Based on the news of multi-million-dollar settlements with large opioid manufacturers, it is tempting to believe the U.S. is finally gaining traction on the opioid epidemic. But now is not the time for health care providers to take a victory lap. There were nearly 400,000 deaths linked to overdoses of opioids, both prescription and illicit, in the U.S. from 1999 to 2017. Over half of those deaths were associated with prescription opioids.
California in particular has taken great strides to reduce the number of opioid deaths. The California Department of Public Health currently hosts the California Opioid Overdose Surveillance Dashboard to provide the latest data publicly, with dashboards available that can parse information down to the county level. A number of initiatives have also been rolled out across the Golden State to address the opioid epidemic, including increasing access to naloxone, promoting public education, and expanding Medication Assisted Treatment (MAT).
For outpatient surgery providers in California, including ambulatory surgery centers (ASCs), this information is particularly important to consider. ASC health providers deal with patients on a daily basis that require prescriptions for post-operative pain. Given the growth of surgeries in ASC settings, an at-risk aging population seeking care at surgery centers, and the importance of physician intervention at the point-of-care, ASCs are well-positioned to play an important role in combatting opioid dependence, both nationwide and in the Golden State.
The reality is that all patients are at risk to abuse opioids or develop substance use disorders (SUDs). The is especially true for patients treated in the surgical setting. Research suggests persistent opioid use occurs in 3-10% of patients who were not using opioids prior to surgery. Additionally, some patients are at a higher risk of addiction than others, and this addiction can translate into serious medical complications beyond the SUD itself. A recent study in JAMA Network Open on opioid use following total knee replacement surgery (a common procedure in the outpatient setting) found 7.2% of patients with a history of opioid use prior to surgery had higher risks of revision operations, vertebral fractures, and opioid overdoses within 30 days after the operation, compared with patients who had not used opioids during the previous 12 months. The demographics of those at risk of being newly addicted are not necessarily consistent. For example, older patients, women, and millennialshave all been listed as demographics at risk of becoming persistent opioid users following surgery.
Administrators and clinicians in ASCs throughout California, and the rest of the county, can help their patients by focusing on three strategies to help prevent patient progression to misuse or abuse:
Use the preoperative assessment as an opportunity for prevention. Lack of integration between ASC software and other health system partners (hospitals, clinics, pharmacies, etc.) can make it difficult to closely examine patients’ pharmacological histories. Preoperative dialogue between clinicians and patients is a prime opportunity for good opioid stewardship. Certain factors, such as previous and existing mental health and substance abuse issues or a family history of substance abuse, increase the risk of long-term opioid use, but not exclusively. Preoperative interviews should include a frank, sensitive conversation about opioid risks, regardless of patient history, and staff should conduct a review of relevant prescribing databases as part of their patient onboarding. However, prior history is not the only indication of addiction, especially for those at-risk that have never used before. Screening tools like the Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) can aid providers in collecting the necessary data to better understand and act based on their patients’ social determinants of health.
Collaboratively develop a pain plan with patients. Setting expectations with patients ahead of procedures can help with post-operative pain management. Patients should understand both that pain may follow their procedure and is to be expected, but should also be aware of alternative approaches to pain management. A pain plan, centered in a dialogue about options for pain management, will help patients understand that they should include non-opioid alternatives for pain relief, including massage, stretching, meditations, and acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) to improve pain control. Use of an electronic health record (EHR) has been highly effective in other healthcare settings to help with opioid stewardship. This could include prompts to remind clinicians to discuss and document pain plans, reminders to follow up with questions relating to pain medication post-operatively, or flags when an opioid dose could be lower.
Educate, then educate again. As part of the California Ambulatory Surgery Association (CASA), HST Pathways recently participated with a team of experts alongside the California Society of Anesthesiologists (CSA) to create recommendations and resources for addressing the national opioid crisis at the surgery center level. This resulted in the creation of a new ASC Opioid Toolkit that contains a variety of resources that may be used in ASCs to help clinicians and patients with pain management. One of the five areas of focus is the importance of informing and educating patients on the proper use of, replacement for, and disposal of opioid medications. Materials and a video, available in English and Spanish, are based on the latest research and policies from nationally recognized medical organizations, including the American Medical Association (AMA), Centers for Disease Control and Prevention (CDC), and the U.S. Department of Health and Human Services (HHS).
With these strategies top-of-mind, ASCs can better prevent the suffering associated with opioid dependence and SUD, helping to ensure that patients in California are protected post-operatively, and long into the future.
Tara Vail, MBA, is the chief operating officer of HST ASC Software, the top-ranked software solutions company for the ASC industry. She has deep expertise in helping healthcare organizations leverage information technology to improve operational efficiency and optimize revenue cycle management. She also serves on the California Ambulatory Surgery Association Board of Directors.