Preoperative communication promotes opioid stewardship

The art of communication is the language of leadership.
– James Humes1

Nearly 40 percent of the outpatient prescriptions that surgeons write are for opioids, a prescribing rate second only to that of pain medicine specialists (49 percent).2 As a result, surgeons are uniquely positioned to address the opioid epidemic.

Up to 10 percent of opioid-naive patients (specifically those who are not receiving chronic opioid therapy on a daily basis) who receive a postoperative narcotic prescription require opioids to control pain symptoms at one year from surgery.3 Notably, data suggest that surgeons vastly overprescribe narcotics after procedures, with unused pills inevitably stored in patients’ medicine cabinets where they can be accessed by anyone for nonmedical purposes.4 Improper disposal of medications is a major source of opioids among individuals who abuse them, a practice known as diversion.

Despite the ubiquity of pain among the ill and injured, education regarding optimal opioid prescribing practices has historically been little more than an afterthought in medical school and surgical residency curricula. According to a 2016 article in the New England Journal of Medicine, “…many physicians admit that they are not confident about how to prescribe opioids safely, how to detect abuse or emerging addiction, or even how to discuss these issues with their patients.”5 Filling this educational gap is perhaps one of the greatest obstacles surgeons face in terms of addressing the opioid epidemic. Not only must the surgical community develop a better understanding of the magnitude of the opioid epidemic, but it is essential that surgeons assume responsibility for safely and appropriately prescribing these powerful medications. Because surgeons are central to the genesis and management of surgical pain, it is our professional duty to be responsible stewards of opioids and to play a key role in crafting the medical community’s response to the opioid epidemic.

Similar to the multimodal approach that has proven efficacious to manage pain, the health care community must adopt a multifaceted approach to ensure that we are addressing the biological, psychological, and social factors that contribute to the opioid epidemic.6 We anticipate that heightened awareness will inform opioid prescribing practices for surgeons, and that targeted patient education will lead to more responsible use and disposal of opioids.

Opioid stewardship, in the form of surgeon-led preoperative discussions, may be a powerful tool in reducing the immense societal costs of the opioid epidemic. In this article, the authors discuss several strategies surgeons can use in the preoperative period to facilitate more effective communication with patients regarding risk assessment, expectations for pain management, and the harms associated with opioid analgesics.

Defining the problem

Despite recent efforts to develop multimodal analgesic regimens to control perioperative pain symptoms, opioids remain the most common pain relievers  patients use in the postoperative period. Ideally, opioid analgesics are one aspect of multimodal postoperative analgesic regimens. However, opioids are often used independently.7 In patients with pain symptoms refractory to nonopioid treatments, opioids can greatly alleviate pain symptoms and significantly improve quality of life. However, like any medical treatment, opioids carry a risk. Even moderate opioid use, as recommended after successive operations, can result in misuse, addiction, and diversion.8,9 Prolonged postoperative opioid use is associated with increased morbidity, poor quality of life, increased risk of traumatic injury, cardiac events, and delayed wound healing.10-15 Notably, surgical patients who suffer from opioid-related complications accrue greater hospital costs, higher readmission rates, and longer hospital lengths of stay.10

Opioid misuse and dependence is associated with significant morbidity and mortality. More than 500,000 people died from opioid overdose in 2000−2015.16,17 Unintentional drug overdoses have become the leading cause of accidental death in the U.S., surpassing motor vehicle-related deaths, unintentional falls, and fatal firearm injuries.18 Of the 33,091 opioid-related deaths in 2015, 61 percent were attributed to prescription medications.17 In 2011, 366,181 emergency department visits were attributed to opioid overdose, an increase from 168,379 in 2005.19 As frequent prescribers of opioids, it is essential that surgeons recognize the morbidity and mortality associated with taking these medications. Given that patients often receive opioid pain medications postoperatively, these individuals may be particularly susceptible to these harms.

The surgeon’s contribution to diversion

Opioid-related deaths and injuries have risen concurrently with opioid prescription sales, and undoubtedly, the prescribing practices of surgeons have contributed to this situation. Between 2007 and 2012, surgeons wrote 9.8 percent of opioid prescriptions in the U.S.2 Although surgeons write only a fraction of all opioid prescriptions, the average dose of opioids prescribed postoperatively appears to be rising. Wunsch and colleagues found that the average morphine equivalent dose prescribed after four common low-risk surgical procedures had increased to 247 in 2014 from 219 in 2004 (p < 0.001).20 Another factor contributing to opioid diversion is related to individuals who misuse prescription pain medications after receiving them from someone they know. In 2015, 53.7 percent of people who misused prescription pain medication received them from a friend or relative.21

Studies suggest certain patients are at higher risk for long-term postoperative opioid use.22 In a population-based study from Canada on long-term postoperative opioid use, patients were associated with an increased risk of opioid use at 90-days postoperatively if they met the following criteria:11

  • In the lower-fifth income bracket
  • Have comorbidities such as diabetes
  • Heart failure
  • Pulmonary disease
  • Preoperative use of benzodiazepines, antidepressants, and antihypertensive medications

Genetic factors also have a strong correlation with potential opioid addiction.23 Preoperative screening of patients for known risk factors offers surgeons an opportunity to educate at-risk patients and to consult specialists for recommendations regarding pain management in the perioperative period.

Changing the preoperative dialogue

Patient-centered preoperative communication is integral to setting realistic expectations for postoperative pain, developing successful nonopioid analgesic regimens, reducing opioid consumption during the postoperative period, and reducing the number of opioid pills at risk for diversion. Through shared decision making, patients can play an active role in determining the pain management plan that best addresses their medical and psychological history.24

Risk assessment

Understanding risk factors that predispose patients to opioid abuse can help surgeons to identify patients who may require preoperative interdisciplinary consultation. Essential components of a thorough risk assessment include a comprehensive understanding of previous and existing mental health and substance abuse issues, knowledge of pharmacologic treatments for substance abuse (such as methadone and buprenorphine), and an awareness of family history of substance abuse. High-risk patients, including those with complex substance abuse histories, should be referred for interdisciplinary consultation, which may include specialists in psychiatry, psychology, anesthesiology, acute or chronic pain management, pharmacy, and social work. In addition to understanding patient risk factors, physicians should inquire about the presence of children and adolescents in the household, as well as relationships with individuals suffering from drug addiction. If opioids are part of the postoperative pain management plan, surgeons should discuss safe storage and disposal methods of unused pills to reduce the likelihood of diversion. Surgeons should be sensitive to concerns regarding patient privacy and fear of discrimination as they engage in these discussions. Patients should be informed that disclosures are confidential and conducted for the safety of all involved.

Tools are emerging to assist providers in identifying patients who may be at risk for opioid dependency. The Opioid Risk Tool (ORT), available via the National Institute on Drug Abuse, is a validated self-report screening tool developed for use in chronic pain clinics, based on known risk factors for substance abuse (see Table 1).26 Although this tool has not been specifically applied or validated in the perioperative setting, it could be useful during the preoperative consultation.26 Studies aimed at validating and refining such screening and risk-assessment tools are needed to identify patients at risk for postoperative opioid dependency.

Table 1. Patient risk factors for opioid abuse

Female

Male

Family history of substance abuse
Alcohol

2

3

Illegal drugs

2

3

Prescription drugs

4

4

Personal history of substance abuse
Alcohol

3

3

Illegal drugs

4

4

Prescription drugs

5

5

Age between 16 and 45 years

1

1

History of preadolescent sexual abuse

3

0

Psychological disease
Attention-deficit disorder, obsessive-compulsive disorder, bipolar disorder, schizophrenia

2

2

Depression

1

1

Scoring total

Setting expectations in the surgical clinic

Surgeons are responsible for discussing expectations for pain management before an operation. Specifically, surgeons must set realistic expectations for perioperative pain levels and symptom control. Most surgeons anticipate that patients will experience a degree of pain following an operation, whereas patients often perceive pain as a complication. A qualitative study published in 1997 concluded that most “patients expected pain after surgery but the intensity of the pain they experienced was often significantly greater than anticipated” and that inadequate information regarding expectations for pain control was a contributing factor.27 Not only should surgeons convey realistic expectations for perioperative pain for professional reasons, but studies have demonstrated that patients want to be informed. A U.K. study examined patient perceptions of pain and recovery during the perioperative period and demonstrated that “patients wanted information on procedures, sensory-temporal matters, coping, and reassurance in that order and most preferred to receive this as outpatients prior to admission.”27,28

Several educational strategies have been used to help physicians and patients work together to set expectations for perioperative pain control, including booklets, videos, and structured discussions with physicians, psychologists, and nurses—all of which have been studied with varying results.27 The advent of social media and other web-based platforms, including apps, has increased the physician’s ability to educate a diverse patient population with different levels of health care literacy.

Surprisingly, when some patients are educated in the differences in the safety and efficacy profiles of opioid and nonopioid pain management strategies, they may decline opioid prescriptions. In a study on the importance of communication in postoperative pain management, 90 percent of patients (n = 69) declined a prescription for hydrocodone after receiving preoperative education two weeks before an operation.7

Studies show that preoperative pain management planning is reinforced with a family-centered approach. Grondin and colleagues demonstrated a reduction in postoperative pain and anxiety and an increase in the use of positive coping strategies (for example, positive attitude toward recovery) during the postoperative period when family members were involved in the preoperative discussion.29,30

Preoperative discussions regarding postoperative opioid use should also focus on developing a strategy for safe disposal of leftover medications. Patients should understand strategies for safe disposal, which may include local take-back programs at pharmacies and police stations, as well as emerging methods, such as drug deactivation systems.30 One example of a drug deactivation system is the Deterra pouch—a small bag containing carbon capable of deactivating opioid medications—that is beginning to be used in medical clinics and even by patients in their own homes.31

Improved recovery models

Interdisciplinary collaboration with other health care professionals leveraged anesthesiologists’ expertise in pain management and led to the formation of Enhanced Recovery After Surgery (ERAS)—the forerunner of the new Agency for Healthcare Research and Quality (AHRQ) Safety Program for Improving Surgical Care and Recovery (ISCR), which the American College of Surgeons (ACS) recently launched in collaboration with the Johns Hopkins Medicine Armstrong Institute for Patient Safety and Quality, Baltimore, MD. These programs call for a multidisciplinary approach to perioperative patient education, including discussions of pain management focused on improving coping strategies, limiting narcotic use, accelerating recovery, reducing complications, and shortening length of stay.32 Originally developed in 2001, ERAS has been increasingly recognized as highly effective in reducing opioid use throughout recovery and can be tailored to patients undergoing diverse surgical procedures ranging from craniotomy to amputation.32 Importantly, these pathways maximize multimodal analgesic regimens, mental health optimization, expectation setting, and patient education to improve pain control. A key contributor to the success of ISCR protocols is patient participation in preoperative discussions regarding expectations for postoperative pain.

Whenever possible, surgeons should use ISCR principles of pain management to enhance perioperative care and reduce narcotic use.

Informed consent platform

Informed consent is an essential element of quality medical care. Classic tenets of informed consent include a discussion of the recommended procedure and its rationale, as well as the risks and benefits of the procedure, any alternative treatments, and what may happen if no treatment is provided.33 Despite patient concerns regarding postoperative pain and the potential for opiate addiction, the data suggest that pain is rarely discussed during the informed consent process.34,35 A 2016 survey of 552 patients who had completed an informed consent demonstrated that although 65 percent of patients wanted to know the risk of developing chronic pain after an operation, 34 percent did not know the risk of chronic postoperative pain when interviewed.34

In addition to managing patient expectations, full disclosure regarding risks of acute opioid therapy is important from a medicolegal perspective. Cheatle and Savage argue that because individual patient vulnerability to opioid misuse and addiction is unpredictable, informed consent on the opioid issues of tolerance, dependence, and hyperalgesia is essential to minimizing patient-physician conflict and limiting liability.36 Although satisfying legal requirements is sufficient motivation for informed consent, surgical informed consent that honors patient autonomy will include a thorough discussion of opioid-related risks and benefits and will use educational interventions when necessary. In this way, informed consent can be a powerful tool that can help surgeons structure their patient-centered conversations to set realistic expectations and effectively motivate and facilitate an opioid-sparing pain management strategy.

The future of opioid stewardship

The end of the opioid epidemic will be actualized through opioid stewardship by all physicians. To reach that goal, surgeons must restructure training programs and Continuing Medical Education programs to prioritize recommended opioid prescribing practices. Specifically, education on how to conduct effective perioperative discussions—including informed consent and expectation management of postoperative pain—is warranted.

Educational interventions to address the opioid epidemic traditionally have focused on filling knowledge gaps regarding practice management guidelines without emphasizing the role of effective communication, which is necessary to successfully implement these guidelines. Notably, a randomized controlled trial among internal medicine residents from five different programs demonstrated the benefit of a training intervention that taught shared decision making and communication skills.37 The University of Washington, Seattle, offers Collaborative Opioid Prescribing Education for Risk Evaluation and Mitigation Strategy—an online, interactive curriculum that incorporates communication training and is offered at no cost to surgeons and other health care professionals who treat patients with chronic opioid pain.38 Incorporating strategies into graduate medical education that help trainees communicate more effectively with their patients could serve as an important step in preparing the next generation of surgeons to tackle the opioid crisis.

To ensure a lasting effect on future opioid prescribing practices, we also must look beyond the bedside. Promoting opioid stewardship necessitates change at many levels, including at the health care systems level. In contrast to more traditional paradigms of morbidity and mortality, the definition of successful health outcomes now incorporates more patient-centered outcomes. Going forward, it is integral that surgeons not only study these outcomes, but that we develop targeted interventions to reduce the patient experience of pain, which has a considerable effect on quality of life.38

Undoubtedly, these changes will need to be considered within the context of the complex U.S. health care system, as well as regulations issued by hospital accreditation organizations and state and federal governments. In the future, surgeons will need to engage with policymakers to ensure the development of meaningful initiatives that translate to tangible benefits for our profession and our patients.

Conclusion

The complexity of the opioid epidemic cannot be underestimated. Meaningful reduction in opioid use disorders necessitates a diverse and multifaceted approach. The surgical community must acknowledge the potential harms of opioid therapy and tailor our practices to ensure that opioid analgesics are used responsibly. Improving physician-patient communication in the preoperative setting is a potentially powerful preventive strategy.

Surgeons are positioned to play a leadership role in reducing opioid-related deaths, as well as the societal and individual tolls of opioid addiction. Through special attention to communication, patient education, opioid risk assessment and addiction screening, preoperative planning and expectation management, and reduced opioid prescriptions, surgeons can significantly limit their contribution to iatrogenic opioid dependence.


References

  1. Humes J. The art of communication is the language of leadership. Fresh Business Thinking. www.freshbusinessthinking.com/the-art-of-communication-is-the-language-of-leadership/. Published March 27, 2008. Accessed May 10, 2017.
  2. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, U.S., 2007–2012. Am J Prev Med. 2015;49(3):409-413.
  3. Alam A, Gomes T, Zheng H, Mamdani MM, Juurlink DN, Bell CM. Long-term analgesic use after low-risk surgery: A retrospective cohort study. Arch Intern Med. 2012;172(5):425-430.
  4. Bates C, Laciak R, Southwick A, Bishoff J. Overprescription of postoperative narcotics: A look at postoperative pain medication delivery, consumption and disposal in urological practice. J Urol. 2011;185(2):551-555.
  5. Volkow ND, McLellan AT. Opioid abuse in chronic pain—misconceptions and mitigation strategies. N Engl J Med. 2016;374(13):1253-1263.
  6. Borrell-Carrio F, Suchman AL, Epstein RM. The biopsychosocial model 25 years later: Principles, practice, and scientific inquiry. Ann Fam Med. 2004;2(6):576-582.
  7. Sugai DY, Deptula PL, Parsa AA, Parsa DF. The importance of communication in the management of postoperative pain. Hawaii J Med Public Health. 2013;72(6):180-184.
  8. Compton WM, Boyle M, Wargo E. Prescription opioid abuse: Problems and responses. Prev Med. 2015;80:5-9.
  9. Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US lifetime heroin use and heroin use disorder: Prevalence from the 2001–2002 to 2012–2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(5):445-455.
  10. Minkowitz HS, Gruschkus SK, Shah M, Raju A. Adverse drug events among patients receiving postsurgical opioids in a large health system: Risk factors and outcomes. Am J Health Syst Pharm. 2014;71(18):1556-1565.
  11. Clarke H, Soneji N, Ko DT, Yun LS, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population-based cohort study. 2014;348:g1251.
  12. Buckeridge D, Huang A, Hanley J, et al. Risk of injury associated with opioid use in older adults. J Am Geriatr Soc. 2010;58(9):1664-1670.
  13. Solomon DH, Rassen JA, Glynn RJ, et al. The comparative safety of opioids for nonmalignant pain in older adults. Arch Intern Med. 2010;170(22):1979-1986. doi:10.1001/archinternmed.2010.450.
  14. Martin JL, Koodie L, Krishnan AG, Charboneau R, Barke RA, Roy S. Chronic morphine administration delays wound healing by inhibiting immune cell recruitment to the wound site. Am J Pathol. 2010;176(2):786-799.
  15. Shanmugam VK, Couch KS, McNish S, Amdur RL. Relationship between opioid treatment and rate of healing in chronic wounds. Wound Repair Regen. 2017;25(1):120-130.
  16. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths: United States, 2000–2014. MMWR-Morbid Mortal Wkly Rep. 2016;64(5051):1378-1382.
  17. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths: United States, 2010–2015. MMWR-Morbid Mortal Wkly Rep. 2016;65(50-51):1445-1452.
  18. Kaafarani HM, Weil E, Wakeman S, Ring D. The opioid epidemic and new legislation in Massachusetts: Time for a culture change in surgery? Ann Surg. 2017;265(4):731-733.
  19. Drug Abuse Warning Network, 2011: National estimates of drug-related emergency department visits. Substance Abuse and Mental Health Services Administration; 2013. Available at: www.samhsa.gov/data/sites/default/files/DAWN2k11ED/DAWN2k11ED/DAWN2k11ED.pdf. Accessed May 9, 2017.
  20. Wunsch H, Wijeysundera DN, Passarella MA, Neuman MD. Opioids prescribed after low-risk surgical procedures in the United States, 2004–2012. 2016;315(15):1654-1657.
  21. Substance Abuse and Mental Health Services Administration: Hughes A, Wilson MR, et al. Prescription Drug Use and Misuse in the United States: Results from the 2015 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration; 2016. Available at: www.samhsa.gov/data/sites/default/files/NSDUH-FFR2-2015/NSDUH-FFR2-2015.htm. Accessed May 9, 2017.
  22. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016;176(9):1286-1293.
  23. Mistry CJ, Bawor M, Desai D, Marsh DC, Samaan Z. Genetics of opioid dependence: A review of the genetic contribution to opioid dependence. Curr Psychiatry Rev. 2014;10(2):156-167.
  24. Khokhar JY, Ferguson CS, Zhu AZ, Tyndale RF. Pharmacogenetics of drug dependence: Role of gene variations in susceptibility and treatment. Annu Rev Pharmacol Toxicol. 2010;50:39-61.
  25. Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med. 2012;366(9):780-781.
  26. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: Preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-442.
  27. Carr EC, Thomas VJ. Anticipating and experiencing post-operative pain: The patients’ perspective. J Clin Nurs. 1997;6(3):191-201.
  28. Shuldham C. A review of the impact of pre-operative education on recovery from surgery. Int J Nurs Stud. 1999;36(2):171-177.
  29. Wallace LM. Communication variables in the design of pre-surgical preparatory information. Br J Clin Psychol. 1986;25(Pt 2):111-118.
  30. Grondin F, Bourgault P, Bolduc N. Intervention focused on the patient and family for better postoperative pain relief. Pain Manag Nurs. 2014;15(1):76-86.
  31. Verde Technologies. The Deterra Drug Deactivation System. FAQ. Available at: http://deterrasystem.com/faq/#What-drugs-will-Deterra-deactivate. Accessed June 27, 2017.
  32. Vimont C. New drug deactivation system allows patients to safely dispose of opioids at home. Partnership for drug-free kids: Where families find answers. July 13, 2016. Available at: http://drugfree.org/learn/drug-and-alcohol-news/new-drug-deactivation-system-allows-patients-safely-dispose-opioids-home/. Accessed May 10, 2017.
  33. Ljungqvist O, Scott M, Fearon KC. Enhanced recovery after surgery: A review. JAMA Surg. 2017;152(3):292-298.
  34. McCullough LB, Jones JW, Brody BA. Surgical Ethics. New York: Oxford University Press; 1998.
  35. Oliver JB, Kashef K, Bader AM, Correll DJ. A survey of patients’ understanding and expectations of persistent postsurgical pain in a preoperative testing center. J Clin Anesth. 2016;34:494-501.
  36. Cheatle MD, Savage SR. Informed consent in opioid therapy: A potential obligation and opportunity. J Pain Symptom Manage. 2012;44(1):105-116.
  37. Sullivan MD, Gaster B, Russo J, et al. Randomized trial of web-based training about opioid therapy for chronic pain. Clin J Pain. 2010;26(6):512-517.
  38. Treating chronic pain, managing risk, restoring lives. Collaborative Opioid Prescribing Education for Risk Evaluation and Mitigation Strategy. Available at: www.coperems.org/. Accessed May 10, 2017.

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