By Elizabeth Hofheinz, M.P.H., M.Ed., September 3, 2019
Pain will always be with us. With statistics estimating that musculoskeletal diseases affect more than one out of every two persons in the United States age 18 and over, and nearly three out of four age 65 and over, we had better learn to deal with pain…and as we now know, throwing opioids at the problem is not the answer.
Hospital for Special Surgery (HSS) in New York has been addressing this scourge head on. Todd Albert, M.D., Surgeon-in-Chief Emeritus at Hospital for Special Surgery and a Professor of Orthopedic Surgery at Weill Cornell Medical College, describes how HSS decided to tackle the problem of opioid prescribing. Dr. Albert: “There are gaps and inconsistencies in physicians’ knowledge regarding opioid prescribing. We at HSS realized this early on and in 2016 we created an educational program for our healthcare providers and demanded 100% participation.”
“We then launched into developing service-specific guidelines and simultaneous studies on what exactly was being prescribed. For a total knee, for example, we would track how many opioid pills were prescribed and how many went unused. One of our studies demonstrated that because of our educational efforts and revised prescribing guidelines, we saved 500,000 pills from being ‘in circulation.'”
This is what we do…period.
“In the case of spine, we pulled together all of the physicians, nurses and physician assistants involved in these procedures. We asked, ‘What is the appropriate number of opioid pills to give someone after a lumbar discectomy?’ We decide to begin with 30 and then track it to see if patients call back asking for more. For each procedure we created what we thought to be the appropriate average number of opioid pills. Having to do this was naturally a shift for doctors and there was an initial hesitation because it meant that their offices could receive a flood of additional phone calls for refills. In the end, an institution must draw a line and say, ‘This is what we do…this is our protocol for the institution.”
“Our third step was to develop guidelines to help patients dispose of unused opioids appropriately. We created a disposal program that encouraged and allowed for safe disposal (receptacles, education and acceptance of unused opioids). Information on the safe storage and disposal of opioids was also integrated into our pre-operative patient education classes. Although not many patients have used the program as of yet, we know it can be valuable as extra pills are the major source of opioid deaths.”
“Physicians find that it is advantageous to comply because the data show good results, with happier patients and less recidivism. It is typically more difficult to manage refills once someone is out of the hospital, but with our system—and in our state—it is not a problem. New York state has a technology where, before you refill an opioid prescription, you must check to see that the person has not refilled the prescription elsewhere.”
Win the war by eliminating the need for war…
Seth A. Waldman, M.D. is Director of the Division of Pain Management at HSS. “As we saw patients coming in on higher and higher doses of opioids and trying to manage their postop pain, it became increasingly clear that not only could we do better in terms of patient care but that doing so would help reduce the risk of unnecessary surgery and additional opioid use downstream. It is becoming evident that there is a benefit to slowing down when it comes to performing procedures on certain patients who need additional preoperative care. The concept is similar to performing a time-out before surgery in the operating room. During this prehab period, we can optimize patients from a pain standpoint. While I believe our efforts in this area are unique, my hope is that they would become standard operating procedure.”
Regarding the educational program, Dr. Waldman said, “We did a two-hour presentation with a hospital attorney regarding safe prescribing practices and the law…and we did that 18 times so that the clinical staff on every shift received the information. This information is now part of the educational package that the entire medical staff have when they begin working here.”
“Opioid prescribing can have dangerous consequences, and at our institution we made a conscious decision to do what we could to minimize the individual variability between clinicians. It is no longer acceptable to write a prescription without details on why this patient needs a certain medication and dose, as well as the plan for how she or he will be safely tapered off the medication. We require all our prescribers to establish an opioid contract with their patients…and our electronic health record (EHR) notifies the clinician when it is time to renew it. In addition, when necessary, we provide individual coaching for prescribers who need help discussing opioid treatment with their patients.”
There are few textbook opioid prescribing situations, and thus the need for a strategy as big as the problem. Dr. Waldman: “With the current volume of complex surgeries and complex patients we often need to dig deeper. For someone who has, for example, sleep apnea or excessive alcohol use, opioid prescribing is much riskier, and we have to mitigate that risk by improving their underlying condition, changing the way we use the pain medication, or both.”
A flowchart that works…
“All internists, surgeons, and their clinical staff are instructed to ask these questions: Are you on medication and if so, what? Do you have a history of addiction? Do you have a history of alcohol abuse? Have you experienced pain control problems in the past?’ If someone answers ‘yes’ to any of these, then he or she is triaged via the EHR to have an appointment with a pain specialist preoperatively. If the patient is already using an opioid or a benzodiazepine, the specialist then speaks with their prescriber, performs a toxicology screen, and checks the state’s controlled substance prescribing databases. Detection and treatment of addiction is an important component of this as well, and the pain team works closely with our psychologist and addiction social workers to make an appropriate referral for treatment when necessary. Counseling the patient about their perioperative pain treatment and setting realistic expectations is critical to success.”
Francis Lovecchio, M.D. is a fourth-year orthopedic surgery resident at HSS and was personally motivated to find a creative solution to opioid prescribing woes. “I saw how people in my hometown of Williamsport, Pennsylvania were being affected by the opioid crisis, and I was greatly disturbed that once these drugs were prescribed, that in most cases we had no idea what happened to them. Thus, we developed an app to track how many people took the pills, do they take all of them or not, etc. When I did a literature review, I found zero prospective data on how many pills people were actually taking. So, working with Ajay Premkumar, we created an automated web-based text messaging platform that includes patients from all types of orthopedic surgery that allows them to send texts as to how many pills they are taking.”
“To date we have found that when many patients finish their prescription, they do not request a refill. We came to realize that patients tend to take whatever they are given because they assume that this is what the doctor wants. In the end the procedures best served by quantitative prescribing guidelines are those involving short stays or outpatient procedures because those are the ones where you don’t know how many pills people are taking as inpatients. It is easier to estimate opioid use in someone who has undergone a complex spine surgery and has to be in the hospital for a long time.”
Get a baseline…
“We are at the point where people expect opioids after most procedures. The most pragmatic way to change that is to start determining how people are using them after surgery in the first place. Then you work on reducing those numbers. We know that patients who report higher pain scores don’t always report taking more opioids and vice versa. Taking opioids is not an automatic pain reliever, and there are a lot of different factors that go into how someone responds to medications. And sometimes people forget that opioids can have an anxiety-relieving effect. It is just my opinion, but I believe that some patients are taking higher doses and not getting any physiologic relief—what’s getting relieved is their anxiety.”
Jeffrey Stepan, M.D., MSc, now a hand surgery fellow at Washington University in St. Louis, completed his orthopedic surgery residency at HSS and was former chair of the House Staff Quality Council (HQSC). He told OSN, “Through initiatives started with HQSC and by conducting my own research, we were was able to evaluate how many opioids patients were taking after common surgeries, how our prescriber guidelines affected postoperative prescriptions, and how patient education on postoperative pain management could reduce opioid use after orthopedic surgery.”
“It is vital that surgeons be aware of the simple actions we can take to make a dent in this national emergency. You can have a quick discussion on pain expectations after surgery, provide fewer pills, offer educational materials, etc. It would also be helpful for large governing organizations such as the AAOS and the subspecialty organizations to develop free patient education materials that surgeons could provide to patients. We have shown that simple patient education materials can cut opioid use by 50% after hand surgery. Patient expectations after surgery play a huge role in both satisfaction and use of opioid medication.”
“Clinicians have the ability to make a significant impact on decreasing excessive opioid use with only a minor investment of time. Limiting prescription sizes and having honest discussions with patients regarding postoperative pain can help move the needle on this problem.”
Dr. Waldman: “Those who wish to implement similar programs at their own institution should know that the first and most important thing you have to change is the culture of the hospital itself. At HSS, opioid stewardship is everyone’s responsibility. Surgeons want the best outcomes for their patients and wouldn’t bring someone with a complex pain problem to the OR without the evaluation and treatment of a pain specialist, any more than they would ignore the preoperative recommendations of a cardiologist. If you want to effectuate this kind of change at your facility, get your administrators and surgeons on board.”
