How Hospitals Can Fight the Opioid Epidemic

Seth A. Waldman, MD: Good morning. I'm Dr Seth Waldman, director of the Pain Management Center at the Hospital for Special Surgery (HSS) in Manhattan. I have the pleasure today of discussing an evidence-based response to the prescription opiate epidemic in orthopedic surgery.

Joining me this morning are Peter Grimaldi, senior director of our Physician Assistants Department, and social worker and addiction specialist Justin Donofrio.

Meeting Challenges Head-On

Confronting the difficulties and managing the population of patients who are on prescription opioid medicines and having surgery has become a significant challenge in the United States over the past 10-20 years. This is particularly acute in the setting of orthopedic surgery. It is perhaps not surprising that orthopedic surgeons are the third-highest prescribers of opioids among physicians in the United States, accounting for about 7.5% of all prescriptions for opioids nationwide.^[1]

The specific challenges include, first, caring for opioid-naive patients undergoing elective surgery in such a way as to minimize their exposure to opioids and prevent long-term dependence. Second, how best to evaluate and manage patients who are on high-dose prescribed opioids and need to have elective orthopedic surgery. And third, how to plan the care of patients who use opioids and other medicines in an aberrant or illegal pattern—in other words, people who have substance use disorders.

Several years ago, our hospital developed a controlled substances task force for the purposes of evaluating these three aspects of patient care. This included members of the anesthesia department, orthopedic surgery department, medicine, social work, physician assistants, nursing, risk management, administration, and pharmacy. The work of this committee is summarized in an article authored by Dr Ellen Soffin, to be published in Anesthesia and Analgesia in November 2017.^[2]

Our first step was to understand the current state of prescribing at our hospital. This quickly necessitated an educational campaign for both patients and clinicians and the development of cultural changes to alter prescribing habits, all while continuing to provide the highest level of care for patients undergoing surgery, specifically with respect to opioid pain medications.

Because of the nature of opioid medicines, changing our practice has both clinical and regulatory aspects. Multiple professional organizations have recommended that although opioids are certainly efficacious in the treatment of acute postoperative pain, they should be used at the lowest effective dose, only when necessary, and for as a short duration as possible.

Research,^[2] however, show that patients are often prescribed up to three times more opioids than are consumed after orthopedic surgery, and very few have any counseling regarding the safe disposal of unused narcotic medicines. It is hard to know the impact that this has had on the amount of medication available for overuse and diversion, but it is likely to be very significant.

There are limited data to suggest that minimizing the variability in opioid prescribing after orthopedic surgery reduces use. However, given the concern regarding the risk for diversion of unused medication, we felt it would be prudent to start there.

Initial Efforts at HSS

Dr Waldman: Peter, can you tell us what the state was at HSS when we began this effort?

Peter W. Grimaldi, MS, PA-C, MBA, MPT: When we set about establishing some kind of guidelines as they related to opioid prescribing, we knew that we did not have any clear direction as to what should be prescribed and when. We had two goals. The first was acknowledging that we had to be conservative in the way we prescribed opioids. The second was acknowledging that there is an interdependence between good pain control and return to function, which is so critical in orthopedic surgery.

With that, we felt it prudent to engage our surgeon experts to identify a process by which we would establish some kind of prescribing guidelines, specifically in the opioid-naive patient. As you know, we do not necessarily have a sense of what these patients' needs are going to be before surgery. We set about looking at the various procedures we did and stratified them by complexity, and with that, what the expected medical need for pain control was going to be. We established certain levels and guiding principles as they relate to opioid prescribing at our service level within our institution.

Dr Waldman: Was there some difficulty with that? Did you find that the surgeons were resistant to cooperating on the doses, for example, with a certain surgery?

Mr Grimaldi: No, actually. Consensus-building anywhere is always a challenge. I think our approach was to first engage the surgeons very early on in the process—engage the leaders of the surgeons to help them understand and support the process. Because we involved them at our service level, where we have service chiefs and various leaders, and let them be the decision-makers, we were very successful in facilitating the process and arriving at these guidelines.

Three-Step Addiction Counseling

Dr Waldman: Our next challenge was to develop educational programs that provided clinicians, including orthopedic surgeons and preoperative internists, with tools to determine which patients would benefit from preoperative pain screening. Patients who were receiving high-dose opioid pain medications and those who have a history of substance use disorders would then be triaged before surgery is scheduled to see a physician and a nurse practitioner in the preop screening clinic. They would then discuss their care, speak with their prescriber, query the state prescription databases, and perform toxicology screening. When indicated, they would also be referred to see Justin Donofrio, our addiction specialist for counseling, and if necessary, for referral beyond that.

Justin, can you tell us a little bit about what those evaluations are like?

Justin Donofrio, LCSW: The screening, brief intervention, and referral to treatment (SBIRT) approach program began in the late 1980s. SBIRT is a three-step process for how we screen and evaluate patients who could potentially have a substance use disorder. It starts at the physician level. They will do a screening using one of the evidence-based tools that are available.

Once patients are referred to me, then I would perform what is called a brief intervention. With that, we are looking for the patient to gain some insight into the problem if they do not already have it. A lot of the patients that come to me with a substance use disorder may have already had treatment in the past. They are very familiar with the process of what happens once referred to treatment.

The assessment takes about 20 minutes, depending on the patient and what we are talking about. I provide basic counseling and try to use some of the skills in motivational interviewing that I learned when I was working in the substance abuse clinics while in social work school. Then from there, if I feel like the patient needs to go to additional treatment, I will refer them to either a local clinic, or we will find an addiction specialist that they can go to.

Dr Waldman: From your perspective, do you find that this is something that you have had success with, or that the patients or referring doctors were resistant to you?

Mr Donofrio: There is going to be resistance at every level when it comes to substance abuse. Unfortunately, it is just part of this process. A lot of people are not aware of where they are in this process of change. They do not have insight into their issues yet. Of course, resistance is natural.

Risk to Providers

Dr Waldman: When we began the coordination of these services, the idea was to try to recognize when possible in advance circumstances where the use of pain medications represents an inordinate risk, such as with an uncontrolled substance use disorder, but also in circumstances where there may simply be risk to the downstream provider—not the surgeon, but the person perhaps in their office or on their team who is going to be writing their prescriptions.

Peter, I wonder whether you can tell us a little bit about how the physician assistants in our hospital have responded to that challenge.

Mr Grimaldi: Physician assistants, as an extension of our surgeons, are managing patients in the perioperative setting, quite commonly in the postoperative setting, and are often responsible for writing for the discharge prescription.

In this current environment, when there is a lot of attention around opioids and the opioid crisis, it was very important that we ensured that our physician assistants, nurse practitioners, or physicians themselves were well supported by the organization in terms of how we go about addressing this issue and use conservative prescribing practices. Because we did a great job of engaging all disciplines that are involved with prescribing, it helped control the anxiety that was invariably going to be created as a result of this issue.

Dr Waldman: It is going smoothly now?

Mr Grimaldi: It is. Some of [our] initial data that came out since we instituted our guidelines show that we had about a 30% decrease in the amount of opioids we were prescribing at discharge and very close adherence to our guidelines, which was a great success. We saw that very early on in the process.

We are not going to stop there. Certainly, we are looking to learn what the downstream impact of that is. In other words, are we just shifting the need for writing for additional opioids further downstream to the surgeon or physician's office? Or perhaps, as we're looking at in some studies we have going on concurrently with these guidelines, we can start reducing our numbers even further and use evidence-based research to get there.

Dr Waldman: Justin, what happens after you have seen a patient for counseling and make a referral? How often is it that they have any difficulty in today's environment in getting care when they have an addiction problem or substance use disorder?

Mr Donofrio: It is difficult to access certain aspects of it. If we are going to look at a harm reduction approach, something like Suboxone® (buprenorphine/naloxone) can be difficult to access for patients who have limited resources. In those cases, you would refer them to a methadone clinic, for instance. It is harder to find addiction specialists who will work with patients with their insurance or depending on what kind of financial resources they have in order to pay for the treatment.

Next Steps

Dr Waldman: Do either of you have any final thoughts to add. Peter, anything you would like to add?

Mr Grimaldi: In the current environment, where there are a lot of legislative changes afoot at the state and federal level, along with changing practices—whether it be pharmacies or other providers—it is important that we are focused on our patients and what we determine to be in their best interest. Again, this entails balancing the delicate art of good pain control with ensuring that they can return to function.

Our approach is patient-centric, and the reason I think that is because it is based on what we expect their medical needs are going to be. That is critical. Rather than just reacting to the emotion associated with this issue, we are doing what we believe is truly in the medical best interest of the patient.

Mr Donofrio: I would have to agree with you, Peter. I think that a multidisciplinary approach is probably the best approach when treating substance abuse. I think that layering in social workers along with the nurse practitioners and doctors is going to get the best results for our patients.

Dr Waldman: Thank you very much, Justin and Peter. I am Dr Seth Waldman of HSS. Thank you very much.