The first principle of medicine is to “do no harm.” Over the past two decades, the medical community has attempted to honor this principle by treating patient pain with opioid prescriptions. Unfortunately, these good intentions have driven an epidemic of opioid addiction and drug overdoses, now the leading cause of accidental death in the United States.
Inpatient overprescription of opioids such as morphine, oxycodone, and hydrocodone happens in a variety of ways—doctors prescribe too many doses, too large a dose, or allow patients to continue opioid treatment for too long. And many times, doctors could avoid opioid overprescription by setting realistic pain management expectations or by considering alternative analgesics or non-pharmacologic approaches. Prolonged narcotic usage that stems from these clinical decisions could properly be termed a hospital-acquired condition and should be considered a question of patient safety, instead of the result of moral weakness among patients.
The policies of both the Joint Commission, in referencing pain as the “fifth vital sign,” and the Centers for Medicare and Medicaid Services (CMS), in using pain control as a barometer of patient satisfaction, have helped normalize the practice of excessive opioid prescribing. The pharmaceutical industry has also contributed to the problem by blocking efforts to curtail opioid prescription. The medical community has only recently started to accept that there is a link between the epidemic and their clinical behaviors. In April 2017, representatives from a handful of leading health systems met in Nashville, Tennessee, for a two-day perioperative pain management collaboration summit. The mission was to examine relevant clinical evidence, best practices, and outcomes data, and then apply that knowledge to develop organization-specific strategies for implementing modern, multimodal approaches to managing surgical pain.
The meeting had a strong storytelling component, and a common narrative quickly emerged. Everyone knew a person admitted to the hospital for a simple procedure who was discharged with a significant dose of opioids. Some of these stories ended with the patient transitioning to street drugs or with their excess pills being used non-medically by a relative or friend. Many of them ended with the patient’s death. What began as a dialogue about optimizing order sets pivoted to brainstorming ways to change the pervasive and damaging culture of reflexive prescribing for pain management and the roadblocks that would make them difficult to implement.
The group began by reviewing several papers connecting opioid prescription for post-surgical pain relief and subsequent addiction. A study in Oregon found that long-term dependence occurred in 5 percent of opioid-naïve patients who received a prescription. Among those younger than age 45, getting a second prescription filled more than doubled the chances of dependence, and patients receiving more than 400 morphine milligram equivalents (MMEs) had three times the risk of addiction as those receiving less than 120 MMEs.
A retrospective study of opioid-naïve adults who underwent either a major or minor surgical procedure found significant opioid use persisted three to six months after surgery among 6.5 percent and 5.9 percent of patients, respectively. Examination of the risk factors for ongoing use revealed no statistically significant correlation with procedure type but a strong association with patient factors such as anxiety and depression, and a connection between the amount of opioid prescribed and eventual long-term use—all pointing toward an iatrogenic cause of the longer-term dependence. Interestingly, almost 15 percent of patients screened for study inclusion did not fill an opioid prescription 30 days prior or 14 days after surgery, suggesting alternative treatments are likely an option for many patients. A 2012 study conducted in Canada examining short-stay surgeries (such as laparoscopic cholecystectomy and cataract surgery) in opioid-naïve patients showed 7.7 percent of patients prescribed opioids within seven days of surgery were taking opioids at one-year postoperative, a 44 percent higher rate than a matched cohort that did not receive a prescription in the postoperative period.
These studies, and others, support the conclusion that current physician prescribing patterns and beliefs about pain control—in conjunction with factors such as clinical inertia, physical dependency, and patient misperceptions about their surgical recovery—cause prolonged postoperative opioid usage and addiction. Summit participants were visibly disturbed by this revelation and by the alarming frequency of opioid dependence relative to other surgical complications (for example, surgical site infection, in which evidence-based treatment and prevention practices have driven down occurrence rates as low as 1.9 percent).
Long-term opioid usage that begins with a prescription for a self-limited problem fits the CMS definition of a hospital-acquired condition in every respect: It arises during a hospitalization, is a high-cost and high-volume condition, and could reasonably have been prevented through the application of evidence-based guidelines. While the ability of hospitals to track ongoing opioid usage is limited, the prevention of harm to patients, their families, and society are compelling reasons to eradicate this hospital-acquired condition with every available resource. The negative side effects of opioids are well known and extend beyond addiction, including (most commonly) constipation and nausea but also physical dependence, tolerance, testosterone suppression, and respiratory depression.
The interventions needed to change opioid prescribing behavior must be sweeping and are largely untested. Broad educational efforts will be necessary to reset patient expectations of post-procedure pain and pain relief, and must include hospital-based providers and the entire continuum of care. Further research is required to better identify patients vulnerable to dependence so that they can be managed effectively. Research can also help develop interventions to change ingrained clinical behavior, such as education to decrease opioid prescribing. Improving providers’ personal clinical approach will also require data-based evaluation and benchmarking of prescribing patterns. Nursing practices should also be adjusted to focus on enabling patient function instead of treating a pain score. Finally, awareness must translate into industrywide action to control the epidemic, which now claims more lives than car accidents and gun violence.
It was against this backdrop that collaborating health systems at the summit drafted detailed, role-specific action plans for their organizations that included approaches to raising awareness and gaining support, educational tactics, potential barriers and measures of success, and quick wins. (Exhibit 1 provides an overview of key preventive steps).
The science of optimizing pain management using fewer opioids is relatively well established but only one piece of the puzzle. Achieving wholesale reform will require rapidly scaling multifaceted strategies and a dogged determination to prevent harm in lieu of ascribing blame. Although individual providers are the source of the initial prescriptions that trigger a heartbreaking cascade for too many patients, engaging all the major constituents in the health system—including payers, providers, and patients—is necessary to achieve a viable, sustainable solution to prolonged postoperative opioid use and addiction. It is harm that, much like pressure ulcers, results from many missteps and inactions across multiple care episodes and patient interactions.
To turn the tide on the opioid epidemic, integrated health systems must mobilize their resources, as they did for antimicrobial stewardship programs to reduce rates of hospital-acquired infections. Redefining continued post-surgical opioid use and addiction as a preventable harm and, therefore, an avoidable hospital-acquired condition, is an appropriate first step.
Exhibit 1: Blueprint For Preventing Ongoing Post-Surgical Opioid Use
|First steps||Near-term actions||Long-term goals|
|Ensure top senior executives are aware of patient safety issue||Expand efforts with regional collaborative learning summits||Link prevention efforts to organizational mission in new employee orientation and ongoing education|
|Make business case for resource investment, leveraging established programs||Standardize opioid patient risk-assessment tools||Provide consistent messaging across care sites about risks of opioids|
|Develop audit tool for assessing current prescribing patterns||Audit current opioid prescribing patterns and establish benchmarks and reporting||Improve patient experience and satisfaction with enhanced surgical recovery tools|
|Write elevator pitches for clinical leads to facilitate change||Engage cross-disciplinary team to build multifaceted education program||Add opioid awareness questions to patient safety culture surveys|
|Launch public “did you know” campaign||Develop metrics for assessing improvement of opioid prescribing||Conduct study measuring impact of efforts on incidence of long-term opioid use and addiction among surgery patients|
|Encourage CMS to adopt long-term, postoperative use of opioids as a formal hospital-acquired condition|
Source: 2017 HCA/HealthTrust Perioperative Pain Management Collaboration Summit, Nashville, Tennessee.