Opioids used to be the go-to choice for treating surgical patients’ pain. Now some hospital officials are trying to get those patients through their surgery without ever receiving any of the highly addictive drugs.
They’re doing so by revamping surgical pain management, implementing a more thoughtful prescribing approach and relying on non-addictive and less-addictive alternatives.
He said much has been learned over that time about the health risks associated with prolonged exposure to such drugs.
“Historically patients were getting opioids intraoperatively, in the recovery room, in the hospital as they recovered and at the time of discharge,” Martin said.
Danville, Pa.-based Geisinger, like many other health systems, has launched initiatives in recent years aimed at reducing the number of opioids patients receive during their care.
The focus has largely been on improving prescribing practices within the emergency department, as well
as among primary-care clinicians and dentists, who have traditionally accounted for nearly half of all prescriptions written annually in the U.S.
Changing protocols
But a growing number of hospitals and health systems have begun to examine ways to reduce the potential for overprescribing among surgeons.
Doing so requires providers to change protocols and practices, which have been widely accepted for decades, that recognize opioids as the primary option for managing postoperative pain.
Research is supporting the expanded attention. A study published in November in the journal JAMA Surgery highlighted the problem of overprescribing among surgeons. It found they prescribed opioids for nearly four times the amount that patients actually used and that the quantity of opioids prescribed was associated with higher patient consumption of such drugs.
Martin said Geisinger’s effort overall to limit opioid use has led to a dramatic decline in prescribing at the health system, with the number of opioid prescriptions written cut almost in half from 60,000 a month in 2014 to 31,000 a month currently.
Last November, the system launched its Proven-
Recovery program to introduce best practices on opioid prescribing to more than 40 surgical procedures with an objective to implement it in more than 100 elective procedures by the end of 2019.
A key goal of the program has been to eliminate the use of opioids for postoperative pain management altogether. Patients may receive a combination of nerve-blocking anesthesia during their surgery and a combination of non-opioid medications such as acetaminophen, ibuprofen, ketamine and lidocaine to manage pain during their recovery.
But the approach also focuses on managing patients’ nutrition level before surgery, which Martin said accelerates the postoperative healing process. Martin said the program so far led to an 18% reduction in the use of opioids in surgery.
“We’re in the process of reassessing that figure right now, and I’m sure it’s going to be twice that much of a reduction,” Martin said.
“Historically patients were getting opioids intraoperatively, in the recovery room, in the hospital as they recovered and at the same time of discharge. We’re in the process of reassessing that figure right now, and I’m sure it’s going to be twice that much of a reduction,” said Dr. Neil Martin, chief quality officer at Geisinger and chair of its neuroscience institute.
Challenging norms
The Cleveland Clinic over the past couple of years also has developed a postoperative pain management initiative that examined the potential for using narcotic alternatives and it has shown promising results.
Cleveland Clinic’s approach relies on a greater use of narcotic alternatives before, during and after surgery, according to Dr. Eric Chiang, an anesthesiologist at the Clinic. The approach involves regional anesthesia (injecting a drug directly into the surgical site or pain area), and increasing the use of medications like acetaminophen and ibuprofen.
“The science behind it shows that opioids are not the best pain medicine,” Chiang said. “We’re probably not using Tylenol and nonsteroidals enough.”
Cleveland Clinic last year began a pilot program to change postoperative pain management protocols for patients who undergo cesarean sections, one of the most common surgical procedures in the U.S.
Chiang said C-section patients were traditionally prescribed Percocet or Vicodin while in the hospital only to receive more opioids upon discharge. Under the new protocol, patients got scheduled doses of either 1,000 mg of Tylenol or a large dose of Motrin every three hours even if they did not request pain medication.
Patients were informed they could still request an opioid if their pain was too great, but within the first month of making the change, opioid use among post C-section patients fell by 70%. Upon discharge most C-section patients are no longer prescribed an opioid, and those who do receive a prescription get an average of five pills compared with the 31 pills patients typically received in 2015.
“By minimizing and prescribing appropriate amounts of narcotic medicine—that’s how you fight the opioid crisis,” Chiang said. “It’s all those extra pills sitting at home that get diverted, and those pills in the community are what fuel the crisis.”
Dr. Candace Granberg, a pediatric urologic surgeon at the Mayo Clinic, said her department since at least 2012 has adopted an opioid-free pain management approach toward postoperative patients that has been successful enough for many patients to not require any pain medications while in recovery or after discharge.
She said a key part of her approach has been the focus on anticipating the need for treatment before the patient actually experiences pain, with patients receiving doses of acetaminophen and ibuprofen on an alternating schedule throughout their visit and having a nerve block applied to surgical areas prior to their procedure.
Prior to a procedure, the surgical team discusses the best ways to block patient pain during the operation and to control it during the patient’s recovery and at home.
Geisinger’s Martin said the system’s ProvenRecovery approach has been used with more than 2,000 patients since November. But he acknowledged the goal of eliminating opioids entirely from surgery has been difficult to achieve.
He estimated only about 20% to 30% of patients undergoing certain procedures are opioid-free. “There’s very few where absolutely no opioids are prescribed—that’s an aspirational goal for us,” Martin said. “But our No. 1 goal is to make sure patients’ pain is controlled.”
The goal of prescribing zero opioids is complicated by the fact that such drugs are still needed to control pain in a minority of patients. Further complicating matters, more people in general use opioids to treat chronic pain and may build a tolerance over time and so require stronger medications to successfully manage acute pain that’s common after many surgical procedures.
Martin said some surgery patients cannot easily be taken off such medications without going through physical withdrawal symptoms. “It’s a little more nuanced issue than just going for total opioid-free surgery,” Martin said.
While illicit drugs like fentanyl have overtaken prescription opioids as the primary driver of the opioid epidemic, prescribed opioids remain a significant contributor. Nearly a quarter of all overdose deaths and more than a third of all opioid-related deaths in 2017 were related to using prescription opioids, according to the Centers for Disease Control and Prevention.
Providers and lawmakers in recent years have worked to address opioid overprescribing through greater education for clinicians as well as through laws in several states limiting prescriptions to just a few days’ supply.
As a result the number of written opioid prescriptions fell from a record set in 2012 of more than 255 million to more than 191 million by 2017, according to the CDC.
Improving prescribing practices
Yet some contend the robust number of prescriptions written in the U.S. still reflects an overprescribing problem that points to the need for even greater improvement in prescribing practices.
“Culturally, providers have always been heavy-handed with narcotics,” the Cleveland Clinic’s Chiang said. “We’re fighting against tradition, against the way things have been done for years and years in this country.”
Clinical concerns notwithstanding, Chiang’s point about breaking long-standing practices on managing pain may help to explain why even in the middle of the worst drug epidemic on record more hospitals don’t stop prescribing opioids to postoperative patients with no other pain issues or current dependence on such drugs.
Dr. John Daly, co-chair of the Patient Education Committee at the American College of Surgeons, said the decision whether or not to prescribe opioids has to be weighed with an understanding of both the benefits and risks for the patient.
“The benefit of opioids is that they do reduce pain,” Daly said. “If a surgeon is going to utilize opioid-free surgery for some procedures then they would need to adopt other mechanisms for reducing pain, because it’s not the goal to simply eliminate opioids.”
But many hospitals say the benefits of successfully managing pain for common surgical procedures without opioids can go beyond minimizing the risk of patients becoming addicted.
Dr. Charles Luke, an anesthesiologist and system director of the Acute Interventional Perioperative Pain Service at UPMC in Pittsburgh, said his system has cut in half the number of opioid prescriptions that surgeons write. He said the reduction in opioid use has been shown to decrease hospital lengths of stay, recovery times and opioid-related complications.
“Overall, long-term opioid reduction often leads to improved patient well-being,” Luke said. “The estimated cost savings to the health system is huge but not well-quantified.”
Mayo’s Granberg believes that not providing opioids for many common surgical procedures is a feasible and achievable goal for any healthcare provider. She expects more hospitals to adopt such policies as data on the efforts grows.
“I think that our communication has improved significantly in light of the opioid epidemic to say we’re going to aim to send them home without opioids,” Granberg said.
