Opioid-Sparing Outpatient Surgery

Anesthesiologists in and around Atlanta respond to the opioid epidemic.

Sitting across from me in our office at the WellStar East Cobb Surgery Center, patient Ryan Coker shares the story of his son Roger. Ryan and I first met in October 2018 when he came to our center for outpatient surgery. On that day, as he quietly requested a narcotic-free surgery, I sensed the untold story that he would share with me six months later. 

Ryan lost his brilliant, big-hearted and loving son Roger the year before. While he had struggled with addiction for decades, Ryan had turned around his life and was sober, until prescription opioids after orthopedic surgery had undone everything once again. Roger died from an accidental overdose of heroin and fentanyl at the age of 44.

Metro-Atlanta as the Epicenter of Georgia’s opioid epidemic

Georgia stands as the 11th highest state overall for prescription opioid deaths.^iv The recent A&E documentary The Triangle focused on a section of the affluent northern Atlanta suburbs, including Cobb, Fulton, Gwinnett and DeKalb counties that has seen a 4000 percent increase in heroin-related deaths over a 5-year period.^iv Most people are surprised to learn that 80 percent of heroin users begin with prescription opioids. 

What are Atlanta’s physicians doing to combat this epidemic?

With surgery and acute pain from injuries serving as the introduction to prescription opioids for many, perioperative physicians are well-positioned to develop advanced care pathways that minimize both narcotics and pain. It really is possible to create opioid-sparing – even opioid-free – surgery as part of a larger progressive movement known as Enhanced Recovery After Surgery (ERAS), which also includes better fluid management, mobilization protocols, wound care and so on. First developed in 1995 for colorectal surgeries by the Danish surgeon Dr. Henrik Kehlet, ERAS has since been proven to increase patient satisfaction with post-operative recovery, shorter hospital stays, earlier mobilization and lower readmission rates. 

Anesthesiologists and surgeons collaborate to use long-acting nerve blocks and non-narcotic medications before, during and after surgery. Together with the Medical Association of Georgia’s (MAG) Opioid Task Force and county medical societies like Medical Association of Atlanta (MAA), a combination of peer-to-peer training, changes in perioperative workflows, creation of multidisciplinary teams, research and legislation, we are substantially reducing the risk of opioid use and misuse after surgery.

Floyd Medical Center (Dr. Cowan, northwest Georgia)

Dr. Annie Cowan, director of the perioperative evaluation center at Floyd, recalls a tumultuous decade from 2007 to 2017 when the residents of her community suffered the highest death-rate in Georgia from opioid overdoses.^iii During this decade, while emergency departments and first responders were dealing with higher rates of overdose and death, perioperative teams were dealing with higher rates of opioid-tolerance in patients receiving long-term outpatient opioid therapy.^iv 

Moreover, it had become clear that the higher opioid doses needed to control pain in chronic opioid users was delaying post-operative recovery by causing more nausea, vomiting, drowsiness, delirium, constipation and urinary retention. “Enhanced Recovery” pathways calling for early feeding, mobilization and discontinuation of IV fluids and urinary catheters required alert postoperative patients with pain controlled enough to get up and move. Both the Enhanced Recovery movement and the opioid crisis were demanding something better than an opioid-based strategy for surgical pain. 

Floyd anesthesiologists began using multimodal pain regimens, including routine use of oral gabapentin or pregabalin before induction of anesthesia, and more widespread use of regional anesthesia to selectively numb the surgical site. Once IV formulations of acetaminophen and ibuprofen became available, their use was incorporated into the regimen, along with anti-spasmodics. Order sets were written to standardize the new approach into preoperative, intraoperative and postoperative care. Opioids were reserved only for breakthrough pain and with a new mantra of “oral before IV”. Additionally, IV pain medications automatically converted to oral medications within 24 hours postoperatively. 

Preoperatively, opioid-tolerant patients were identified during pre-op assessment and managed in a standardized fashion. Patients taking more than 50 morphine-milligram-equivalents per day (MME/day) had scripted conversations with pain experts prior to the day of surgery to set appropriate expectations around pain control and functional goals after surgery.

Furthermore, perioperative recovery and postoperative floor nurses received formal training, both live and computer-based, emphasizing the goals and concepts of enhanced recovery, multimodal pain control and the reduced role of opioids exclusively for breakthrough pain. 

The results were remarkable. Hospital length of stay dropped significantly. (See Figure 1.) Patients had at least as good, and in many cases better pain control, despite the much lower use of opioids. Moreover, fewer complications occurred, including less respiratory depression. 

On the nursing floors, patients were up and walking within a few hours of arrival. The IV patient-controlled-analgesia (PCA) pumps became obsolete. For patients who had previously suffered with days of nausea, “brain fog” and other opioid side effects after surgery, this new pain regimen was a game changer. Multimodal pain management is now the norm for joint replacement, spine fusion and colorectal surgeries at Floyd. Complete implementation for major urologic surgery is currently underway. 

Lessons Learned at Floyd

While the results have been rewarding, the lessons learned have been many. According to Dr. Cowan, keys of successful implementation include:

1. Identify and involve all stakeholders throughout the patient’s journey from surgeon’s office, to preoperative admission, to preoperative holding area, to post-operative recovery and surgical follow-up. Each hand-off from one caregiver to another represents a risk for reverting to prior (outdated) opioid use.

2. Ensure the night-shift nursing staff are educated and know what to do for breakthrough pain.

3. Have Information Technology and Clinical Informatics create easy-to-use order sets in the electronic medical record. At Floyd, IT pharmacists were instrumental in designing order sets, particularly to facilitate the transition from IV to oral pain medication, and in surveying the patient’s Medical Administration Record (MAR) for sedating medications and detrimental polypharmacy. 

4. Incorporate ERAS into onboarding of new physicians, advanced-practice professional and nurses. 

5. Don’t just tell team members they should follow the new way, discuss why they are doing it. 

6. Incorporate non-pharmaceutical treatments for pain-control, such as expectation-setting, reassurance that pain will subside, empathetic attentiveness of staff and health psychology when needed. 

The Impact of Patient Anxiety

The impact of anxiety on perioperative pain-control deserves special mention. We must reassure patients that low levels of tolerable postoperative pain are expected, even protective, and that their pain control will be both standardized and personalized. Setting expectations can go a long way towards preventing anxiety in the recovery period.

WellStar East Cobb Outpatient Surgery Center (Dr. Haque, North Atlanta) 

In August 2018, our anesthesia department along with a multidisciplinary team of surgeons, pharmacists and perioperative nurses, formed the Collaborative for Opioid Sparing Recovery (CORE) with the intent of reducing opioid use throughout all phases of the perioperative process. A key element of the CORE program included the development of case-specific multimodal protocols aimed at reducing postoperative pain. 

We followed Dr. Cowan’s recipe of stakeholder identification and engagement, clinician education, morning huddles and nursing in-services detailing pharmaceutical regimens and perioperative care. Nurses had the opportunity to voice concerns, ask for further education, and suggest process improvements. The importance of nurses as critical stakeholders to the success of the program cannot be overstated. 

At the same time, every anesthesiologist was trained to perform advanced nerve blocks. The scope of regional anesthesia changed from five types of blocks in January 2018 to 12 different brachial plexus and fascial plane blocks by August of that year. 

With the assistance of educational grants, experts from large centers including Duke University in Raleigh, N.C., and St Francis Hospital in Long Island, N.Y., provided hands-on block training and use of multimodal combinations. Regional anesthesia specialists within the WellStar system, especially Dr. Maggie Holtz and Dr. Vandy Gaffney, helped improve the speed and efficiency of performing nerve blocks. Together, with nursing and pharmacy leadership, we continuously improved the processes and protocols. 

Human factors (workflow) was an important focus. Our clinical informaticists made the order-entry process easier, a wristband was created to relay to all team members the drugs that had been given preoperatively, the timing and sequencing of multiple oral and IV medications in pre-op had to be just right, and nursing had to manage infusion times and compatibility of the different medication combinations (e.g., magnesium, Robaxin, Caldolor, antibiotics and so forth). 

A functional pain scoring tool was created and personnel trained in its use. Opioid-sparing discharge instructions were developed emphasizing scheduled oral NSAIDs and acetaminophen. It took several months to streamline workflows. 

For chronic pain patients or patients with a history of high opioid use, bedtime gabapentin was added the night before surgery and for the first postoperative week after discharge. Narcotics were prescribed and suggested as a PRN agent when patients developed a functional pain score greater than 4. 

As simple as this sounds, the concept of PRN narcotics was revolutionary in a field that historically instructed patients to take narcotics around the clock to stay ahead of the pain. Scheduling Tylenol required participating surgeons to change prescribing patterns from combined agents such as Percocet and Vicodin to single agent stand-alone narcotics. 

The use of long-acting liposomal bupivacaine for regional nerve blocks was instrumental in allowing patients to take as little as zero to one narcotic pill in the first postoperative week. With the combination of multimodal medications and a long-acting block, the majority of patients used 0-10 narcotic pills through postoperative day 5, even in procedures as painful as rotator cuff repairs and open reduction and internal fixation (ORIF) of ankle fractures. 

In speaking with patients on the post-op day 5 phone calls, you hear a combination of excitement and disbelief. Once such patient, Ms. Julia Fincher said “I was offered a narcotic-free alternative to manage my (post-operative) pain with essentially zero side effects. Would anyone turn this down? I went from anxious, concerned and apprehensive the morning of my surgery to optimistic, confident, pain free, narcotic free. If my experience is the ‘norm,’ this is a truly ground-breaking alternative for patients.” 

For patient Caroline Bishop, her narcotic-free experience was a welcome surprise. “Pain pills make me feel terrible. I had prepared myself for nausea, pain, fogginess … to not have any of those side effects and to carry on with my life was such an amazing experience”. 

For patient Ryan Coker, for whom narcotics were not an option, he was mentally prepared to experience pain. “I was ready to feel it, and I never did. My pain was a zero throughout the entire experience. Everyone should hear about this. I did not need a narcotic, and I did not feel pain.”

Lessons Learned at WellStar East Cobb Surgery Center 

1. Get effective executive sponsorship, someone with the ability to make the care transformation happen even if new resources are needed.

2. Get effective service line sponsorship, like Dr. Bill Mayfield, chief surgical officer for the system, who can influence surgeons, nurses, the P&T Committee and anesthesiologists alike.

3. Get effective specialty sponsorship, such as Dr. Maggie Holtz (anesthesiology) and Dr. Stan Dysart (orthopedic surgery). Their groundbreaking work to develop enhanced recovery pathways in total joints, colectomies and spine cases served as the original model that other surgeons could then reference. 

4. Demonstrate the total value of the opioid-sparing protocols by including a subject-matter-expert (SME) in value-based-care, such as Ms. Susan Jackson, executive director of pharmacy system operations, who routinely measures economic benefit of new care models. When better clinical outcomes, higher patient satisfaction, earlier return to work, reduced length of PACU or inpatient stay, and reduced readmission rates are included in the value analysis, the whole organization will get behind the change. 

Northside Hospital (Dr. Heather Dozier, North Atlanta)

Dr. Dozier is a lead anesthesiologist in Northside Hospital’s Fast Track Total Joint program. Similar to Floyd and WellStar, patients in the fast-track program at Northside receive regional anesthesia as a part of a multimodal analgesic plan that uses alternatives to opioids to treat pain. Dr. Dozier is proud of the fact that total joint patients at Northside Forsyth have one of the shortest length-of-stays in the country, which helps get their patients back to normal function. All of this is due to the combined efforts of the anesthesiologists, surgeons, nurses, pharmacy and the support of administration. 

“Our champion was Dr. Mark Hamilton. It’s because of him that our Fast Track Total Joint program is so successful,” Dr. Dozier says. 

Pharmacy costs in the immediate post-operative period increases substantially (opioids are relatively cheap), but the total value of those non-opioid approaches made the total cost of surgery less expensive for payors and patients. 

Cancer Treatment Centers of America (CTCA, Southwest Atlanta)

Since 2016, CTCA has been using their Advanced Surgical Recovery (ASURE) program. Anesthesiologist Dr. Neil Seeley along with CTCA surgical oncologist Kevin Watkins, M.D., began ASURE in patients undergoing the mammoth surgery known as pancreaticoduodenectomy (Whipple procedure). 

They have been able to show that opioid consumption decreased by approximately 85 percent on postoperative day three in patients undergoing this procedure. This was complemented by a decrease in the incidence of Clavien-Dindo 3• surgical complications, from 48 percent to 21 percent and a decrease in mean length of stay from 15 to 5 days. ^6,7

Findings by CTCA gynecologic oncologists John Geisler, M.D., and Kelly Manahan, M.D., show that continued use of narcotics 90 days after surgery decreased from 6 percent to 1.3 percent (P <0.001) after initiation of the program 6,7. These results were accompanied by significant decreases in mean length of stay from 7.1 to 2.6 days for ovarian debulking. 

Everyone wins with the new opioid-sparing protocols (patients first and foremost, but also payors and hospitals). “The old concept that opioids are the mainstay for postoperative pain control has been laid to rest,” says Dr. Seeley. 

Sustaining Our Gains 

The Role of Specialty Societies. The American College of Surgeons (ACS) and the American Society of Anesthesiologists (ASA) along with other professional organizations are working on policies and best practices for its members to reduce the risk of opioid overprescribing and misuse. The ACS has been a prominent supporter of strengthening state-run Prescription Drug Monitoring Programs (PDMP). The ASA was instrumental in passing the Perioperative Reduction of Opioids (PRO) Act, which established a panel of experts to promote opioid reduction in the surgical arena.

Graduate Medical Education (GME) programs are training surgical residents on opioid stewardship. 

Georgia Legislature. Physicians have been given a venue to design and debate health legislation with the Georgia Opioid Task Force (GOTF).  

Physician Leadership. According to Dr. Debi Dalton, the VPMA at WellStar Douglas Hospital and who serves on the systemwide Opioid Steering Committee, “Some physicians were not aware of the staggering numbers of use, abuse and death by opioids. I truly feel that it has been eye opening to understand the deadly impact of how one prescription can lead to addiction and the use of more potent drugs.”

A Holistic Approach. As our colleague Dr. Stephen Barrett writes: “Ultimate pain management requires a multidisciplinary approach … to treat the entire patient, from pain source, to psychological status, sleep patterns, diet, nutrition and metabolic status, pharmacological interventions, hormonal makeup and exercise. Only then can a personalized treatment plan work.”

We look forward to the day that prevention and treatment of pain with ERAS and multimodal protocols is so highly evolved that opioid use in the acute care setting disappears altogether. 

References

1.Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, Bohnert ASB, Kheterpal S, Nallamothu BK. NewPersistentOpioidUse AfterMinor and Major Surgical Procedures in US Adults.JAMA Surg. 2017 Jun 21;152(6):

2. Cerdá M¹, Santaella J², Marshall BD³, Kim JH², Martins SSNonmedical Prescription Opioid Use in Childhood and Early Adolescence Predicts Transitions to Heroin Use in Young Adulthood: A National Study.J Pediatr.2015 Sep;167(3):605-12.
3. Chouinard S¹, Prasad A¹, Brown R^1,2Survey Assessing Medical Student and Physician Knowledge and Attitudes Regarding the Opioid Crisis. WMJ.2018 Mar;117(1):34-37.
4. Cohen R, Gooberman-Hill R Staff experiences of enhancedrecoveryafter surgery: systematic review of qualitative studies.BMJ Open. 2019 Feb 12;9(2):
5. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154-163
6. Geisler J, Seeley N, Manahan K. Decrease in narcotic use after initiation of an advanced surgical recovery program. Society of Gynecologic Oncology Annual Meeting. 2019.
7. Geisler J, Seeley N, Manahan K. Changes in length of stay and 30-day readmission rates after starting an advanced surgical recovery program. Society of Gynecologic Oncology Annual Meeting. 2019.
8. Harbaugh CM, Lee JS, Hu HM, McCabe SE, Voepel-Lewis T, Englesbe MJ, Brummett CM, Waljee JF. PersistentOpioidUse Among PediatricPatientsAfter Surgery.Pediatrics. 2018 Jan;141(1). pii: e20172439. doi: 10.1542/peds.2017-2439. Epub 2017 Dec 4.

9..Jayawardhana J¹, Abraham AJ², Perri M. Opioid Analgesics in Georgia Medicaid: Trends in Potential Inappropriate Prescribing Practices by Demographic Characteristics, 2009-2014.J Manag Care Spec Pharm.2018 Sep;24(9):886-894.

10.Kohlbeck S^1,2, Akert B^3,2, Pace C³, Zosel A. A Multistep Approach to Address Clinican Knowledge, Attitudes, and Behavior Around Opioid Prescribing.WMJ.2018 Mar;117(1):38-41.

11. Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA; Opioids After Surgery Workgroup. Opioid-PrescribingGuidelinesfor CommonSurgical Procedures: An Expert Panel Consensus.J Am Coll Surg. 2018 Oct;227(4):411-418
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Web Based Resources

1. Georgia Department of Public Health’s syndromic surveillance monthly reports(https://dph.georgia.gov/drug-overdose-syndromic-surveillance-monthly-reports)
2. CDC Opioid Prescribing maphttps://www.cdc.gov/drugoverdose/maps/rxcounty2017.html

• GA Department of Public Health Opioid Overdose Surveillance https://dph.georgia.gov/sites/dph.georgia.gov/files/2016%20OPIOID%20PRELIMINARY%20REPORT.FINAL.PDF

1. Atlanta Regional Commissionhttps://atlantaregional.org/news/press-releases/arc-report-opioid-related-overdose-deaths-increase-sharply-in-metro-atlanta/
2. ERAS Society

http://erassociety.org/about/history/

1. Georgia Department of Public Health Drug Overdose/ Opioid Mapping Toolⁱhttps://oasis.state.ga.us/oasis/webquery/qryDrugOverdose.aspx