In August 2016, the Surgeon General sent a letter to every doctor in the United States asking them to help solve the opioid addiction problem in the U.S.

The Centers for Disease Control and Prevention (CDC) has reported that drug overdose deaths nearly tripled between 1999 and 2014. Sales of opioid analgesics increased by a factor of 4 between 1999 to 2010.

Experts believe that several factors have led to the opioid epidemic:

  • Prescriber behavior/characteristics
  • User behavior/characteristics
  • Environmental and systemic determinants

AAAHC Standard 11.K (2017 handbook edition) states: Providers who prescribe, dispense, administer, and provide patient education on medications have easy access to current drug information and other decision support resources.

To support this Standard, the AAAHC Institute has added a new title to its library of patient safety toolkits: Opioid Stewardship. This toolkit is intended to provide an easy-to-use decision support resource albeit one that focuses on the first of these identified factors: opioid prescribing with specific consideration of the volume of prescription, dosage, and length of prescription.

We refer to opioid stewardship to reflect a deliberate effort to improve and measure use so that opioids are only employed when needed and the right drug, dose, and duration are selected. The goals of opioid stewardship include optimizing clinical outcomes while minimizing risk of overuse and addiction.

Opioids in the ASC

Opioids are frequently prescribed for four “low risk” surgical procedures that are commonly performed in ambulatory settings: carpal tunnel release, laparoscopic cholecystectomy, inguinal hernia, and knee arthroscopy. In 2012, the doses prescribed for these procedures had mean daily morphine milligram equivalents (MME) of 50, 51, 54, and 59 mg, respectively. The average duration, in days, for the prescriptions were 4.9, 4.8, 4.6, and 5.4, respectively (again, 2012 data).

Further, we know that:

  • 36.5% of surgical/procedural providers’ prescriptions are
    for opioids
  • 42% of orthopedists’ prescriptions are for opioids
  • Other surgical specialties also may be frequent prescribers

The risk of chronic opioid use by patients who were not taking opiates (opiate-naïve) prior to surgeries, such as laparoscopic cholecystectomy, can increase by a factor of 1.33 to 1.62. For cataract surgery, this increase can be a factor of 1.62; 1.33 for transurethral resection of the prostate; and 1.41 for varicose vein stripping.

Patient Use of Opioids Post Procedure

Patients in a study of prescribing in ambulatory surgery (orthopedic, otolaryngology, general, podiatry, maxillofacial, gynecology, and urology) at Boston Medical Center reported taking less than half of the opioids prescribed within 10-days post-procedure.

While 70% reported that they had pills remaining, 14% reported taking pills more frequently than their prescriptions dictated and 10% sought an early refill. More than 50% of patients reported planning to keep unused medications after pain resolved.

A study of patients who underwent ambulatory shoulder surgery showed that the range of opioid pills prescribed (no information on strength) was 40 to 80. The range of unused pills at 90 days was 0 to 50; only 25% of patients had received education/ instructions on opioid disposal. For hand surgery, 13% of opioid-naïve patients continue to refill their opioid prescriptions 90 days after their procedures.

Alternatives

ASCs committed to Opioid Stewardship have a range of options to consider:

  • Choose local anesthetic techniques, acetaminophen, and non-steroidal anti-inflammatory analgesic drug (or cyclooxygenase-2 specific inhibitor).
  • Provide patient education. Establish goals and manage expectations with regard to post-operative pain. For example, the primary aim of pain management is not to achieve a certain pain score but to improve postoperative function and allow rehabilitation, while maintaining patient comfort.
  • American Pain Society guidelines on post-surgical pain recommend preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care.

The AAAHC Institute for Quality Improvement is committed to expanding the resources for ambulatory facilities. Accredited organizations will receive this new toolkit by mail. Others may order the resource through the AAAHC website.

Naomi Kuznets, Ph.D., is a Vice President and Senior Director at the AAAHC.  She has extensive experience developing and reviewing clinical practice guidelines and performance measures, conducting and reporting on quality improvement and benchmarking studies designed for ambulatory health care, and developing educational tools to help organizations improve patient safety and quality of care.