In the ever-evolving landscape of healthcare, addressing the complexities of opiate prescribing, pain management and the opioid epidemic is paramount.
In a recent talk for CHOC Grand Rounds, Dr. Sarah Keating, medical director of palliative care at CHOC, discusses the importance of comprehensive, layered pain management in pediatric patients. Here, she offers strategies to physicians for safe and compassionate opiate prescribing.
Opiates are a powerful resource, when used responsibly
Dr. Keating begins her talk by pointing out that although there is a technical difference between opiates and opioids, she will be using the terms synonymously. Typical opiates used for pain management include morphine, oxycodone, hydrocodone, hydromorphone (which is related to fentanyl), and methadone.
“We will not be talking about illicit substances, substances laced with fentanyl or narcotics,” says Dr. Keating. “For example, if you are talking about providing analgesia to patients, you are talking about opiates, not narcotics.”
It’s important to respectfully fear opiates and acknowledge the opiate epidemic without stigmatizing responsible opiate use for pain management, she continues. There are strategies that physicians can take to ensure responsible opiate prescribing to pediatrics to mitigate risks of substance misuse and overuse.
“Although the opioid epidemic is complex, I am hoping to shed some light on pediatric prescriptions,” says Dr. Keating. “Although there is some risk, opiate use in pediatrics is not the centering point of the opioid epidemic the way it may be for adults. I am not pro-opiate, but I am pro-pain management.”
All patients deserve a thoughtful approach to pain management, and opiates can be a powerful resource for physicians to best treat their patients. Dr. Keating offers the following strategies to physicians for safe and responsible opiate prescribing for pain management in pediatrics.
Create a pain management plan
Managing pain is a complex issue; undertreated pain can lead to chronic pain syndromes and worsen the mental health conditions of kids and teens, says Dr. Keating.
Before prescribing opiates, it’s crucial to assess the nature of the pain. Big pains like neuropathic pain, bone pain, headaches and visceral pain may only be partially responsive to opiates. You should determine whether the pain is responsive to opiates and whether there is ongoing inflammation or tissue damage. Different types of pain may require different approaches.
The primary goal of prescribing opiates is to improve a patient’s function or comfort level. For example, if a patient can manage their daily tasks more effectively with the help of opiates, it indicates that the medication is working as intended.
On the contrary, if someone receives opiates while in the hospital and they are not getting out of bed and still not functioning, that likely is a sign they’re being underdosed. You should increase their dose and do a test of change to see if that helps. If you still aren’t seeing any improvement in function, that might be a reason to not continue to prescribe, says Dr. Keating.
Promote empathy and effective communication
Empathy is not just a virtue, but a powerful tool in addressing the multifaceted issue of opiate prescribing and the opioid epidemic, explains Dr. Keating.
Understanding the potential for addiction and guiding patients through pain management with compassion is crucial. It fosters trust, transparency and a more productive patient-physician relationship.
“Hands down, the most therapeutic element of any pain management plan is the phrase, ‘I believe you,’ says Dr. Keating. ‘I believe your pain.’”
This connection is central to reducing opioid misuse in your patients. Saying a phrase like this doesn’t mean that you are going to prescribe or keep prescribing them opiates. It will just be soothing for them to hear those words and it will help create an environment where they will be much more likely to be open about their experiences and concerns.
Encourage responsible opioid disposal
While prescribing opiates is a part of pain management, ensuring that unused opioids are disposed of properly is equally important, explains Dr. Keating. She underlines the need for accessible and convenient disposal options for patients.
Law enforcement agencies and pharmacies often offer take-back programs, providing patients with safe ways to dispose of their unused medications. Physicians should actively encourage patients and their caregivers to dispose of unused opioids responsibly to prevent these powerful medications from falling into the wrong hands or contributing to the illicit market.
Understand multimodal pain management strategies
Dr. Keating advocates for a multifaceted approach to pain management. This approach encompasses various therapies beyond opiates, including physical therapy, occupational therapy, deep breathing exercises and topical ointments.
Combining these treatments with opioid prescriptions can result in better pain control while reducing the reliance on opiates, says Dr. Keating. Physicians should consider these alternative strategies alongside opioid prescriptions to maximize patient outcomes.
Use appropriate dosing and weaning techniques for opiates
For dosing strategies for opiates, Dr. Keating advises that physicians keep the number of tablets low and recommends refilling prescriptions as needed. This approach minimizes the risk of misuse and addiction while ensuring patients have access to effective pain relief when required.
Physicians play a critical role in ensuring patients receive the right amount of medication, and ongoing evaluation of patient’s pain control and potential misuse is key.
Consider the timing of dosing opiates and their effectiveness, including the peak benefit of the medication. Avoid unnecessarily prolonging the dosing schedule, as the peak benefit of the opiates may have passed after a certain time.
Develop a weaning plan for patients who no longer require opiates and communicate this plan to patients. Weaning requires patience, the care team needs to go slow. It might not be straightforward all the time, but generally, a 10 percent reduction each day in the total daily dose is very well tolerated and doesn’t cause symptoms for most patients.
This way, you are setting your patients up for success and confidence that the opiates were a tool to get through their pain and not something they need long term.
Educate patients and families on the role of Narcan (Naloxone)
Narcan, an opioid overdose reversal agent, is a vital tool in preventing opioid-related fatalities, says Dr. Keating. She highlights the importance of education for its use, emphasizing the correct dosing and route of administration, particularly for parents who may be prescribed Narcan for their children.
Some parents and patients may be offended or taken aback by your recommendation for Narcan, but we are so lucky to have a full reversal agent for opiates, says Dr. Keating. It may not be for the four-year-old who is getting a few tabs of oxycodone to cover post-operative pain, but it can be lifesaving for an 18-year-old who found the medicine cabinet at home and took too much of their opiate prescription.
Physicians should not only prescribe Narcan to at-risk patients, but they need to ensure that parents understand how to use it. Parents need clear instructions to make sure that they, and those around them, know what to do in case of an opiate overdose.
See CHOC’s advice to parents on over-the-counter Narcan nasal spray
Consider the implications of combining opioids and THC (Cannabis)
Dr. Keating points out the importance of considering respiratory effects when combining opioids and tetrahydrocannabinol (THC) for pain control.
Physicians should exercise caution and educate patients about the potential risks and benefits. Due to the complex interactions between these substances and varying patient responses, careful monitoring and clear communication with patients are necessary.
Addressing patients with multiple substance use and preventing substance misuse
Managing patients who use multiple substances, especially opioids, is challenging, says Dr. Keating. Comprehensive assessments are crucial, considering each patient’s unique needs, potential interactions between substances and the presence of co-occurring disorders.
“It’s important to remember that when we have pain, it’s heightened by what has happened to us in the past,” says Dr. Keating. “It’s heightened by the fear we might have of that pain persisting, the anxiety of what pain, the limitations that might cause for us in the coming days.”
Developing individualized treatment plans that address both pain management and substance use is necessary. Collaboration with psychologists, psychiatrists, case managers, social workers and addiction specialists may also be beneficial.
Make sure to always screen for substance use and misuse, high-risk behaviors, preexisting mental health conditions and adverse childhood experiences (ACEs) when prescribing opiates. Utilize prescription monitoring systems, like the state of California’s system, to monitor controlled substance prescriptions and identify any concurrent opiate prescriptions from different sources.
Additional tools like the Opioid Risk Tool (ORT) and the Screener and Opioid Assessment for Patients with Pain (SOAPP) can help identify patients at risk for opioid misuse or addiction.
Improve patient education
In conclusion, Dr. Keating underscores the need for better patient education. Informed patients are more likely to follow medication instructions and understand the potential risks associated with opioid use.
Implementing clear and comprehensive patient education is a shared responsibility between physicians, nurses and other healthcare professionals. It involves educating patients about the proper use, potential side effects and the importance of not sharing medications.
By embracing these insights, physicians can play a pivotal role in addressing the opioid crisis while ensuring quality pain management for their patients, says Dr. Keating. A thoughtful approach to opiate prescribing and pain management is not only a professional duty, but a compassionate commitment to improving patient outcomes.
Although opiates do have the power to harm patients, a lack of willingness to use opiates responsibly for pain management can also do harm.
With these strategies, I hope physicians are reassured that opiates can be used for good. With empathy, comprehensive dosing and weaning plans, substance misuse considerations and effective education, opiates may improve patient outcomes and quality of life, says Dr. Keating.
Learn more about palliative care at CHOC
