Author: Caroline Helwick
A quality improvement project resulted in a 46% drop in opioid use after urologic oncology surgery, Stanford Health Care researchers reported at the American Society of Clinical Oncology 2018 Quality Care Symposium (abstract 269).
“Pain can be controlled with half as much opioid[s],” said Kerri Stevenson, MN-NP, NP-C, a nurse practitioner in inpatient urology at Stanford Health Care, in Palo Alto, Calif. Over the course of this quality improvement project involving 443 patients, the median opioid use per patient decreased from 95.1 to 51.5 morphine equivalent daily doses (MEDDs). This reduction in opioid requirements was achieved successfully across multiple surgery types.
As Stevenson noted, one study (JAMA Surg 2017;152:e170504) found 6% of patients undergoing major or minor surgery demonstrated opioid dependence 90 days later. For many patients, this was their first exposure to the narcotic. “We, as providers, play a big role in this,” she said. “We need to do something about this, but what?”
Although guidelines exist for managing chronic and cancer-related pain, there is little to no published guidance for postsurgical pain management, despite the fact that acute postsurgical pain is common, she said.
The goal of the quality improvement project at this high-volume surgical department was to reduce the reliance on opioid medications for managing postoperative pain by 50%, from a baseline MEDD of 94 to a target MEDD of 47.
After finding no customized discharge instructions or guidelines for opioid use, the researchers conducted a survey of all providers in all disciplines. The responses validated that the biggest motivation for opioid use was patient satisfaction, along with the provider’s lack of knowledge of adjunctive medications or absence of belief that adjuncts could be effective.
Stevenson and her team then targeted what they concluded were the key drivers of opioid use, focusing on appropriate prescribing, increasing patient and provider awareness of alternatives, standardizing pathways, and setting expectations. They designed opioid-sparing pain regimens using varying combinations of acetaminophen, gabapentin, ketorolac and local anesthetics.
Reduced Opioid Use Across the Board
“Once we started our intervention, we noticed an immediate effect. … We saw a dramatic drop in opioid use,” she reported. The occasional outliers were always patients who were admitted with prior opioid use, she added. Standardization of pathways “really tightened our control to produce more consistent results,” she further reported.
Over the course of this project, median opioid use per patient decreased 46%, from 95.1 to 51.5 MEDDs. This reduction was successfully achieved across multiple surgery types, ranging from robotic prostatectomy (55.1 MEDDs) to open radical cystectomy (50.6 MEDDs). There was no increase in 24- or 48-hour postoperative pain score associated with the use of opioid-minimizing pathways (3.03 vs. 3.04 and 2.92 vs. 2.96, respectively). This implies that “we can have just as good pain control with half the amount of opioid,” she said.
Using the Right Words
Much of the improvement likely came from a shift in communication about pain control, which affects patients’ perception of their care. “We saw a shift from initially saying, ‘Miss Smith, we are going to get you up to walk now. You haven’t had any pain medicine. Would you like me to bring you some oxycodone?’ (In this case, the provider would not mention the patient is already taking acetaminophen, ketorolac and gabapentin.) We saw a shift in the language to something like, ‘Let’s discuss your pain control. How are you feeling today? You’re already on acetaminophen, gabapentin and ketorolac, which all work in different ways. How is this working for you? Do you think you need something a little stronger?’” The provider is communicating that the patient is, indeed, already receiving effective pain medication, she explained.
It is important to “speak with functional language,” she added. “Tell patients you are not going to take all their pain away, but that you want the patient moving around. ‘We want you doing things that you want to do.’ Work toward those goals. Give hope that the pain will improve every day.”
The plan to “sustain this change” involves help from the information technology department, which will design an easier means of self-auditing, she said. The project is now expanding beyond urologic oncology to general urology, pediatric urology and other surgical services in the hospital.