Physicians Getting Inventive on Frontline of Opioid Crisis

Michael Vlessides

March 15, 2019

LAS VEGAS — Preoperative patient education can significantly decrease opioid use, according to results from a new study.

"We're overprescribing and I think we know that at this point," said investigator Steven Andelman, MD, from the Mount Sinai Medical Center in New York City.

"But a standardized patient-education protocol, which literally took 2 or 3 minutes to perform, was able to significantly decrease the number of pills patients took," he told Medscape Medical News.

This was just one of the studies addressing the opioid epidemic presented during a jam-packed practice management session here at the American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting.

"Obviously this is a critical issue, and I was happy to see that so many physicians are focusing their research efforts in this area," said Josef Eichinger, MD, from the Medical University of South Carolina in Charleston, who comoderated the session.

Andelman and his colleagues first undertook an assessment of narcotic prescription and use patterns in 32 patients undergoing arthroscopic meniscectomy.

Although these patients were prescribed an average of 41.97 opioid pills, they had taken a mean of only 16.71 after 4 weeks. Nineteen patients took fewer than 10 pills.

The researchers then used these findings as the foundation for a patient-education initiative designed to promote responsible opioid consumption by patients undergoing the procedure.

In that study, they showed that a 3-minute preoperative education session decreased the consumption of opioids by 420% during the 4-week postoperative period.

During the formalized 3-minute overview — received by 24 adults — a physician emphasized "that opioids are for severe pain only," and explained that NSAIDs and cryotherapy can be used to ease pain, Andelman said.

The other 32 adults in the study cohort did not receive any education on postoperative opioid use.

Patients who received the education used significantly fewer opioid pills after surgery than those who did not (3.21 vs 16.71; P = .001).

There are many complicated interventions we have with respect to opioids, but this is so simple and elegant.

The success of this approach is "one of the great take-aways from this session," said Eichinger. "There are many complicated interventions we have with respect to opioids, but this is so simple and elegant."

Asking physicians to devote even a few minutes of precious preoperative time might be too much to ask in today's high-stress surgical world, he acknowledged, but the education could be incorporated into discharge instructions delivered by a nurse.

"Of course, it will take some work by surgeons to put this into their discharge instructions, but it's obviously worth the effort," he said.

Effort notwithstanding, a reduction in postoperative opioid prescriptions could have an impact on patient satisfaction, which some surgeons believe might reflect poorly on their clinical competence.

This notion was debunked, however, by another study presented during the session that showed no clinically significant association between opioid use and the satisfaction reported by patients undergoing outpatient orthopedic surgery. Orthopedic surgeons can safely limit the number of opioids they prescribe without fear of decreasing patient satisfaction, the researchers conclude.

That trial — performed as part of an ongoing quality-control project at the University of Chicago — assessed 139 patients who completed the International Pain Outcomes (IPO) questionnaire and the depression and pain domains of the Patient-Reported Outcomes Measurement Information System (PROMIS).

Postoperative pain control was rated as satisfactory by 96 patients (69%), and increased opioid consumption was not strongly associated with patient satisfaction (Spearman's rank correlation coefficient = –0.18, P = .03; and Pearson correlation coefficient = –0.11; P = .19).

"One of physicians' fears is that if we don't give enough pain medications, patients are going to be unhappy, we're going to get bad ratings, and it's going to hurt our HCAHPS [Hospital Consumer Assessment of Healthcare Providers and Systems] scores," explained Eichinger.

"This study shows that isn't the case," he said.

The need to change ingrained habits pertains to opioid disposal as well as prescribing.

Opioid Disposal

"One of the things we can do is get unused opioids out of circulation in the community and get people to dispose of them properly," said Christopher Iobst, MD, from the Nationwide Children's Hospital in Columbus, Ohio.

To help evaluate disposal options, Iobst and his colleagues used a scripted phone call to contact every pharmacy in a children's hospital in the United States and a large sample of pharmacies and police stations in every state.

Facilities were asked whether they educate patients about opioid disposal when they dispense them, whether they accept unused opioids and, if they do not, where opioids could be disposed.

Overall, only 415 of the locations contacted (28%) said they take unused medication. Police stations were significantly more likely to than stand-alone pharmacies or children's hospital pharmacies (60% vs 15% vs 11%; P < .001).

Although these findings seem to paint a fairly grim picture of opioid disposal, there are signs that opioid-disposal bins are becoming more common, particularly in police stations where they can be secured 24 hours a day, Iobst reported.

I can tell you I've never had a conversation with a family about how to dispose of opioids.

The issue of opioid disposal is complicated by the fact that physicians are often in the dark about disposal policies in their own institutions, said Matthew Schmitz, MD, from the San Antonio Military Medical Center.

"I don't know what my hospital's practice is regarding opioid disposal," he admitted.

"Maybe that's something we can use as an educational initiative on the physician side," he told Medscape Medical News. "I can tell you I've never had a conversation with a family about how to dispose of opioids."

"There clearly needs to be an education process to decrease the number of pills out there," he said. "That begins with the numbers we are prescribing, but another very important part is how we dispose of the pills that are not utilized."

Initiatives such as these — coupled with the efforts of well-intentioned orthopedic surgeons across the country — can only help stem the flow of opioids through our communities. But such efforts do not stop at the individual level.

Pain Relief Toolkit

The American Academy of Orthopaedic Surgeons has stepped up to the plate and is planning to roll out version 2.0 of its Pain Relief Toolkit later this year, said Kenneth Urish, MD, PhD, from the University of Pittsburgh Medical Center, who is a member of the AAOS patient safety committee.

The committee "has been paying a lot attention to the opioid issue," Urish explained.

Although details of the new toolkit are unavailable, the current version offers clinicians myriad resources that promote the safe dispensing and responsible use of opioids.

The toolkit is designed to promote "conversation between the physician and patient," Urish said. "It offers many suggestions about what physicians might try to help limit narcotic use."

It recommends that physicians create realistic expectations with patients and explore multimodal analgesic routes. "I think one of the interesting things that has happened as part of the opioid crisis is a much clearer focus on alternative techniques we can employ to make a person comfortable after surgery," he noted.

The academy has taken its message to the public. The first version of the toolkit was accompanied by a significant multimedia public-service campaign, which featured print and radio advertising and hundreds of outdoor media signs. Indications are that the next version will be promoted in much the same way.

In the end, it is efforts such as these that will ultimately help solve the opioid crisis. Whether it's individual surgeons, hospitals and academic centers, or healthcare societies, all are playing their part.

Andelman, Eichinger, Iobst, Schmitz, and Urish have disclosed no relevant financial relationships.

American Academy of Orthopaedic Surgeons (AAOS) 2019 Annual Meeting: Papers P456, P457, P458, and P344. Presented March 13, 2019.

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