Implement a Practice-wide Strategy for Safe and Effective Alleviation of Pain

Practice-wide strategies can help to depersonalize discussions about the role of opioids in postoperative alleviation of pain--making it a discussion about addressing the common enemy of pain, rather than the decisions of a “heartless” doctor. 

Consensus opioid strategies [PDF] for your practice might include the following^1,2:

• Identify a single team member that prescribes opioids
• Check statewide databases to ensure you are the only prescriber
• Set upper limits for opioid prescriptions by injury and procedure
• Use electronic prescribing. Discuss smaller initial prescriptions with patients given the relative ease of refills.  Stick to the agreed maximum number of pills and duration of treatment
• Encourage use of a pill cutter to further reduce dosage as recovery progresses   
• Do not prescribe extended-release opioids.  The pain of surgery and injury improves over hours to days, rather than days to weeks.
• Make specific plans for individuals who are on daily opioids or medication-assisted treatment for opioid use disorder.  Coordinate care with their opioid prescribers and pain medicine specialists.
• Use screening tools to identify patients at risk of opioid dependence
• Use screening tools to identify opportunities to relieve pain by relieving stress or distress or nurturing more effective coping strategies.
• If opioids are prescribed, counsel patients on the risks and serious adverse effects, as well as the safe storage and disposal of opioid medications  
• Script and practice empathetic and effective communication strategies geared toward all levels of health literacy
• Optimize emotional and physical support for patients after surgery
• Establish methods for obtaining help, including collaboration with an acute pain service, when postoperative pain is more severe or prolonged than expected, which is often associated with symptoms of depression, posttraumatic stress disorder, and less effective coping strategies such as catastrophic thinking
• Support quality improvement initiatives and continuing medical education for team members on safe and effective alleviation of pain and optimal opioid stewardship.

References

1. American Academy of Orthopaedic Surgeons. Information statement: Opioid use, misuse, and abuse in orthopaedic practice. https://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf.  Accessed August 14, 2018.
2. Agency Medical Directors’ Group. Interagency Guideline on Prescribing Opioids for Pain. http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf. Accessed August 14, 2018.

Sample Orthopaedic Department Opioid Safety Strategy [PDF]

1. Only one doctor prescribes opioids.
2. Patients on buprenorphine, methadone, or daily opioids get opioids from their PCP or pain medicine specialist.
3. New office patients with long-standing conditions will not be prescribed opioids.
4. Orthopedic surgeons do not use long-acting opioids.
5. Orthopedic surgeons do not treat persistent pain with opioids.
6. Statewide databases are checked prior to prescribing opioids.
7. After minor procedures (eg, trigger finger, carpal tunnel release, simple laceration, etc) patients will be encouraged to take acetaminophen and/or NSAIDs only and will receive:
1. No more than 10 opioid pills.
2. Maximum of 5 mg of oxycodone (or equivalent) per pill.
3. No refills.
8. After fracture, laceration, other injuries:
1. Most are treated with non-opioid pain medication (eg, ibuprofen, acetaminophen), splint, ice, elevation, and reassurance. 
2. Some very unstable or complex fractures may, on occasion be treated with opioids prior to surgery.
9. Intermediate procedures (eg, open reduction internal fixation of a radius or humerus fracture, shoulder arthroscopy, etc):
1. No more than 30 opioid pills.
2. Maximum of 5 mg of oxycodone (or equivalent) per pill.
3. A single refill of no more than 15 pills.
4. Discontinue opioids within 2 weeks of surgery.
10. Major procedures (eg, spinal fusion, ORIF acetabular fracture, joint replacement, etc):
1. No more than 60 opioid pills.
2. Maximum of 5 mg of oxycodone (or equivalent) per pill.
3. A single refill of no more than 30 pills.
4. Discontinue opioids within 1 month of surgery.
11. Encourage use of acetaminophen or ibuprofen or both instead of opioids.
12. Encourage use of a pill cutter to decrease the dose to half or quarter pill as comfort improves.
13. Prescribe as little opioid medication as possible. Use e-prescribing to limit the size of initial prescriptions and give more later only after discussion with the patient.
14. Patients with more pain than expected will be evaluated in the office.

Sample Patient-facing Orthopaedic Service Opioid Safety Strategy [PDF]

• Opioid medications include: Codeine, hydrocodone (Vicodin, Norco), oxycodone (Percocet, Oxycontin), and hydromorphone (Dilaudid).
• Opioids can relieve pain.
• Opioids are also addictive and deadly.
• Opioids are tightly controlled and monitored by the federal government through the Drug Enforcement Agency (DEA). 

Americans take more opioid medications and are less satisfied with pain relief after injury or surgery than patients with similar problems in other parts of the world. The leading cause of death among young adults in the United States is accidental poisoning. Overdose of prescription opioid pain medication and heroin accounts for 90% of these deaths. The prescription opioids that are causing these deaths have been traced to physician over-prescribing.

• Most patients take little or no opioids after minor procedures and wean off as quickly as possible after more substantial injuries and surgeries. 
• Continued opioid use is often indicative of stress, distress, or less effective coping strategies. Opioids are often used by patients for non-pain related reasons such as inability to sleep and to treat depression.

For our patients’ well-being and because of ever-tightening regulations and oversight, we have adopted the following strategy for the use of opioids to alleviate pain after surgery and injury. This opioid strategy was developed to limit over-prescription and misuse of opioids. This strategy does not apply to patients who are dying from cancer.

1. Each patient receives opioid pain medications from a single provider.
2. For patients on buprenorphine or long-term opioids, their primary care doctors or pain medicine specialist should be that single provider. 
3. New patients with non-acute problems are not prescribed opioids.
4. We check statewide databases before prescribing opioids.
5. Orthopaedic surgeons do not give opioids for chronic pain.
6. Orthopaedic surgeons do not prescribe extended-release opioids.
7. We have upper limits for opioid prescription specific to: 
1. Minor procedures: eg, trigger finger, carpal tunnel release, excision of a small benign tumor, etc.
2. Fracture, laceration, other injuries
3. Moderate procedures: eg, open reduction internal fixation of a distal radius or humerus fracture, shoulder arthroscopy, etc.
4. Major procedures: eg, spinal fusion, ORIF acetabular fracture, joint replacement, etc.

Strategies for Alleviating Musculoskeletal Pain in the Emergency Department [PDF]

Tips for your Emergency Medicine colleagues helping patients with musculoskeletal injuries get off to a good start.

Pain is the most common symptom presenting in the emergency department (ED)—either acute pain due to trauma or worsening of chronic pain.¹ It is important for ED teams to establish consensus protocols and policies to control and limit opioid prescription and inappropriate use.² Consensus strategies can help to depersonalize decisions made about opioid use and defuse potentially difficult discussions with patients about opioid prescriptions to manage acute musculoskeletal pain.

Consensus opioid strategies might include^3,4:

• Identification of the providers responsible for managing pain and prescribing opioids
• Coordination with that provider.
• Setting ranges for acceptable amounts of opioids
• Determining strict upper limits on opioid prescription size and strength  
• No prescribing of extended-release opioids for musculoskeletal pain by emergency department clinicians
• Encouraging patients to use nonpharmacologic pain management, acetaminophen, and NSAIDs
• Using tools to identify patients at risk of opioid dependence 
• If opioids are prescribed, counseling patients on the risks and serious adverse effects of opioids and their safe storage and disposal 
• Checking statewide databases to see when/if patient has filled recent opioid prescriptions and if they have been seeing multiple providers.
• Using scripts and practicing empathetic and effective communication strategies geared toward all levels of health literacy
• Identifying opportunities for emotional and social support
• Supporting quality improvement initiatives and continuing medical education for safe and effective alleviation of pain and optimal opioid stewardship

Here is an example of an Opioid Safety Strategy for an Emergency Department [PDF].

References

1. Todd, KH. A review of current and emerging approaches to pain management in the emergency department. Pain Ther. 2017;6(2):193-202.
2. Motov S, et al. The treatment of acute pain in the emergency department: a white paper position statement prepared for the American Academy of Emergency Medicine. J Emerg Med. 2018;54(5):731-736.
3. American Academy of Orthopaedic Surgeons. Information statement: Opioid use, misuse, and abuse in orthopaedic practice. https://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf. Accessed August 14, 2018.
4. American College of Emergency Physicians. Policy Statement: Optimizing the treatment of acute pain in the emergency department. April 2017. https://www.ena.org/docs/default-source/resource-library/practice-resources/position-statements/supported-statements/optimizing-the-treatment-of-acute-pain-in-the-ed.pdf?sfvrsn=4e5c71e_4. Accessed August 14, 2018.