Managing Postoperative Pain While Limiting Opioid Prescriptions

General Information 

Institution Name: Aesthetic and Reconstructive Surgery Institute at Orlando Health 

Submitter Name: Deborah Tedesco, DNP, APRN, ANP-BC, CWS, Nurse Practitioner 

Name of the Case Study: Managing Postoperative Pain While Limiting Opioid Prescriptions 

What Was Done? 

Global Problem Addressed 

According to the National Institute on Drug Abuse, in 2017, more than 1.7 million individuals suffered from opioid use disorder, a problematic pattern of opioid use leading to significant distress.^1,2 An individual developing dependence on prescribed opioids is a predictor of future heroin use.³ Transition to heroin from pharmaceutical opioids is often initiated due to difficulty obtaining pharmaceutical opioids.³ Initial exposure to an opioid typically occurs in the medical setting, and the length of time an individual is exposed to the opioid at first exposure is highly related to the risk of long-term use.⁴ 

Surgery practices prescribe 9.8 percent of all opioid prescriptions and contribute to the opioid crisis. In plastic surgery, individuals undergoing breast surgery have the highest likelihood of persistent opioid use.^5,6 

Identification of Local Problem 

In response to the nationwide opioid epidemic, the state of Florida passed the Controlled Substance Bill, mandating continuing education for providers, requiring the use of the state’s prescription monitoring program, and limiting 

the prescribing of opioid pain medications. Opioid prescriptions were limited to three days with an acute pain exemption of seven days for individuals undergoing surgery. It was evident that the new law would affect the pain management of patients undergoing surgery at the Aesthetic and Reconstructive Surgery Institute (ARSI) at Orlando Health. At the time the bill was signed into law, ARSI patients were able to receive prescriptions for opioids until four weeks after surgery. The number of opioid tablets typically prescribed was between 42 and 60 with each prescription. 

How Was the Quality Improvement (QI) Activity Put in Place? 

Context of the QI Activity 

Orlando Health is a not-for-profit healthcare organization located in Central Florida. The hospital system has more than 2,400 beds and has the area’s only Level I trauma centers for adult and pediatric patients. Cancer care is an area of clinical excellence at Orlando Health, and it is provided through the University of Florida Health Cancer Center. The Aesthetic and Reconstructive Surgery 

Institute at Orlando Health provides reconstructive surgery for all patients within the system. While reconstructive surgery services are provided to patients undergoing reconstruction due to multiple types of cancer or trauma, the majority of patients are undergoing reconstruction after a diagnosis of breast cancer. 

Planning and Development Process 

The project was initiated by the clinic nurse practitioner and a surgeon. 

A review of the literature related to postoperative pain management was completed. Evidence was reviewed, including American Pain Society guidelines, Enhanced Recovery After Surgery Society for Perioperative Care in Breast Reconstruction guidelines, and other published recommendations on multimodal analgesia in breast surgical procedures.^7-10 A plan for pain management was formed that incorporated preoperative patient and family education and the standard perioperative analgesia, including multimodal analgesia in all breast reconstruction patients. 

A multidisciplinary team of members inside and outside the practice was formed. Due to time and schedule constraints, face-to-face meetings were not held, but ideas were exchanged among members. The proposed pain management plan was developed and then submitted to group members for approval and recommendations. After revisions were made, the proposed plan was submitted for review to the chief surgical quality officer, a breast surgeon who is chair of the surgical quality committee, and the facility’s pain management physician. 

Buy-in was obtained for this project. First, and before it was presented to other staff, the project was introduced to clinic leaders with influence for approval. A compilation of studies was presented, along with the proposed plan. Individual agreement to proceed was obtained. Next, the proposed plan was presented to the physician assistants, and a small test of change was completed on one patient undergoing breast reconstruction. Once good pain control was noted, additional patients received the new plan of care. Ultimately, all women undergoing breast reconstruction surgery were provided the same pain plan. During this process, the surgeon involved in the initiation of the project provided education on the surgical unit, preoperative unit, and contacted the breast surgeons regarding the changes. Changes that were being implemented were communicated to stakeholders. 

Description of the Quality Improvement Activity 

The pain management program included patient and family education and perioperative analgesia. Patient and family education included an informative letter, preoperative pain education that included expectations-setting, and a written pain plan. The patient letter informed all patients undergoing surgery of the changes in the law and the reasons for our change in practice. The letter 

assured patients that well-managed surgical pain was our goal, within the limits of the legislative changes. 

Perioperative analgesia includes the use of preemptive analgesia, the use of regional nerve blocks, and the use of multimodal analgesia in the postoperative period. First, individuals scheduled for breast reconstruction were provided with preemptive analgesia. Two hours preoperatively, patients received three medications: celecoxib 200 mg, acetaminophen 1,000 mg, and gabapentin 600 mg. Intraoperatively, a number of our patients received intercostal blocks and/or PECS 1/2 blocks with liposomal bupivacaine. Postoperatively, pain was managed with four medications: 

• Methocarbamol 750 mg PO every six hours, as needed for pain 

• Ibuprofen 800 mg PO every eight hours with food, as needed for pain 
• Gabapentin 600 mg PO every eight hours for 14 days 
• Acetaminophen 650 mg PO every six hours, as needed for pain 
• Oxycodone 5 mg PO every four to six hours, as needed for rescue only 

Medication education was provided by a nurse practitioner or physician assistant at the preoperative visit. All medication prescriptions were provided at the same visit and the written pain plan was included. Clinic nurses provided additional education. Pain plans were altered if necessary, based on a patient’s medical history and allergies. 

Small tests of change were conducted between April and June 2018. Full implementation began on July 1, 2018. Over time, small changes were made. For example, several patients complained of side effects with the gabapentin, and surgeons considered stopping the medication. The dosage was decreased to 300 mg three times daily with the use of 100 mg for the elderly. No further complaints have been noted. 

Resources Used and Skills Needed

The project was initiated by the nurse practitioner and a reconstructive surgeon. Members involved in the program included three reconstructive surgeons, one nurse practitioner, four physician assistants, and four clinic nurses. The multidisciplinary team for project development included the practice manager, plastic surgeons, the clinic nurse practitioner, a surgical physician assistant, a clinic nurse, a psychologist, an occupational therapist, and a patient member. 

No additional costs were incurred with this program. Preoperative education was already standard practice. Additional patient visits have not been necessary. No additional funding sources were necessary. 

What Were the Results?

Overall Results 

Beginning in May of 2018, there was a significant decrease in opioid prescriptions provided to patients undergoing mastectomy and expander placement. Between January and April 2018, the average percentage of opioid refills provided was 77.8 percent. After full implementation in July of 2018 through December of 2018, this average percentage decreased to 9.8 percent.

In October 2018, it was noted during postoperative patient interviews that very few individuals needed more than three oxycodone tablets postoperatively. A decision was made to decrease the number of tablets provided in the first prescription from 42 to 20. Following the decrease in tablets prescribed, there was no subsequent increase in prescriptions after this change. The number of opioid tablets prescribed in January of 2018 was 2,531 (n=30). In November of 2018, the number decreased to 658 (n=31). The average number of opioid tablets prescribed to each patient decreased between January and December of 2018. In January, the average number of opioid tablets prescribed was 84.7. By December, the average number of opioid tablets prescribed was 21.7.

Setbacks

Two patients complained about negative side effects related to the gabapentin. The patient’s surgeon initially stated he wanted to stop the use of gabapentin. After discussion, a decision was made to decrease the gabapentin to 300 mg instead of 600 mg, with 100 mg prescribed for individuals over 65 years of age. Pain management continued to be effective following this decrease. Initially, individuals were not always receiving preemptive analgesia preoperatively. A surgeon and a physician assistant provided education to the preoperative staff about the reason for the analgesia, and its use became more routine.

Cost Savings

No additional cost was incurred by the practice or the hospital due to this project. However, a decrease in the number of opioids prescribed for postoperative pain means fewer tablets that are out there in the community. As a result, the risk of diversion decreases, leading to savings for the community since there are fewer individuals potentially developing opioid use disorder and, subsequently, fewer individuals exposed who may become persistent users. This may result in fewer deaths related to opioid overdose. The estimated economic burden of prescription opioid misuse in 2013 was $78.5 billion per year.¹¹

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 change. 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 practice 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: https://www.drugabuse.gov/drugs-abuse/ opioids/opioid-overdose-crisis. Accessed June 12, 2019. 
2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Association; 2013. 
3. Carlson R G, Nahhas R W, Martins SS, Daniulaityte R. Predictors of transition to heroin use among initially non-opioid dependent illicit pharmaceutical opioid users: A natural history study. Drug and Alcohol Dependence. 2016;160:127-134. https://doi.org/10.1016/j.drugalcdep.2015.12.026. 
4. Hadlandsmyth K, Lund BC, Mosher HJ. Science and practice: Associations between initial opioid exposure and the likelihood for long-term use. Journal of the American Pharmacists Association. 2019;59:17-22. https://doi-org.ezproxy.net. ucf.edu/10.1016/j.japh.2018.09.005. 
5. Levy B, Paulozzi L, Mack KA, Jones CM. Brief report: Trends in opioid analgesic–prescribing rates by specialty, U.S., 2007–2012. American Journal of Preventive Medicine. 2015;49:409-413. https://doi.org/10.1016/j.amepre.2015.02.020. 
6. Olds C, Spataro E, Li K, Kandathil C, Most SP, et al. Assessment of persistent and prolonged postoperative opioid use among patients undergoing plastic and reconstructive surgery. JAMA Facial Plastic Surgery. Available at: https://doi-org. ezproxy.net.ucf.edu/10.1001/jamafacial.2018.2035. Accessed June 12, 2019. 
7. Chou R, Gordon DB, de Leon-Casasola OA, Rosenberg JM, Bickler S, Brennan T, Wu CL, et al. Guidelines on the management of postoperative pain. 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. Journal of Pain. 2016;131-157. doi:10.1016/j.jpain.2015.12.008. 
8. Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Ljungqvist O, et al. Consensus review of optimal perioperative care in breast reconstruction: Enhanced recovery after surgery (ERAS) society recommendations. Plastic and Reconstructive Surgery. 2017;139(5):1056e-1071e. doi:10.1097/PRS.0000000000003242. 
9. Alfonso A, Newman M, Seeley N, Hutchins J, Smith K, Mena M, Gadsden J, et al. Multimodal analgesia in breast surgical procedures: Technical and pharmacological considerations for liposomal bupivacaine use. Plastic and Reconstructive Surgery. 2017;5(9):1-9. doi:10.1097/GOX.0000000000001480. 
10. Schmidt PC, Ruchelli G, Mackey SC, Carroll IR. Perioperative gabapentinoids: Choice of agent, dose, timing, and effects on chronic postsurgical pain. Anesthesiology. 2013;119(5):1215-1221. doi:10.1016/j.jpain.2015.12.008. 
11. Florence CS, Zhou C, Luo F, Xu L, et al. The economic burden of prescription opioid overdose, abuse, and dependence in the United States. Medical Care. 2016;54(10):901-906. doi:10.1097/MLR.0000000000000625.

Bibliography 

Demsey D, Carr NJ, Clarke H, Vipler S. Managing Opioid Addiction Risk in Plastic Surgery during the perioperative period. Plastic and Reconstructive Surgery. 2017;140(4):613E-619E. Available at: https://doi-org.ezproxy.net.ucf.edu/10.1097/PRS.0000000000003742. Accessed June 12, 2019.