Paul DeKraai knows about opioid addiction. For years, the 74-year-old Oakland, MD, resident helped those in need: adolescent psych unit, methadone clinic, detox clinic. So the irony didn’t escape him when 1 week after constant dosing with an opioid to treat the pain from a broken collarbone, torn rib and bruised lung following a horse-riding accident, he recognized his own signs of addiction.

Throughout Mr. DeKraai's 6-day post-surgical stay in the hospital, the pain-soothing hydromorphone flowed through a pump. Upon discharge, he was given a script for oxycodone. He filled that script.

During his interaction with doctors, Mr. DeKraai noticed that the consequence of addiction was not discussed with him even once. Though he had some idea due to his prior work experience, he thinks it doesn't bode well for other people. "Don't get me wrong, the nurses took good care of me and gave me a sponge bath, and handled me with care, but not once had anyone discussed with me how to cope with physical and emotional trauma.”

When he recognized the onset of withdrawal symptoms, “I immediately started breaking my tablets into half,” Mr. DeKraai told Medical Daily in an interview.

But not everyone does that, as recent studies have shown.

Researchers at the University of Texas Medical Branch, Galveston, looked at opioid prescriptions given to 236,631 patients who underwent knee and hip replacement surgeries between 2014 and 2017. For those who underwent knee surgery, the proportion of patients who filled a script within 60 days of discharge increased from 82% in 2014 to 91.5% in 2017. Similarly, the proportion of hip-surgery patients who had opioid prescriptions filled within 60 days of hospital discharge increased from 82% to 89.7% over that same time span.

Despite the level of prescription activity, the researchers found that there was "… no clinically meaningful improvement in postoperative pain level at discharge or even up to 2 months after surgery.”

High Dosages Increase Likelihood of Prolonged Usage

The morphine milligram equivalents (MME) of prescribed opioids is a common measurement that clinicians use to calculate opioid dosages for safety and ease of reference. The Centers for Disease Control and Prevention guidelines recommend that increasing opioid dosage to more than 50 MME per day should be done with careful consideration. Also, clinicians are advised against increasing dosage to more than 90 MME per day.

The findings by Texas Medical Branch said that clinicians did heed this rule and the study and the researchers noted there was a substantial decrease in opioid dosages. But, a 2020 study by University of Pennsylvania researchers found that high dosages were prescribed to patients after knee surgery, although the rate of prescriptions varied across the country, they said. (You can find that story here.)

The Agency Medical Directors’ Group Interagency Guidelines on Prescribing Opioids for Pain recommend taking opioids for 6 weeks after surgery. Opioids are then to be discontinued with 20% weekly reductions in the dosage.

According to a 2017 CDC Morbidity and Mortality Weekly report, opioids prescriptions peaked in 2010 at 782 MME per capita, decreasing to 640 MME per capita in 2015. This illustrates that clinicians are still excessively prescribing the pain-relieving medication.

“Taking medication does help with pain immensely, so it cannot be eliminated totally,” Mr. DeKraai said. “A more integrated program with medication, physical therapy and counseling should be used to stop people from depending on these drugs to feel better.” With one arm still in a sling from the August mishap, he said he could get another prescription if needed, but for now he is avoiding it.

When asked whether cutting down prescriptions would help addicts, Mr. DeKraai didn't completely agree. From his experience with his own intense pain and through his professional interaction with people living with addictions, he said cutting them off the medication is adding to the opioid crisis. It only steers them towards heroin, available illegally online and on the streets, he said. Instead, Mr. Dekraai advocates for a more holistic approach, including counseling or therapy.

The Take-Away

The CDC Guideline for Prescribing Opioids for Chronic Pain says that non-pharmaceutical therapies such as physical movement, behavioral therapy and acupuncture should be given more emphasis than pain-relieving medication. The agency cites contextual evidence to suggest exercise therapy for hip and knee osteoarthritis, which proved to have a positive impact on pain and functionality. The CDC recommends a combination of both medication and physical exercise if necessary, though only if the benefits of the painkillers outnumber the health risks.

Seema Prasad is a freelance health and climate change reporter based in Bengaluru, India. She tweets @SeemaPrasad_me.

Opioids are commonly prescribed to relieve pain but can be dangerous when they are misused. Pixabay