Author: Christina Frangou
“Evidence is quite clear that we have, in general, given more pills out for standard procedures than are consumed by our patients. But by following best practices, using alternatives and setting expectations for our patients, we can decrease the number of pills that are prescribed while still adequately controlling patients’ pain,” said Jonah J. Stulberg, MD, PhD, an assistant professor of surgery at Northwestern University Feinberg School of Medicine, in Chicago, and the director of opioid reduction efforts for the Illinois Surgical Quality Improvement Collaborative, a 56-hospital quality collaborative in Illinois.
Dr. Stulberg was a panelist and an organizer of a daylong postgraduate course for surgeons dedicated to opioid-sparing postoperative pain, a program offered for the first time at this year’s meeting. Faculty presented practical tips from their own institutions that have led to improved pain management for patients and reduced opioid prescriptions.
- counsel patients preoperatively on opioid use, including reframing the conversation around pain;
- prioritize patient engagement with regard to management of pain, use opioid agreements with patients when appropriate, and perform risk screening;
- talk to patients about safe disposal of opioids; as part of this, surgeons were advised to help their hospitals develop opioid drop-off programs; and
- when possible, use multimodal pain control, which has been shown to reduce opioid use for a number of general surgery procedures.
John M. Daly, MD, the dean emeritus and Harry C. Donahoo Professor of Surgery at Temple University, in Philadelphia, said surgeons and physicians bear some responsibility in the opioid crisis. They prescribed too many opioids over the past two decades—an unintentional consequence of the ethos that elimination of all pain was necessary for patient satisfaction.
Efforts by surgeons and other physicians in the past few years have demonstrated a significant reduction in opioid prescriptions written for patients, he said, but it will take time for these efforts to have an impact on opioid-related deaths.
Between 2001 and 2009, opioid prescriptions rose substantially throughout the United States. Beginning in 2010, age-adjusted opioid-related overdose deaths began a similar trajectory, tripling over a six-year period, according to figures presented by Dr. Daly.
Even many overdose deaths from illegal drugs have their origins in prescription drug use: Among new heroin users, three of four report having abused prescription opioids before using heroin, he said.
How Does Opioid Use Affect Surgical Patients?
One of every two surgical patients still receives opioids after surgery, translating to about 38 million opioid prescriptions per year. Studies report varying rates of long-term opioid use after surgery among previously opioid-naive patients: The Plan Against Pain (PAP) campaign (www.planagainstpain.com), a coalition of physicians, patients and industry focused on reducing prescription opioid use, reported nearly 9% of surgical patients in 2017 became newly persistent opioid users who continued to take opioid three to six months after surgery. That figure climbed as high as 17% after certain procedures: Colectomy and total knee replacement reached 17.6% and 16.7%, respectively, followed by 10.2% for rotator cuff repairs, 8.5% for sleeve gastrectomy and 7.2% for hernia.
The PAP report found postsurgical opioid treatments pose the greatest risk to women: Women are 40% more likely than men to become newly persistent users of opioids after surgery. Although 11.3% of women continued to use opioids three to six months after surgery in 2017, just 8.1% of men became long-term users.
Despite growing concerns about opioid misuse, prescriptions for opioid tablets continue to be filled in high numbers after surgery. A retrospective study published this year showed initial opioid prescribing attributable to surgical and dental care is increasing relative to primary and chronic pain care (Ann Surg [Epub Jul 24, 2018]). Nationwide insurance claims data showed the proportion of prescriptions for patients receiving surgical, emergency and dental care increased by 15.8% from 2010 to 2016 (P<0.001), with the greatest increases related to surgical (18.1%) and dental (67.8%) prescribing, according to the report. In 2016, surgery patients filled 22% of initial prescriptions, whereas emergency medicine and dental patients filled 13% and 4.2%, respectively. Surgical patients’ mean total oral morphine equivalents per prescription increased from 240 mg in 2010 to 403 mg in 2016 (P<0.001).
Efforts in the United States
Around the country, there are state and local initiatives to reduce the mismatch between opioids prescribed and opioids needed.
In October 2017, a group of surgeons and anesthesiologists launched the Opioid Prescribing Engagement Network (Michigan-OPEN, www.michigan-OPEN.org). Michigan OPEN works in partnership with a number of surgical collaboratives funded by Blue Cross Blue Shield of Michigan, including the Michigan Surgical Quality Collaborative. Its chief effort has been the development of guidelines for procedure-specific opioid prescriptions, based on studies conducted at the University of Michigan and throughout more than 30 Michigan hospitals over the past three years.
To date, Michigan-OPEN has published guidelines for 18 common general surgery procedures, available at opioidprescribing.info and note that several more are expected later this year, including orthopedic prescribing reommendations. The guidelines offer suggestions on ways surgeons can counsel patients on pain, saying, for instance, “some pain is normal. You should be able to walk and do light activity, but may be sore for a few days. This will gradually get better.” It stresses the need for physicians to set norms for patients: “Half of patients who have this procedure take fewer than 10 to 15 pills.”
In addition, the Michigan-OPEN team published a list of best-practice recommendations. It calls for preoperative counseling; intraoperative nerve blocks, local anesthetic catheters or epidurals where appropriate; avoid co-prescribing benzodiazepines (but do not acutely withdraw benzodiazepines in those taking them preoperatively); avoiding meperidine in outpatient operations; and when opioids are deemed appropriate, oral is preferred over IV; if opioids are prescribed, only prescribe one short-acting medication type; and co-prescribe naloxone in high-risk patients.
The aim is to reduce new persistent opioid use and opioid abuse, said Chad Brummett, MD, an associate professor of anesthesiology and the director of the Division of Pain Research at the University of Michigan, in Ann Arbor.
“New persistent opioid use after surgery is common and is not significantly different between minor and major surgical procedures, but rather associated with behavioral and pain disorders. This suggests its use is not due to surgical pain but addressable patient-level predictors,” he said. “New persistent opioid use represents a common but previously underappreciated surgical complication that warrants increased awareness.”
Michael Englesbe, MD, a professor of surgery at the University of Michigan and the co-director of Michigan-OPEN, presented five “pearls” to reduce prescribing when patients are discharged. He recommended the following:
1. Discharge teaching should include discussion about the opioid epidemic.
2. Clarify that surgery hurts.
3. Ask for a pain history.
4. Explain average opioid consumption.
5. Stress to the patient that “we care for you.”
Since Michigan-OPEN published its recommendations, the number of opioid tablets prescribed for general surgery procedures at the University of Michigan declined significantly. Investigators have reported decreases in the number of opioids initially prescribed in open incisional hernia repair (–25%), open colectomy (–25%), laparoscopic colectomy (–22%) and breast biopsy (–50%) (JAMA Surg 2018;153:285-287; Ann Surg 2018;267:468-472).
In Massachusetts, Brigham and Women’s Hospital runs a program called Brigham Comprehensive Opioid Response and Education (B-CORE) program. In addition to prescribing guidelines, the campaign calls for improved access to naloxone to help reverse overdoses, improved access to treatment for patients with opioid use disorder, more interaction with the larger health care system to improve resources for providers, and better education of providers and patients regarding the safe use of opioids.
“Opioids should be the last consideration for acute pain management,” said Scott Weiner, MD, MPH, the director of B-CORE and an assistant professor at Harvard Medical School, in Boston.
The protocol also requires physicians to review the duration of the therapy and educate patients about practical storage and disposal methods of medication.
Since 2015, opioid prescriptions have declined at Brigham and Women’s as a result of B-CORE, he said. For laparoscopic appendectomy, the median number of 5-mg oxycodone pills has decreased from 30 in 2015 to 15 in 2017.
He also called on physicians to be aware of the stigma associated with opioids and “approach each patient with respect. It’s crucial to communicate why the measures are being taken and to be mindful of not underrating pain.”
Recovery Programs Reduce Pain
Michael F. McGee, MD, an assistant professor of surgery at Northwestern University, presented the case for enhanced recovery after surgery programs to reduce patients’ pain and their opioid needs. ERAS programs can benefit patients at every step of their surgical process, but preoperative counseling is a key component, he said.
Evidence shows patients’ thoughts and feelings before their surgery can affect their outcomes; anxiety, depression and a tendency to catastrophize contribute to higher levels of pain and dissatisfaction after surgery, Dr. McGee said. He cited a 2015 study of 38 surgical patients that showed a simple assessment of preoperative catastrophizing tendency and anxiety scores can assist medical teams in postoperative pain management (Clin J Pain 2005;21:439-445). A 2016 Cochrane Review found that the overall quality of evidence was “very poor” with regard to psychological preparation for surgery. However, the evidence suggests that psychological preparation “may be beneficial in the outcomes of postoperative pain,” as well as behavioral recovery, negative effect and length of stay, and is unlikely to be harmful (Cochrane Database Syst Rev 2016;:CD008646).
Dr. McGee’s patients undergo education about ERAS, receive all preoperative medicines in advance, undergo preoperative medicine evaluations with opioid screening, and discuss postoperative expectations.
“Perioperative educational programs focusing on patient expectation management is probably the most economic component of perioperative analgesia,” Dr. McGee said.
Several studies presented at the 2018 Clinical Congress showed that ERAS protocols can affect opioid use. A study from Northwell Health, in Great Neck, N.Y., found that adopting an ERAS protocol reduced average opioid use from 91.77 to 54.52 morphine equivalents. A review that compared pediatric patients undergoing colorectal procedures at Children’s Healthcare of Atlanta found that after the institution of an ERAS protocol, the percentage of patients receiving an opioid prescription after discharge fell from 64.6% to 34.3%. The ERAS protocol at Cleveland Clinic Akron General showed that the goal of opioid-free surgery is achievable with a multimodal analgesic approach that employed patient education, preemptive analgesia, ketamine-based nonopioid general anesthesia, modified liposomal bupivacaine nerve blocks and postoperative programmed non-narcotic analgesics.
Jessica L. Gross, MD, an assistant professor of trauma surgery at Wake Forest School of Medicine, in Winston-Salem, N.C., detailed how her hospital created a multidisciplinary team that reduced opioid prescriptions for trauma patients by standardizing their approach to pain control. Using a new pain management protocol, the team began discussions with patients about opioid use at admission, and transitioned from plain oxycodone to formulations with acetaminophen. They encouraged multimodality therapy, such as muscle relaxants, neuropathic pain medications and nonsteroidal anti-inflammatory drugs, when possible. All patients were discharged with an opioid-weaning plan.
A comparison of 1,670 patients treated before the new pain management protocol and 2,025 treated afterward showed patients experienced no change in pain control or satisfaction, despite a decrease in opioid prescribing in both the inpatient and outpatient settings.
Medication Take-Back Programs
Several surgeons recommend that hospitals set up programs to accept unused opioid pills. In Michigan, Medication Take-Back Day last spring collected over one ton of pills, including 54,000 opioids. The oldest dated back to 1976.
Dr. Stulberg encouraged surgeons, quality improvement officers and chief medical officers to apply for a reverse distributor license so unused medications can be collected and disposed of safely.
“We’ve seen patients really appreciate having easy access for appropriate disposal. It’s very easy to do,” he said.