Managing postoperative pain while limiting opioid prescriptions

Opioid abuse has come to the forefront of medical issues in recent years. What began in the 1990s with an increase in opioid prescriptions, fueled by a desire to better treat pain and reassurances from pharmaceutical companies on safety, developed into a crisis affecting nearly 1.7 million individuals by 2017, according to the National Institute on Drug Abuse.^1,2

Frequent patterns of opioid use disorder repeatedly have been traced to the initial prescribing of opioids in the medical setting.³ Chronic opioid dependence after introduction in a medical setting is directly dependent on length of initial exposure to opioids. Once dependence has developed and prescriptions run out, some patients seek out heroin as an alternative.⁴ In fact, up to 80 percent of people first using heroin have a history of misusing prescription opioids.¹

The surgical setting accounts for 9.8 percent of opioid prescriptions, making it a clear contributor to the crisis. The highest incidence of opioid prescribing within the field of plastic surgery is found in surgical procedures involving the breast.^5,6

Identification of local problem

The Aesthetic and Reconstructive Surgery Institute (ARSI) at Orlando Health, FL, in conjunction with the recently passed Florida Controlled Substance Bill, sought to develop a program to treat pain while limiting narcotic prescriptions. The legislation limits opioid prescriptions to three days, with an acute pain exemption that allows a seven-day prescription. At the time, ARSI generally prescribed opioids after surgery for up to four weeks. Typically, 42–60 5 mg opioid tablets were prescribed per patient. A multifactorial plan to curtail the prescription of opioids was necessary, but not at the expense of increased patient pain after operations.

Putting the quality improvement activity in place

The ARSI is a division of Orlando Health, a not-for-profit health system in central Florida. Orlando Health is a 2,400-bed system that comprises standalone pediatric and women’s hospitals, Level I trauma hospitals for both adults and pediatrics, and a robust cancer center affiliated with the University of Florida, Gainesville. While providing a full array of plastic surgery services to the Orlando Health system, ARSI resides within the umbrella of the Orlando Health Cancer Center and predominantly offers services for cancer reconstruction, the majority of which involve reconstruction after breast cancer treatment.

Planning and development

The project began with a clinical nurse practitioner and an ARSI plastic surgeon, who conducted a literature review to determine guidelines and explore the dynamics of postoperative pain control. American Pain Society guidelines, Enhanced Recovery After Surgery Society for Perioperative Care in Breast Reconstruction guidelines, and other accounts of multimodal therapies after breast surgical procedures were reviewed.^7-10 Quickly, a multimodal approach became the centerpiece of the improvement protocol. This developing plan included introduction of additional methods of pain control, as well as preoperative patient and family education.

A multidisciplinary team within the practice developed and reviewed an outline of the protocol. After a review of recommendations, revisions, and ultimate acceptance, the plan was submitted to the chief surgical quality officer, the breast surgeon who chairs the surgical quality committee, and the facility’s pain management physician. Final adjustments were made, and global approval was obtained.

After a short pilot program within the practice was completed with early success, the standardized program was enacted. The nurse practitioner educated the office staff, including nurses and other advanced practice providers (APPs). The surgeon involved in initiating the change provided education to breast surgeons, preoperative units, and surgical floors at the hospital. Once all involved parties were educated on the new protocol, it was put into action.

The new pain management program included patient/family education in the preoperative setting and multimodal perioperative analgesia (see Table 1). Patient and family education consisted of an informational letter, preoperative pain education focused on expectations, and a written pain plan. The letter described new laws put into effect and our goal of providing excellent pain control within the confines of the recent legislative changes.

The perioperative analgesia plan consisted of both multimodal oral pain therapies and regional nerve blocks. Preemptive analgesia, which was given two hours preoperatively, included celecoxib 200 mg, acetaminophen 1,000 mg, and gabapentin 600 mg. Intraoperatively, patients received a combination of regional blocks (PECS 1, PECS 2, intercostal blocks) with liposomal bupivacaine. The surgeon administered these blocks intraoperatively. Postoperative pain management included five medications: methocarbamol, ibuprofen, gabapentin, acetaminophen, and oxycodone 5 mg as rescue only.

The pain plan, including a written outline, was laid out to the patient at the preoperative appointment. All patients undergoing breast reconstruction have a preoperative visit with one of the APPs. This consultation included going over the surgical plan in detail, including the pain plan. The plan was explained, changes were altered to account for specific medical conditions and allergies, and prescriptions were given.

Between April and June 2018, a small sample size was evaluated, and early success was evident. Small adjustments were made to the protocol, but the only significant change was lowering the gabapentin dose to 300 mg three times a day and to 100 mg three times a day for elderly patients. This modification was driven by reported symptoms of side effects, which ceased after dosing alterations.

Resources used and skills needed

In addition to the nurse practitioner and reconstructive plastic surgeon who initiated the project, the ARSI team included two other reconstructive surgeons, four physician assistants, and four clinical nurses. The size of the team was driven by the preexisting needs of the practice. No additional clinicians or educators were necessary as the education and administration of the pain plan was all within the existing structure of the practice.

Additional resources used in developing the plan included a psychologist, pharmacist, occupational therapist, patients, and those hospital administrators sought in approval. Again, all changes implemented fit within current practice structure, only requiring change in protocol and staff member education. No additional costs were incurred.

Overall results

Before starting the project, refills for narcotics were provided to more than 70 percent of the ARSI’s patients. The project launched in May 2018, and an immediate decrease in refills occurred (see Figure 1). By the end of 2018, refills dropped to just under 10 percent of patients. In 2019, a further decrease in number of refills was seen as numbers stabilized. From July 1 to December 31, 2019, only 1.4 percent of patients received refills for narcotics.

Figure 1. Opioid prescriptions in immediate breast reconstruction patients, 2018–2019

The total number of tablets prescribed dropped at similar rates (see Figure 2). Before initiation of the pain plan, the average number of opioid tablets (5 mg oxycodone) prescribed to patients ranged from 68 to 85. Once the pain plan was initiated, this number dropped to 40–53 tablets per person on average. In October 2018, based on postoperative interviews, the initial prescription number was reduced from 42 tablets to 20 tablets. One final drop occurred in July and August 2019 after additional counseling was instituted covering education on alternative pain medicines. This drop was the result of patients actually asking that fewer pills be prescribed; some patients chose to forgo narcotics entirely. With these changes, the number of refills prescribed did not increase, nor did patients respond negatively. In fact, ARSI has maintained 100 percent satisfaction with pain control, according to our routine postoperative questionnaires.

Figure 2. Average number of opioid tablets prescribed per patient, 2018–2019

Setbacks

The first setback came with the findings of side effects related to the gabapentin prescription. The operating surgeon felt that withdrawal of gabapentin altogether was warranted. However, after team discussion, the protocol was changed from 600 mg gabapentin to 300 mg in the general population. Elderly patients are prescribed 100 mg by mouth (PO) three times a day.

Another hurdle was found in the preoperative area. The logistics of timing and administration of oral medication given preoperatively often was a struggle. This difficulty was alleviated with further education of preoperative nurses, administrators, and the anesthesia team.

Cost savings

No additional cost to the practice or hospital was incurred. Potentially, a decrease in the number of narcotics and refills benefits the community in that fewer opioids in circulation can lead to a reduction in the incidence of opioid use disorder and lower reliance on the resources necessary to treat patients requiring treatment for substance abuse. Ultimately, fewer deaths associated with opioid abuse would be seen as well. The economic burden of prescription opioid misuse in 2013 was $78.5 billion.¹¹ With global changes related to multimodal pain therapy and reduction in prescribed opioids, this economic burden could be lessened significantly.

Tips for others

Obtaining buy-in from providers was important to effectively implement this change. Good communication with stakeholders was necessary in the planning, implementation, and sustaining phases of the effort. Without communication before the change, patients and providers may not have been receptive to the new protocol. During implementation, it is important that all stakeholders are aware of the plan and its purpose so less resistance is encountered.

It is important to communicate effectively with all providers to ensure they are aware that one department is providing pain management to the patient. In this project, resident physicians were unaware of the provision of pain medication prescriptions by the reconstructive department. Good communication is required to ensure that patients are not receiving duplicate pain prescriptions.

REFERENCES

1. National Institute of Drug Abuse. Opioid overdose crisis. Available at: www. drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis. Accessed August 24, 2020.

2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition. Arlington, VA: American Psychiatric Association, 2013.

3. Hadlandsmyth K, Lund BC, Mosher HJ. Associations between initial opioid exposure and the likelihood for long-term use. JAPhA. 2019;59(1):17-22.

4. Carlson RG, Nahhas RW, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug Alcohol Depend. 2016;160:127-134.

5. Levy B, Paulozzi L, Mack KA, Jones CM. Brief report: Trends in opioid analgesic–prescribing rates by specialty, U.S., 2007–2012. Am J Prev Me. 2015;49(3):409-413.

6. Olds C, Spataro E, Li K, Kandathil C, Most SP. Assessment of persistent and prolonged postoperative opioid use among patients undergoing plastic and reconstructive surgery. JAMA Facial Plast Surg. 2019;21(4):286-291.

7. Cho R, Gordon DB, de Leon-Casasola O, et al. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17(2):131-157.

8. Temple-Oberle C, Shea-Budgell MA, Tan M, et al. (2017). Consensus review of optimal perioperative care in breast reconstruction: Enhanced recovery after surgery (ERAS) society recommendations. Plast Reconstr Surg. 2017;139(5):1056e-1071e.

9. Alfonso A, Newman M, Seeley N, et al. Multimodal analgesia in breast surgical procedures: Technical and pharmacological considerations for liposomal bupivacaine use. Plast Reconstr Surg. 2017;5(9):e1480.

10. Schmidt PC, Ruchelli G, Mackey SC, Carroll IR. Perioperative gabapentinoids: Choice of agent, dose, timing, and effects on chronic postsurgical pain. Anesthesiology. 2013;9(5):1215-1221.

11. Florence CS, ZhouC, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States. Med Care. 2016;54(10):901-906.