Physicians, clinics working together to manage acute pain without opioids
West-central Minnesota health system is implementing an easy reference guide for physicians and information for patients about managing acute pain without using opioid pain medications. Often, the first line of treatment is over-the-counter painkillers, which doctors say are more effective than people think.
WILLMAR, Minn. — In years past, a patient might have gone home after surgery with a bottle of opioid pills, enough for a week or two.
If the patient didn’t take all the pills, they might sit in a medicine cabinet or a drawer, forgotten, until someone found them. And the pills could have ended up in the hands of an addict.
That has led to dramatic changes in how opioids are prescribed.
Dr. Nathaniel Slinkard, an orthopedic surgeon, says he almost never prescribes opioid medications for acute pain. Neither does internal medicine specialist Dr. Kendall Bos.
Slinkard said he explains to patients why he’s treating them the way he is. If the underlying issue isn’t treated, he tells them, “Your pain’s going to come right back as soon as that medicine wears off.”
Both doctors favor treatments that have less potential for harm or addiction, and also target the cause of pain. They practice at the Carris Health-Willmar Main Clinic in Willmar, Minnesota.
Slinkard and Bos are part of a rollout of new clinical practice guidelines for treating acute pain. That’s pain in the first couple days after an injury or surgery.
Dr. Kathryn Duevel led the development of the guidelines, which have been rolled out at Carris Health and throughout CentraCare, its parent organization. It was related to her work forming the Addiction Services program at the Willmar clinic.
CentraCare and Carris Health operate eight hospitals, more than 30 clinics, 10 senior housing facilities and seven long-term care facilities in central, west central and southwestern Minnesota.
The misuse of opioids grew from two things happening in the 1990s, Duevel said. Doctors were under pressure to treat their patients’ pain more effectively, and pharmaceutical companies assured them that opioid pain medications were not addictive.
The result was an epidemic of opioid abuse and overdoses that continues today. Over time, addicts’ use of synthetic opioids, heroin and fentanyl has overtaken prescription opioids.
Duevel said overdoses and overdose deaths jumped dramatically during the pandemic, and that led to the development of the local guidelines.
“To me, it’s a pretty compelling reason — we have people dying,” Duevel said. “It’s hard to get more compelling than that.”
Duevel and a working group condensed the highlights into a one-page document for physicians. Links to the state guidelines are included if needed for additional research or to double-check something as providers get used to the new guidelines.
The recommendations are based on dozens of pages of state regulations, condensed into a quick reference guide, she said.
There’s an accompanying handout for patients explaining the treatment of acute pain in the first days after surgery or an injury. It offers a list of first-line treatments, including over-the-counter pain relievers, heat or ice, massage and exercise.
Teresa Behm, Carris Health marketing and communications director, assisted in developing and packaging the new recommendations and patient information, Duevel said.
Acetaminophen, under the brand name Tylenol, and nonsteroidal anti-inflammatory drugs such as aspirin and ibuprofen are more effective for acute pain than many people think, Duevel said.
The system is in the process of reviewing the new guidelines with providers to gauge how they are working in practice. As it develops, doctors will be able to look at their own prescription record and compare themselves across their department and the entire organization, Duevel said.
Bos and Slinkard said they have been using the guidelines, and both like them. In both cases, the new recommendations reinforce what they were already doing.
“The way I treat pain is, pain is a symptom, and my job is not to cover up the symptom,” Slinkard said. “Instead of just treating the symptom, we try to treat the issue.”
Often, the pain is caused by inflammation, and anti-inflammatory drugs can help. Other medications can be used to address nerve pain.
“There’s all kinds of different ways to treat pain,” he added.
“We use a varied bunch of injections and medications to try to treat people’s pain that don't involve opioid narcotics,” Slinkard said.
Bos said he has reduced the opioids he prescribes over the 22 years he’s practiced in Willmar. “I’d say that’s probably true of most doctors,” he said. “There’s been a gradual movement over the last 20 years.”
Bos said he was in training in the 1990s, when pain was called the “fifth vital sign,” alongside temperature, pulse rate, blood pressure and respiration rate.
Rather than prescribing opioids, he now recommends patients take anti-inflammatory drugs or “good old-fashioned Tylenol.” The guidelines are flexible, and he may prescribe a day or two of opioids, if he feels the situation warrants it.
For the most part, patients are accepting of the recommendations, Slinkard and Bos said.
“In general more and more people are educated about it and are willing to follow these guidelines,” Bos said.