Tapering opioid prescriptions and reducing polypharmacy for inpatients with spinal cord injury at Rancho Los Amigos National Rehabilitation Center.

INTRODUCTION Reducing opioid prescriptions in the United States is vital. The Department of Health and Human Services has declared that the current rate of deaths from overdose of prescription opioids is an epidemic [1]. U.S. deaths from overdose of prescribed opioids increased by a factor of four from 1999 to 2010, with 16,651 prescription opioid deaths recorded in 2010. This number exceeded heroin deaths by more than a factor of five. In addition to the high mortality, overuse of opioid analgesics causes withdrawal, impaired cognitive function, depression, loss of motivation, constipation, and endocrine and sexual dysfunction. What is more, patients on high levels of opioids also experience hyperalgesia (decreasing pain threshold), which can mask the resolution of the pre-existing pain condition [2]. How did this epidemic of opioid overuse happen? A newly coined acronym is telling: OOPS, for opioid overuse pain syndrome [3]. The 1999 edition of the Merck Manual emphasized that opioids were often underused for chronic nonterminal pain due to over-concern about addiction. At that time, the Joint Commission on Accreditation of Health Care Organizations declared pain assessment to be a "fifth vital sign," and the prescribing culture changed dramatically. However, although opioids are appropriate for postoperative pain, tooth abscess, and cancer, they do not have proven efficacy or safety for treating long-term pain in persons with spinal cord injury (SCI) [4-5]. Many trauma patients are prescribed narcotic analgesics and sedatives in acute care. Unfortunately, it is possible that postoperative and rehabilitation primary care clinicians did not pause to identify the source of pain; they simply renewed medications. Why? Was it time constraints, patient pressures, lack of training? How can we improve prescribing decisions in rehabilitation hospitals and clinics? THE PROBLEM AT RANCHO LOS AMIGOS Rancho Los Amigos National Rehabilitation Center (RLANRC) is a public hospital in Los Angeles County with 395 licensed beds for rehabilitation of SCI, traumatic brain injury, stroke, general neurological conditions, gerontology, and reconstruction. We admit an average of 3,600 newly injured individuals each year, including 250 with SCI (54% traumatic, 40% tetraplegic). Chronic pain is reported after SCI in about 75 percent of patients; tends to persist; and is severe in about one third, being a leading cause of disability among veterans [6]. In 2013, RLANRC served 10,905 unique outpatients, including 1,918 with SCI. Many of these patients present sensitive chronic pain cases, including a history of drug addiction, use of opioids for 10 or more years, and pain so severe that they report their quality of life to be very low when not using opioid analgesics. Many come from poverty, high-risk lifestyles, and dysfunctional families. Serious complications related to opioid and sedative overprescription began to be documented at RLANRC as a result of a greater emphasis on creating a coordinated continuum of care and patient safety. We also saw drug-seeking and disruptive behaviors (belligerence, yelling, throwing things, and threatening nursing staff). We realized that our SCI patients were overmedicated with muscle relaxants, pain killers, opioids, and sedatives. We determined that the overuse of medication had arisen through five different avenues: (1) polypharmacy in general (which is common in recently hospitalized patients with comorbidities and disabilities), especially the "unholy trinity" drug combination (opioids, benzodiazepines, and muscle relaxants with sedating properties); (2) sedatives for sleep in a population at risk for sleep apnea; (3) overuse of acetaminophen (risk of liver toxicity); (4) opioid use for inappropriate conditions; and (5) inadequate awareness of the need to decrease dosages as people age, or have changes in ability to metabolize medications, or have changes in body mass. …