Evidence Based Approach to Prescribing for Pain Management

Roberta Heale, Associate Editor EBN @robertaheale @EBNursingBMJ

A recent commentary in EBN

(http://ebn.bmj.com/content/ebnurs/21/2/50.full.pdf) highlighted a research study by Chang et al. 1 which demonstrated that non-opioid analgesia is as effective as opioid medication in management of acute pain. This definitely flies in the face against the common perception that opioid medications are superior in acute pain management.  It also raises some important questions about marketing in health care and the quality of evidence we use in practice.

I’m sure I’m not alone in thinking back to the early 2000’s when there seemed to be a sudden and steady increase in the number of patients requesting Oxycodone (or equivalent) for pain management for both acute and chronic conditions.  Not able to prescribe opioids at the time, I relied on my physician partners who all employed best practices for opioid prescriptions.  Somehow these measures weren’t as effective as they had been.   Patients were seeking out these medications from a variety of sources. More and more people who presented to my clinic were dependent and addicted to opioids.

There have been a number of recent, high profile, investigations and lawsuits looking at the extent to which Purdue knew about its addictive qualities of its product, Oxycontin.  Just a few here:

http://www.latimes.com/projects/la-me-oxycontin-full-coverage/

http://www.cbc.ca/radio/thecurrent/the-current-for-april-3-2018-1.4602682/drug-company-knew-oxycontin-was-addictive-and-lied-about-it-says-plaintiff-in-class-action-suit-1.4602691

https://www.freedommag.org/magazine/201604-pill-pushers/cover-story/pill-pushers-purdue-pharma-cloacked-drug-dealers-in-lab-coats.html

Regardless of what was known, or not known, we have a global opioid crisis. Looking back, I wonder how compelling the research evidence was to support prescribing opioids in the first place, especially in light of studies such as the one cited earlier, which point to the effectiveness of non-opioid medication in acute pain management.

When I became a nurse practitioner and prescriber in 1999, the collaborative physician I worked with told me he didn’t prescribe anything new for the first five years on the market because he’d found that issues arose with many new products. While not an official part of an approved evidence-based strategy, I’ve taken the same cautious approach to prescribing in my own practice.   It’s difficult, especially with the lure of intense marketing for new products with shiny handouts and promises and with patients who arrive specifically requesting a specific new medication.  However, as the years progress, I’m increasingly more comfortable in waiting to see how new medications play out in the real world.

  1. Chang AK, Bijur PE, Esses D, et al. Effect of a single dose or oral opioid and non-opioid analgesics on acute extremity pain in the emergency department: a randomised controlled clinical trial. JAMA 2017;318:1661–7

 

(Visited 1 times, 4 visits today)