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Preoperative protocol at HSS aims to identify patients at risk for difficult pain management
Physicians across the United States have encountered patients scheduled for orthopedic surgery who are already on high-dose opioid pain medication. While surgeons may refer these patients to a pain management specialist, not all do, and of the patients who are referred, not all follow through with an appointment.
“[For] those patients, it becomes a real problem not only to manage them in a hospital but also to manage them once they have left the hospital, particularly in agreement with the way their medicines were being prescribed or if they had other things that made their prescribing more risky,” Seth A. Waldman, MD, director of the Pain Management Center and advisor for opioid prescribing practices at Hospital for Special Surgery, told Healio.com/Orthopedics.
Preoperative protocol
Waldman noted Hospital for Special Surgery implemented a preoperative program that included a series of questions designed to identify patients at high risk for difficult pain control after surgery. This includes patients prescribed opioids above a certain dosage, on strong or long-acting opioids, with infusion pumps of opioids, with a substance abuse history or with a history of bad pain control following surgery.
“The goal was to get those patients all seen by a pain management specialist beforehand so that we could speak to their provider, check their medications, know what they are on, make adjustments in medicines if possible, check toxicology screening and so on,” Waldman said.
This preoperative program became more formalized around 2016 as the public became more aware of the opioid crisis, according to Waldman. In addition, Hospital for Special Surgery continued to adopt other protocols to reduce opioid use after surgery, starting with staff education and training.
“Every prescriber, every surgeon, every internist, every [physician assistant] PA, every nurse practitioner is required to take a course ... so that everyone has basic information with regard to the history of the opioid crisis, why opioid pain medication sometimes can cause increased pain, information about diversion, information about safe prescribing and that material became part of our enduring content,” Waldman said.
Additional protocols
Once an education protocol was in place, Waldman noted they began to monitor opioid prescribing patterns per surgical procedure and standardize documentation through their electronic health record. He added they implemented surgical specific guidelines for discharge after surgery, which has led to a significant reduction in the number of opioids being prescribed. Waldman noted they also meet with physicians individually on an ongoing basis to discuss their prescribing habits.
“It is educational when a clinician sees that [their prescription rates] for exactly the same group of patients ... is higher than one of their colleagues,” he said. “They have to ask themselves were they doing everything the right way.”
Waldman noted they implemented a multimodal analgesia protocol to not only reduce opioid doses but to improve pain control as well. This protocol includes the use of regional anesthetics in conjunction with IV medicine during surgery and steroids, NSAIDs, acetaminophen and other medications postoperatively.
“We are working on a program right now to be able to provide acupuncture, massage therapy, distraction therapy with virtual reality headsets to reduce pain by any means we can that is not an opioid,” Waldman said.
Improvements warranted
Despite these changes, Waldman noted there are still areas of the protocol that could be improved. Specifically, he said it can be difficult to identify all patients who need to undergo preoperative screening due to patients not accurately reporting their medications or any alcohol or substance abuse problems.
“We are trying our best to make sure that we capture all those people beforehand because we can provide them better treatment if we are aware [of] what we are getting into and what they are getting themselves into,” Waldman said.
Even when they are able to identify these patients, insurance may not cover substance abuse treatment, which Waldman noted is an area in need of improvement throughout the United States.
“We have hired on our service an addiction-trained social worker. We have a psychologist on the service and they can provide some treatment,” Waldman said. “But it is not the kind of treatment that you need to provide on a more massive scale and that is a problem across the United States, not just here in New York and not just at our hospital.” – by Casey Tingle
Disclosure: Waldman reports no relevant financial disclosures.