Curbing the Opioid Epidemic

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Curbing the Opioid Epidemic

The role of ASCs and EHRs

Emergency rooms (ER)—where a 2016 New York Times report says up to 75 percent of visits are for pain—can be a starting point for addiction. Many patients’ initial exposure to opioids, however, is immediately following outpatient surgery.

The continued use of opioids after the initial postoperative recovery period has increased greatly in recent years. Studies have shown that up to 10 percent of surgery patients given postoperative opioid medications have continued opioid use after one year. We must do a better job of understanding the connection between the need for immediate postoperative pain relief and the long-term effects of overprescribing opioids and find the balance.

Timing of Opioids Administration is Critical

If initial administration of opioids during and immediately after surgery is low, the post-discharge need for these types of pain meds decreases, according to a February 2016 study published in The Journal of Pain.

The ASC community is already putting a lot of effort into reducing pain in the initial postoperative period. To facilitate a patient’s transition from the postop area to home without delay, they often use less long-acting anesthesia and fewer opioids during surgery and the immediate postoperative period than hospitals. Toward this end, I am seeing more and more ASCs using adjunct pain relief methods as a matter of routine. Instead of waiting for pain to start in the post-anesthesia care unit (PACU), anesthesia providers often give doses of acetaminophen IV and other non-opioid medications to certain surgery patients at the end of the procedure in the operating room. Having been at the forefront for finding alternatives, ASCs have used creative ideas to combat pain because of the necessity for short stays and concerns for the safety of patients (i.e., not just loading them up with opioids and sending them out the door).

ASCs also achieve effective analgesia using regional anesthesia techniques in conjunction with non-opioid therapies. These postoperative pain blocks give patients immediate pain relief that will wear off gradually over several hours, decreasing the need for opioids in the immediate postoperative period. Hospitals are less focused on these alternatives since patients will not be discharged home immediately postop.

After surgery, a patient needs rest to heal. Patients rest better and more comfortably in their homes, decreasing the need for pain medications. In the hospital, when the nurse enters the room—frequently just as patients have fallen asleep—to take vital signs and check IV fluids, they often ask, “Are you in any pain?” If patients say yes, they bring more medications. Patients who are resting at home or sleeping in their own beds with no one disturbing them every hour are less likely to wake up and get up to take medication for mild pain.

EHR Could Help Prevent Overprescribing

One underutilized tool in the ASC setting in the battle against opioid addiction is the electronic health record (EHR). According to a July 2018 study in JAMA Surgery, decreasing the number of pills prescribed through an EHR is an economical and convenient way to prevent overprescribing and track the use of pain medications.

Using an EHR, ASCs can standardize order sets. Setting standard order sets for the treatment of pain by the anesthesia team would assist in the implementation of an effective multimodal analgesia protocol. Low-dose pain management requires multidisciplinary communication and coordination. An EHR allows multiple users to concurrently chart the same patient, which allows all providers to be aware of pain assessment, vital signs and medication administration for their patients throughout the continuum of care.

Addressing pain early requires lower doses of medication and will respond to non-medication pain control options (e.g., ice, positioning and relaxation techniques). The EHR also provides a medication summary for the current visit and shows providers the total amount of medications administered during the visit in real time. This prevents overmedication due to lack of information on how much has been given so far. The EHR’s medication reconciliation section also provides a convenient way to evaluate the patient’s home medications and any interaction they have with the planned discharge medications.

The plan for the treatment of postoperative pain starts before surgery and ends well after the patient has gone home. An EHR allows the surgery center and the care providers to design questionnaires specific to their surgeries and the known patient population. Gathering the appropriate information prior to surgery ensures that the best possible plan for the appropriate combination of pain therapies is ascertained and made available for the patient. The EHR also allows the center to design discharge instructions by procedure that include an educational document for patients being discharged on opioids, thereby substantiating the review of this document with the patient and/or family to stress adherence to the prescriptions and provide alternative interventions to opioids for pain management.

Last, an EHR can provide data for accountability and analysis. Reports that allow the center to track the usage of opioids by procedure, ordering provider and administering personnel also allow careful monitoring of opioid administration and trending of usage. The ability to report opioids given at an ASC helps reduce and track any potential overuse.

All health care providers must play a role in decreasing the use of opioids. One way to do that is to use the tools available in more inventive ways to care for, monitor and educate patients and our colleagues. The EHR is a new tool for ASCs that can play an effective role in this crisis.

The advice and opinions expressed in this column are those of the authors and do not represent official Ambulatory Surgery Center Association policy or opinion.