception about the value of opioids. When used sparingly and under careful supervision, opioids should continue to have a place in the pain management toolbox. However, the current one-size-fits-all approach to dispensing narcotics needs to change, and regulators need to focus efforts on reducing our reliance on opioids, rather than adding more opioid options to the market. As Dr. Kolodny concluded, "If doctors believe Targiniq is safe, they may be more inclined to prescribe it instead of seeking alternatives," and exploring alternatives to opioids is precisely how health care providers and institutions can do their part in battling this national crisis.
Kevin R. Hiler is a board-certified cancer and general surgeon at the California Pacific Medical Center in San Francisco.