Promising Data on Opioids Detracts From Ongoing Problem: Postsurgical Dependence

By Elizabeth LaBouyer, RN, CNOR, CASC; and Tara Vail

Are we finally getting a handle on the opioid epidemic?

The most recent data from the Centers for Disease Control and Prevention (CDC) suggest the answer is yes. U.S. overdose deaths—67.8% of which involve opioids—decreased last year for the first time in nearly three decades and are projected to decline another 3.4% this year. Other data show opioids are prescribed less often, and at lower dosages, than in the past.

But it is far too early, and too simplistic, to claim that the tide has turned. Opioid misuse and dependence is complex and multifaceted. Efforts to curtail prescriptions of opioids over concerns about their addictive potential, for example, may be related to increases in deaths from other drugs, like fentanyl. While naloxone prescriptions doubled between 2017 and 2018, only one is dispensed for every 69 prescriptions of high-dose opioids. And one in four individuals concurrently use opioids and benzodiazepines, a potentially deadly combination.

Another worrisome trend is that although opioid prescribing by primary care physicians has decreased, new opioid prescriptions by surgeons have increased by 18% between 2010 and 2016. For many patients, surgery represents their first exposure to opioids. Though these drugs may play an important role in pain management when used safely in accordance with physician recommendations, research has found some surgery patients are especially vulnerable to dependence, with research suggesting persistent opioid use for 3%–10% of opioid-naive patients following surgery. Too many patients take too many opioids, at too high a dosage, long past the time they are necessary for pain control.

While many people associate surgery with hospitals, surgery is not a hospital-specific concern. In fact, by 2020, about 60% of outpatient surgeries are projected to be performed in ambulatory surgical centers (ASC), which allow for same-day surgeries to be conducted in a high-quality, efficient outpatient setting. Healthcare providers at ASCs play an increasingly vital role in safer prescribing and communication practices, and in patient education efforts surrounding safe opioid use. Rather than letting up in light of promising new opioid data, clinicians at ASCs need to double down on their efforts.

Many studies have noted that safer clinician prescribing practices still allow patients’ postsurgical pain needs to be met, such as through encouraging patients to taper as quickly as possible and to incorporate alternative pain management options. These “best practices” are more important than ever given that a recent study by Harvard researchers found a significant relationship between the number and duration of opioid prescription refills and subsequent opioid misuse in the surgical population. A single refill increased the potential for misuse by more than 40%, and the duration of use appeared to be the most prominent predictor of misuse.

Critically, postsurgical pain management must address patients’ hope for zero pain. There are almost no surgical procedures for which a patient may realistically expect a pain-free recovery, and when patients expect to have zero pain, they may overmedicate to achieve that goal. Some physicians fail to communicate the reality of the recovery process—perhaps afraid it will reflect poorly on their surgical skills—but when a clinician tells a patient to expect mild, tolerable pain, that patient will be less likely to turn to opioid therapy for relief of all pain.

As part of its ongoing initiatives to help ASC providers combat opioid misuse, the California Ambulatory Surgery Association has introduced a new toolkit, developed in collaboration with the California Society of Anesthesiologists, that contains a variety of tools usable in ASCs for physician guidance and patient education on pain management. Its materials outline a five-pronged approach to postprocedure opioid prescribing:

  • Develop a pain plan with patients, centered in a dialogue about options for pain management
  • Screen for risk, using the CURES database, electronic health record, and patient history (which may suggest heightened risk for substance use disorders)
  • Prescribe wisely, including combining opioids with non-opioid adjuvants like acetaminophen and NSAIDs to improve pain control at lower opioid doses
  • Inform and educate, to support patients in their recovery
  • Exercise overdose and prevention education; the toolkit’s written materials and patient video are based on the latest research and policies from national medical organizations, including the AMA, the CDC, and the U.S. Department of Health and Human Services

The toolkit is only one strategy to combating the serious challenge of postsurgical opioid dependence. As ASCs grow, the industry will need to continue its leadership via strategies that acknowledge new trends in medication misuse, both prescribed and illicit. With those practices, ASCs can help decrease postoperative misuse and dependence while keeping patients healthy and safe.

Elizabeth LaBouyer is executive director of the California Ambulatory Surgery Association, and Tara Vail is chief operating officer of HST Pathways and board member of the California Ambulatory Surgery Association.