EXECUTIVE SUMMARY
The number of drug abuse fatalities has doubled to more than 47,000 annually. Common surgical procedures , including laparoscopic cholecystectomy, total hip arthroplasty, total knee arthroplasty, and simple mastectomy, have been tied to increased risk for chronic opioid use in the first year after surgery by opioid-naïve patients.
- Providers should be judicious about prescribing opioids and consider non-opioid and non-pharmacological treatments of pain. They should track opioid use after surgery.
- Educate patients about sharing, storing, and disposing of medications, as well as their expectations on pain. A one-page resource can help providers discuss the risks and benefits of these medications with patients. (To access the resource, go to http://bit.ly/1PE1mNT.)
With 78 opioid-related deaths a day, what can one healthcare staff member do? The answer is plenty, according to a panel discussion at the recent annual meeting of the American Medical Association (AMA).
At its June meeting, the AMA adopted policies that promote non-opioids and non-pharmacological treatments for pain. The AMA’s new policies also encourage providers to co-prescribe naloxone, which reverses the effects of narcotics, when they prescribe opioids to patients who are at risk of an overdose.
“The AMA and our nation’s physicians have demonstrated our commitment to ending this epidemic,” said Patrice A. Harris, MD, MA, chair-elect of the AMA and chair of the AMA Task Force to Reduce Opioid Abuse. “These policies will save lives. That’s the bottom line.” Also, insurers must change and cover non-opioid and non-pharmacological therapies, Harris said.
The Department of Health and Human Services (HHS) recently announced several actions, including a proposal to eliminate any potential financial incentive for doctors to prescribe opioids based on patient experience survey questions. CMS also is taking action: to provide greater access to buprenorphine, which is an FDA-approved opioid addiction treatment, to encourage greater reliance on state Prescription Drug Monitoring Programs, and to invest in research and training.
These changes can’t come soon enough. According to the Associated Press (AP), there were more than 47,000 drug abuse fatalities in the United States in 2014, which was double the death rate in 2000.1 Most of the deaths were from heroin or opioids, AP said.
HHS Secretary Sylvia M. Burwell said, “More Americans now die from drug overdoses than car crashes, and these overdoses have hit families from every walk of life and across our entire nation.”
Part of the blame might fall on outpatient surgery providers. Physicians are prescribing more opioids than ever to patients undergoing common outpatient surgeries, according to research reported on by Same-Day Surgery in the May issue. (Readers can see “Researchers show rising opioid prescriptions following low-risk surgeries” at http://bit.ly/1rgmCi6.)
In more recent research published in JAMA Internal Medicine, common surgical procedures were tied to increased risk for chronic opioid use in the first year after surgery by opioid-naïve patients, who were patients who hadn’t filled a prescription for the pain relievers in the year before surgery.2 Patients who underwent some procedures, including laparoscopic cholecystectomy, were particularly vulnerable. Other procedures that showed patient vulnerability for chronic opioid use included total hip arthroplasty, total knee arthroplasty (TKA), simple mastectomy, open cholecystectomy, open appendectomy, and cesarean delivery.
The incidence of chronic opioid use in the first postoperative year ranged from 0.119% for cesarean delivery to 1.41% for TKA. For nonsurgical patients, the baseline incidence of chronic opioid use was 0.136%. Patient factors that were tied to increased risk included being male; being older than 50; and having a preoperative history of drug abuse, alcohol abuse, depression, benzodiazepine use, or antidepressant use.
Eric Sun, MD, PhD, instructor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine, California, and coauthors analyzed administrative health claims data for privately insured patients: 641,941 opioid-naïve surgical patients and more than 18 million opioid-naïve nonsurgical patients for comparison. They defined chronic opioid use as having filled 10 or more prescriptions or more than 120 days’ supply within the first year after surgery. They excluded the first 90 postoperative days because some opioid use is expected during that period.
One important lesson from the research is to be “always judicious about prescribing,” Sun says. “That’s the bottom line. Keep in mind the increased risk, and think, do you really need an opioid to control pain?”
Sun and his coauthors say that “results suggest that primary care clinicians and surgeons should monitor opioid use closely in the postsurgical period.”
In an interview with Same-Day Surgery, Sun said, “Your surgeons are in a world where patients get discharged. You need coordination between surgeons and primary MDs in terms of patients’ subsequent opioid use after surgery.” Ultimately, it will be the primary care doctor who is following the patient, Sun says. “It’s important that they know what’s going on.”
David Hoyt, MD, FACS, executive director of the American College of Surgeons, says that when providers receive a request for more medication, they should refer back to the medical record to see if adequate medication has been given and whether it is appropriate to renew. Also, some states have registries that track prescriptions for opioids, Hoyt says.
The emphasis on tracking is backed by the American Academy of Orthopaedic Surgeons (AAOS) Board of Directors, which released an information statement in 2015 that outlined ways to track opioid prescription use. (Readers can see the full information statement online at http://bit.ly/2aAICxK.)
David Ring, MD, PhD, who has served as a member of the AAOS Patient Safety Committee, encourages providers to address patients’ concerns about post-surgical pain and to develop a strategy that includes acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDS), ice, elevation, and splinting.3 Ring also encourages providers to call patients the day after outpatient surgery. He said that being able to communicate with patients and show empathy are critical. Providers should develop a script for difficult situations that allows them to practice what they will say, he says. Empathy is a key component, he says.
Educating providers can make a difference. Officials at Labette Health in Parsons, KS, used a team approach and focused their efforts on education in staff meetings, where staff reviewed policies, forms, and reporting procedures.
Phillip Gorman, MD, medical director of anesthesia, says, “We stay up-to-date and implement multi-modal pain management strategies such as IV acetaminophen, gabapentin, steroids, NSAIDs, and regional anesthesia with local.”
As a result, the number of patients receiving opioids dropped by 36%. In one year, the health system reduced the use of naloxone by 51%.
“These strategies have not only helped reduce the amount of opioids being administered, but also improved the patient experience related to pain management,” Gorman says.
Pain management scores for the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) rose at Labette Health. Starting in the fiscal year 2018, CMS proposes to no longer use results from three pain management questions in the HCAHPS survey in determining hospitals’ value-based purchasing program scores, the agency said in the outpatient prospective payment system proposed rule for the calendar year 2017. (See stories on that proposed rule in this issue.)
Educating Patients Is Key
Educating patients can help them manage opioids, according to an article in the August issue of Pharmacology Watch, also published by AHC Media. (Access the article at http://bit.ly/2actWUV.)
A survey showed patients have little to no idea about opioid management. The article examined a recent research letter that looked at 3,300 respondents who had received an opioid prescription and examined their sharing, storing, and disposing of the medications, according to William Elliott, MD, FACP. “About 21% reported sharing their medication with another person, primarily to help the other person manage pain,” Elliott said. “More than half of respondents reported they had leftover medication, of which 60% reported keeping the medication for future use. Nearly half did not recall receiving information on safe storage or disposal of opioids.”
Also, patients need to understand that pain tolerance and the length of time they are in pain is variable, Hoyt says. They should understand that there will be a transition from the immediate postop period, through the first couple of days, and the time that follows.
“Transition periods are not pain-free,” Hoyt says.
At the same time, patients should understand that physicians will try, in general, to make this experience as painless as possible. “That’s an educational conversation and goal you need to have with the patient,” Hoyt says.
Another important part of the conversation with patients should focus on disposal, he says. Many places, including hospitals and pharmacies, are set up to collect unused medication, Hoyt says. Emphasize that the medications should not be used by another patient who is not under the direct care of a physician, he says.
To assist providers, the American Hospital Association and the CDC just released a one-page resource for patients who are prescribed opioids before discharge so staff can discuss risks and benefits of these medications. (To access the resource, go to http://bit.ly/1PE1mNT. For an additional resource, see the end of this article.)
A lot of providers and patients are anticipating more medication than is needed, which leaves leftover medication that can be stolen or sold, Hoyt warns. “The length of time should be adequate to control symptoms from the operation or another source of pain, followed by disposing of it,” he says. “That is the best practice.”
The bottom line? “Physicians need to be vigilant as they treat pain and not overtreat it, for sure,” Hoyt says. “Patients need to realize if they have excessive medication, it’s probably best to get rid of it so someone else doesn’t get a hold of it. This is particularly the case for patients with young kids who might want to experiment. If it’s around, it increases the opportunity for that to occur.” (For more information on opioids, see “American Pain Society publishes guideline for post-surgical pain management,” Same-Day Surgery, April 2016, at bit.ly/1XNBWwi and “The Joint Commission Defends Standards Under Fire as Opioid Abuse Grows,” Same-Day Surgery, July 2016, at http://bit.ly/28Jz2b1.)
REFERENCES
- Daly M. Congress sends Obama compromise drug-abuse bill. July 13, 2016. Accessed at http://yhoo.it/2ay0qKw.
- Sun EC, Darnall B, Baker LC, et al. Incidence of and risk factors for chronic opioid use among opioid-naïve patients in the postoperative period. JAMA Intern Med 2016; published online July 11; doi:10.1001/jamainternmed.2016.3298.
- Hofheinz E. AAOS taking on opioid epidemic. Ortho This Week Oct. 16, 2015.
RESOURCE
- See an on-demand webinar from AHC Media about the CMS Conditions of Participation hospital requirement on safe opioid use. Access the webinar at http://bit.ly/2ajEMtS.
With 78 opioid-related deaths a day, what can one healthcare staff member do? The answer is plenty, according to a panel discussion at the recent annual meeting of the American Medical Association.
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