Devastating consequences of the opioid epidemic include increases in opioid misuse and related overdoses, as well as the rising incidence of newborns experiencing withdrawal syndrome due to opioid use and abuse during pregnancy. According to the Centers for Disease Control, more than 130 people in America-- or one person every 11 minutes-- dies everyday due to accidental misuse of these drugs.
Dr. AuBuchon joins the show to discuss this serious national crisis, and what pediatricians and other heath care providers can do to help combat this deadly addiction.
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Opioid Epidemic Update
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Learn more about Jacob AuBuchon, MD
Jacob AuBuchon, MD
Jacob AuBuchon, MD is a Washington University pediatric pain management specialist at St. Louis Children's Hospital.Learn more about Jacob AuBuchon, MD
Transcription:
Melanie Cole, MS (Host): Devastating consequences by the opioid epidemic are seen everyday by providers. Here to give us an update is my guest, Dr. Jacob AuBuchon. He’s a Washington University pediatric pain management specialist at St. Louis Children’s Hospital. Dr. AuBuchon, I'm so glad to have you with us today to give us this update. Tell us a little bit about what's going on with the opioid epidemic today. What are we seeing that’s any different?
Jacob AuBuchon MD (Guest): You know, this has been prevalent in the media for the last five years specifically. In the last few years we've started to really address this and come up with different strategies. What the general landscape is is these are high powered pain mediations that still have clear indications but have run into problems leading to addiction or more appropriately termed opiate use disorder, and that’s where we’ve run into problems. Patients stay on these for a period of time and then get dependent on them and starting to have addiction symptoms to these. So that’s the opiate epidemic in a nutshell.
Host: Thank you for that. Then what are the indications for opioid pain medications, and what have been the parameters and guidelines for the prescription in the past. What’s different now as you guys are looking at this epidemic and trying to be good stewards for pain management. Tell us a little bit about the parameters.
Dr. AuBuchon: First and foremost there's still clear indications for these medications. They're still gold standard treatments for severe, short-lived, or acute pain. So if somebody has had a surgery, especially a major surgery or a major traumatic event—major bone break in an arm or a leg—it’s still appropriate to use opiates. It’s better to tie these to improving recovery after a surgery or traumatic event. For example, if you're going to prescribe this, having it used to facilitate physical therapy or getting out of bed is the most appropriate use of these medications. In the last few years what we try to do though, knowing that there's risk of these, is educate providers about not allowing lingering days or doses of these medications outside of what we would expect the normal severe pain to last. We know that across the country one of the biggest problems is is that after surgery that instead of prescribing a few days or a weeks’ worth of opioid medication, that’s lasted month. They were given a prescription for 90 pills, for example, or 90 doses. That leads to a lot of leftover medication sitting in medicine cabinets that are available to anybody strolling through the home if they're not appropriately locked up.
Host: So then how do you assess the risk and addressing the harms of opioid use. Give us some stats over abuse and misuse, and how you are now using some strategies to mitigate that risk
Dr. AuBuchon: So about 10% of high school seniors on a national survey have admitted to using an opioid pain medication illicitly. So that leaves patients just using these medications in order to receive a high. We know that about four out of five heroin users start off with a prescription opiate pain medication. So all of these have led to the adolescent death rates from opioid overdose increasing to about 450% over the last decade to two decades.
Host: So what would you tell other providers about some of the other options that you can use even post-surgery or just past that. What would you like them to know about some of the other options out there for pain management?
Dr. AuBuchon: Sure. To get back to one of your questions, screening. There are validated screening techniques that you can use to establish risk of substance use disorder and specifically opioids for different ages and even for adults. So first establishing what their risk is for substance us or opiate use disorder. Second, educating or going over expectations with patients and families is at the top of the list. If somebody has a major surgery or has a major traumatic event, we are unlikely to ever achieve complete pain relief, especially in the first few days after surgery. So expectation management can go a long way. If you are going to prescribe opioid pain medication, you should be always linking that if clinically appropriate to acetaminophen and non-steroidal anti-inflammatories in order to reduce the amount of opioid pain medication.
Other techniques that we’ve used and increased over the last five to ten years at St. Louis Children’s have been doing more nerve blocks and more non-opioid pain medication in addition to Tylenol and things like ibuprofen. Such as gabapentin prior to surgery or even for a few days after very painful surgery, or different muscle relaxants that don’t have the same addictive potential as opioid pain medication.
Host: That’s really interesting Dr. AuBuchon to tell us about some of those other options out there. When you do have to prescribe opioids, what's involved in that selection? Dosage, duration, follow up and discontinuation. How do you follow up with patients about that?
Dr. AuBuchon: So we’ve been mostly talking about what to do in the acute setting for surgery and for traumatic events. The biggest piece of advice, in addition go overring expectations, is to limit the dose. Actually, in the state of Missouri and across the nation even pharmacies and state legislation will limit the amount you can prescribe on that initial prescription after a traumatic event. Usually that’s seven days. Actually the legislation may change, or the pharmacies may change to get even a lower amount of days, maybe even three to five days. The big thing about that is you are going to be limited but giving patients appropriate expectations on what to do and limiting the amount that you give is a reasonable strategy. You can always refill the medication. That way at least you're erring on the side of them using more of the complete prescription with less leftover medication. The other thing that I would want to stress that can really reduce the risk of people abusing these medications out in the community is storing the opioids after a surgery and then disposing of them in an FDA approved fashion after they're done using them.
Host: So would you council other providers to council their patients, the parents of their patients, about what you just stated about storage and disposal. If their child doesn’t need them anymore to get rid of them or give them back to doctor or whatever it is.
Dr. AuBuchon: Absolutely. I want to empower all the community physicians and whatever disciplines do prescribe some opioid pain medication to council those patients on an appropriate storage. You're just locking up the medicine in medicine cabinets while they're still using it after being prescribed. The very best thing you can do for disposing it is actually taking it back to an FDA approved takeback program or facility. They often do annual or biannual takeback programs through the community. That’s first tier.
Second tier is actually they recommend to either flush these medications if they're on the FDA flush list or to dispose of them mixed in an undesirable substance such as coffee grounds or kitty litter and throwing them away in household trash after scratching out the prescription bottle and throwing that away too.
Host: Wow, good suggestions all. As we wrap up, give us some take home points for other providers about not hesitating to ask for guidance from you if patients are on long-term opioids, and what you would like them to know as an update on the epidemic. And what we can expect to see.
Dr. AuBuchon: So mainly that opioids serve clear indications for acute short-lived pain. Even end of life or cancer pain. Where we get into trouble is if we’re prescribing it for chronic non-cancer pain. That’s when I would ask the community physicians or anybody in these situations to just reach out and consult our pain management team so we can—In addition to pharmacologic strategies, we can add in non-pharmacologic approaches like physical therapy and psychology in order to address these chronic pain patients. That’s where the evidence shows we get the most benefit is using these interdisciplinary approaches with physical therapy, physical functioning, psychology, and limiting the amount of opioid pain medications.
Host: Certainly the adjuvant therapies are so important in this epidemic. Thank you so much Dr. AuBuchon for coming on with us and explaining what's going on today and giving other providers that referral service so that they can ask you questions about this. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or learn more about services and resources available at St. Louis Children’s Hospital, please call Children’s physician access line at 1-800-678-HELP, or head on over to our website at stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider found this podcast informative, please share. Share on your social media, share with other providers, and be sure not to miss all the other fascinating podcasts in our library. Until next time, this is Melanie Cole.
Melanie Cole, MS (Host): Devastating consequences by the opioid epidemic are seen everyday by providers. Here to give us an update is my guest, Dr. Jacob AuBuchon. He’s a Washington University pediatric pain management specialist at St. Louis Children’s Hospital. Dr. AuBuchon, I'm so glad to have you with us today to give us this update. Tell us a little bit about what's going on with the opioid epidemic today. What are we seeing that’s any different?
Jacob AuBuchon MD (Guest): You know, this has been prevalent in the media for the last five years specifically. In the last few years we've started to really address this and come up with different strategies. What the general landscape is is these are high powered pain mediations that still have clear indications but have run into problems leading to addiction or more appropriately termed opiate use disorder, and that’s where we’ve run into problems. Patients stay on these for a period of time and then get dependent on them and starting to have addiction symptoms to these. So that’s the opiate epidemic in a nutshell.
Host: Thank you for that. Then what are the indications for opioid pain medications, and what have been the parameters and guidelines for the prescription in the past. What’s different now as you guys are looking at this epidemic and trying to be good stewards for pain management. Tell us a little bit about the parameters.
Dr. AuBuchon: First and foremost there's still clear indications for these medications. They're still gold standard treatments for severe, short-lived, or acute pain. So if somebody has had a surgery, especially a major surgery or a major traumatic event—major bone break in an arm or a leg—it’s still appropriate to use opiates. It’s better to tie these to improving recovery after a surgery or traumatic event. For example, if you're going to prescribe this, having it used to facilitate physical therapy or getting out of bed is the most appropriate use of these medications. In the last few years what we try to do though, knowing that there's risk of these, is educate providers about not allowing lingering days or doses of these medications outside of what we would expect the normal severe pain to last. We know that across the country one of the biggest problems is is that after surgery that instead of prescribing a few days or a weeks’ worth of opioid medication, that’s lasted month. They were given a prescription for 90 pills, for example, or 90 doses. That leads to a lot of leftover medication sitting in medicine cabinets that are available to anybody strolling through the home if they're not appropriately locked up.
Host: So then how do you assess the risk and addressing the harms of opioid use. Give us some stats over abuse and misuse, and how you are now using some strategies to mitigate that risk
Dr. AuBuchon: So about 10% of high school seniors on a national survey have admitted to using an opioid pain medication illicitly. So that leaves patients just using these medications in order to receive a high. We know that about four out of five heroin users start off with a prescription opiate pain medication. So all of these have led to the adolescent death rates from opioid overdose increasing to about 450% over the last decade to two decades.
Host: So what would you tell other providers about some of the other options that you can use even post-surgery or just past that. What would you like them to know about some of the other options out there for pain management?
Dr. AuBuchon: Sure. To get back to one of your questions, screening. There are validated screening techniques that you can use to establish risk of substance use disorder and specifically opioids for different ages and even for adults. So first establishing what their risk is for substance us or opiate use disorder. Second, educating or going over expectations with patients and families is at the top of the list. If somebody has a major surgery or has a major traumatic event, we are unlikely to ever achieve complete pain relief, especially in the first few days after surgery. So expectation management can go a long way. If you are going to prescribe opioid pain medication, you should be always linking that if clinically appropriate to acetaminophen and non-steroidal anti-inflammatories in order to reduce the amount of opioid pain medication.
Other techniques that we’ve used and increased over the last five to ten years at St. Louis Children’s have been doing more nerve blocks and more non-opioid pain medication in addition to Tylenol and things like ibuprofen. Such as gabapentin prior to surgery or even for a few days after very painful surgery, or different muscle relaxants that don’t have the same addictive potential as opioid pain medication.
Host: That’s really interesting Dr. AuBuchon to tell us about some of those other options out there. When you do have to prescribe opioids, what's involved in that selection? Dosage, duration, follow up and discontinuation. How do you follow up with patients about that?
Dr. AuBuchon: So we’ve been mostly talking about what to do in the acute setting for surgery and for traumatic events. The biggest piece of advice, in addition go overring expectations, is to limit the dose. Actually, in the state of Missouri and across the nation even pharmacies and state legislation will limit the amount you can prescribe on that initial prescription after a traumatic event. Usually that’s seven days. Actually the legislation may change, or the pharmacies may change to get even a lower amount of days, maybe even three to five days. The big thing about that is you are going to be limited but giving patients appropriate expectations on what to do and limiting the amount that you give is a reasonable strategy. You can always refill the medication. That way at least you're erring on the side of them using more of the complete prescription with less leftover medication. The other thing that I would want to stress that can really reduce the risk of people abusing these medications out in the community is storing the opioids after a surgery and then disposing of them in an FDA approved fashion after they're done using them.
Host: So would you council other providers to council their patients, the parents of their patients, about what you just stated about storage and disposal. If their child doesn’t need them anymore to get rid of them or give them back to doctor or whatever it is.
Dr. AuBuchon: Absolutely. I want to empower all the community physicians and whatever disciplines do prescribe some opioid pain medication to council those patients on an appropriate storage. You're just locking up the medicine in medicine cabinets while they're still using it after being prescribed. The very best thing you can do for disposing it is actually taking it back to an FDA approved takeback program or facility. They often do annual or biannual takeback programs through the community. That’s first tier.
Second tier is actually they recommend to either flush these medications if they're on the FDA flush list or to dispose of them mixed in an undesirable substance such as coffee grounds or kitty litter and throwing them away in household trash after scratching out the prescription bottle and throwing that away too.
Host: Wow, good suggestions all. As we wrap up, give us some take home points for other providers about not hesitating to ask for guidance from you if patients are on long-term opioids, and what you would like them to know as an update on the epidemic. And what we can expect to see.
Dr. AuBuchon: So mainly that opioids serve clear indications for acute short-lived pain. Even end of life or cancer pain. Where we get into trouble is if we’re prescribing it for chronic non-cancer pain. That’s when I would ask the community physicians or anybody in these situations to just reach out and consult our pain management team so we can—In addition to pharmacologic strategies, we can add in non-pharmacologic approaches like physical therapy and psychology in order to address these chronic pain patients. That’s where the evidence shows we get the most benefit is using these interdisciplinary approaches with physical therapy, physical functioning, psychology, and limiting the amount of opioid pain medications.
Host: Certainly the adjuvant therapies are so important in this epidemic. Thank you so much Dr. AuBuchon for coming on with us and explaining what's going on today and giving other providers that referral service so that they can ask you questions about this. That wraps up this episode of Radio Rounds with St. Louis Children’s Hospital. To consult with a specialist or learn more about services and resources available at St. Louis Children’s Hospital, please call Children’s physician access line at 1-800-678-HELP, or head on over to our website at stlouischildrens.org for more information and to get connected with one of our providers. If you as a provider found this podcast informative, please share. Share on your social media, share with other providers, and be sure not to miss all the other fascinating podcasts in our library. Until next time, this is Melanie Cole.