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Stopping Opioid Dependency

“We already know opioids are an epidemic,” said Heather M. Weinreich, MD, with the University of Illinois-Chicago. She and her panel of three speakers explored alternative strategies to opioids during Tuesday’s “Opioid-Sparing Strategies in Otolaryngology: Approaches to Eliminate Opioids.”

“Approximately 80 percent of pills (opioids) prescribed will go unused,” said Vikas Mehta, MD, with the Montefiore Medical Center. “Most patients will stick the leftovers in their medicine cabinets.” He said many former patients have no plans of disposing of the extras and reportedly plan on keeping them.

In 2017, 11.1 million people misused pain prescriptions, he said. The illuminating factor is 60 percent of adults and 70 percent of adolescents obtained opioids without a prescription.

During his presentation, Dr. Mehta encouraged otolaryngologists to limit the number of pills they prescribe or prescribe no opioids at all. He cited studies showing patients undergoing otologic surgery, thyroidectomy, parathyroidectomy, tonsillectomy (in adults), sinonasal surgery, and head and neck cancer surgery had low pain, with tonsillectomy as the greatest pain factor.

John D. Cramer, MD, with Wayne State University, agreed. “Most otolaryngology surgeries are low pain except for the tonsillectomy at a pain level of 6.”

Citing how many homes store extra opioids from previous surgeries, they collectively suggested hospitals and doctors recommend disposal strategies and take-back programs via the DEA, most pharmacies, and police stations. However, they suggested the most successful strategy is to provide patients bags for disposal with detailed instructions when they receive the opioid prescription.

Dr. Cramer offered strategies of controlling pain and avoiding opioids for 90 percent of patients. He suggested a four-prong approach preoperatively: discuss the level of pain the patient can expect after surgery, assess comorbidities that would contraindicate pain control strategies, assess the risk factors for opioid dependency, and discuss the postoperative plan. Then, immediately after surgery, he said to revisit the pain levels and reinforce the plan for postoperative pain control.

Preventive anesthesia such as a long-acting local and nerve blocks, he said, is a good approach, saying an acetaminophen component should be scheduled around the clock for basal level of pain control. He said this enables a straightforward transition to non-opioid therapy when pain is mild.

He said NSAIDs such as celecoxib with acetaminophen could be the next combination.

“Data doesn’t support that opioids are better than NSAIDs,” he said.

Pediatric patients are not immune to opioid exposure, said David H. Chi, MD, with Children’s Hospital of Pittsburgh, saying they are often exposed via maternal opioid use and accidental ingestion.

For children, he recommended “just saying no” to prescribing opioids, seeking alternative treatments, minimizing dosing when possible, and proper disposal if opioids are prescribed.

In conclusion, Dr. Cramer asked how many doctors in the audience currently had opioids in their medicine cabinets at home. A majority of hands went up.

“We should start with ourselves,” he said. “Ninety percent of home break-ins are looking for opioids.”

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