By Dr Gajan Srikanthan, Director of Clinical Pathways, Lumeon
Effective post-surgical pain management is an essential part of a patient’s recovery. But the word “management” is crucial — the goal should be to control pain, not necessarily erase it entirely. However, the rise of a “pain-free” ethos in medicine has led to an expectation that the majority of discharges should include the prescribing of an opioid.
As a result, opioid prescriptions for surgical and dental patients continue to rise despite the recent focus on the opioid crisis. Post-operative pain has become a quality indicator by which providers are compared and reimbursed. Accordingly, physicians — and specifically surgeons — have come under increasing pressure to over-prescribe opioids, in an attempt to improve patient satisfaction, reduce ED visits, and stop unnecessary readmissions.
Indeed, the use of opioids is increasing in postsurgical care faster than it is in primary and chronic pain care. A 2018 retrospective cross-sectional study revealed that the proportion of prescriptions for U.S. patients receiving surgery, emergency, and dental care increased by 16% between 2010 and 2016. Over the study period, surgical patients received the highest proportion of potent opioids.
Despite the continual growth of opioid prescribing, there remains a dearth of standardized prescribing guidelines. Prescribing practices vary greatly across providers, with widely differing postoperative opioid prescriptions given by different providers to similar patients undergoing similar procedures.
Current prescribing practice does not necessarily discriminate among patient-reported pain scores, inherent patient factors, and the procedures performed. A study done for a single payer in Michigan demonstrated that postoperative opioid prescribing was not correlated with HCAHPS pain measures. Surgical patients are a key contributor to HCAHPS scores, and opioids account for almost 40% of surgical prescriptions.
Additionally, there is growing evidence that postoperative opioid prescriptions exceed patient needs. For example, a 2019 study showed that the quantity of opioid prescribed was significantly higher than patient-reported opioid consumption. Patient-reported pain in the week after surgery tracked well with how many opioids they were consuming, but was not very well associated with how many pills a doctor had prescribed, suggesting that doctors are not reliably matching their prescriptions to patients’ actual or anticipated pain levels. This is also a concern because most patients who receive opioids after surgery do not dispose of leftover medication, posing a risk for diversion and abuse by other patients.
To address these problems, several single-institution initiatives have successfully reduced prescribing by matching postoperative prescription size to patients’ opioid consumption in selected general surgery procedures. In one such institution, patients undergoing laparoscopic cholecystectomy were surveyed regarding how much opioid medication they used after surgery. Patient responses were then used to develop evidence-based prescribing recommendations. These recommendations resulted in an immediate and sustained 63% reduction in opioid prescription size without an increase in refill requests or patient-reported pain scores.
There is a great opportunity to target patients with specific prescribing regimes based on their individual risk factors. While guidelines for opioid management in the treatment of chronic pain have significantly impacted opioid prescribing practices, clinical practice guidelines for the management of postoperative pain have not gained traction. Several factors have been found to be associated with opioid consumption following surgery, including tobacco use, ASA classification, and obesity. Conversely, outpatient surgery and increasing age were associated with decreased opioid consumption. These results may assist surgeons in using patient characteristics to provide opioid prescriptions that more accurately reflect a given patient’s analgesic needs following surgery.
Although creating a one-size-fits-all formula encompassing individual patient pain management requirements for various surgeries would be difficult, inter-specialty collaboration among surgeons, anesthesiologists, and primary care physicians can help address the absence of opioid prescription guidelines for acute postoperative pain.
In the immediate term, the following interventions may help improve opioid prescribing during the peri-operative process:
- Early, preoperative identification of patients at risk of postoperative opioid abuse by using screening tools, such as the Opioid Risk Tool, encouraging vigilance of medical providers when prescribing opioids
- Improved communication among the preanesthetic clinician and the primary care and surgical teams
- Education for patients about postoperative pain and its management, to reduce anxiety and prepare them for reducing opioid analgesia
- In-depth education for patients about the adverse effects of opioids and the negatives of long-term opioid use
- Attention to standardization of postoperative pain management and opioid prescribing
Key to solving the problems of Post-Surgical Opioid Prescribing is to ensure the shift in prescribing practices to be based on recognition that the treatment of pain does not necessarily mean the absence of pain. Physicians can use evidence-based practices to better match prescribing with anticipated patient needs and educate patients about pain management and opioid abuse to prepare them to cope with the anticipated pain after surgery.
While opioid medication may be a necessary part of acute postoperative pain management, it should be employed thoughtfully and in ways consistent with the latest medical evidence. Best-practice guidelines and effective post-operative follow up can ensure the necessary outcomes and quality targets are met. Systems can also be deployed that automate pain screening, include a recommendation engine and management process. All of which should serve to ensure the more appropriate usage of opioids in surgical patients – before, during and after their operation.
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