Implementation of a restrictive opioid prescription protocol after minimally invasive gynecologic oncology surgery

2021 ◽  
pp. ijgc-2021-002968
Author(s):  
Soyoun Rachel Kim ◽  
Stephane Laframboise ◽  
Gregg Nelson ◽  
Stuart A McCluskey ◽  
Lisa Avery ◽  
...  
Keyword(s):  
Minimally Invasive ◽  
Pain Control ◽  
Gynecologic Oncology ◽  
Cancer Center ◽  
Provider Education ◽  
Opioid Use ◽  
Post Intervention ◽  
Opioid Prescription ◽  
Post Surgery ◽  
The Impact

ObjectivesOpioids are routinely prescribed after minimally invasive gynecologic oncology surgery, with minimal data to inform the ideal dose. The aim of this study was to evaluate the impact of a restrictive opioid prescription protocol on the median morphine milligram equivalents prescribed and pain control in patients undergoing minimally invasive surgery.MethodsA restrictive opioid prescription protocol was implemented from January through December 2020 at a single tertiary cancer center in Ontario, Canada. Consecutive patients undergoing minimally invasive hysterectomy for suspected malignancy were included. Simultaneously, we implemented use of multimodal analgesia, patient and provider education, pre-printed standardized prescriptions, and tracking of opioid prescriptions. Total median morphine milligram equivalents prescribed were compared between pre- and post-intervention cohorts. Patients were surveyed regarding opioid use and pain control at 30 days post-surgery.ResultsA total of 101 women in the post-intervention cohort were compared with 92 consecutive pre-intervention controls. Following protocol implementation, median morphine milligram equivalents prescribed decreased from 50 (range 9–100) to 25 (range 8–75) (p<0.001). In the post-intervention cohort, 75% (76/101) used 10 median morphine milligram equivalents or less and 55 patients (54%) used 0 median morphine milligram equivalent. There was no additional increase in opioid refill requests after implementation of our strategy. Overall, patients reported a median pain score of 3/10 at 30 days post-surgery; the highest pain scores and most of the pain occurred in the first week after surgery.ConclusionsImplementation of a restrictive opioid prescription protocol led to a significant reduction in opioid use after minimally invasive gynecologic oncology surgery, with over 50% of patients requiring no opioids postoperatively.

scholarly journals Long-term postoperative opioid prescription after cholecystectomy or gastric by-pass surgery: a retrospective observational study

2021 ◽  
Vol 0 (0) ◽  
Author(s):  
Viktoria Larsson ◽  
Cecilia Nordenson ◽  
Pontus Karling
Keyword(s):  
Observational Study ◽  
Postoperative Period ◽  
Medical Records ◽  
Early Postoperative Period ◽  
Retrospective Observational Study ◽  
Opioid Use ◽  
Opioid Prescription ◽  
Post Surgery ◽  
Gastric By Pass

Abstract Objectives Opioids are commonly prescribed post-surgery. We investigated the proportion of patients who were prescribed any opioids 6–12 months after two common surgeries – laparoscopic cholecystectomy and gastric by-pass (GBP) surgery. A secondary aim was to examine risk factors prior to surgery associated with the prescription of any opioids after surgery. Methods We performed a retrospective observational study on data from medical records from patients who underwent cholecystectomy (n=297) or GBP (n=93) in 2018 in the Region of Västerbotten, Sweden. Data on prescriptions for opioids and other drugs were collected from the patients` medical records. Results There were 109 patients (28%) who were prescribed opioids after discharge from surgery but only 20 patients (5%) who still received opioid prescriptions 6–12 months after surgery. All 20 of these patients had also been prescribed opioids within three months before surgery, most commonly for back and joint pain. Only 1 out of 56 patients who were prescribed opioids preoperatively due to gallbladder pain still received prescriptions for opioids 6–12 months after surgery. Although opioid use in the early postoperative period was more common among patients who underwent cholecystectomy, the patients who underwent GBP were more prone to be “long-term” users of opioids. In the patients who were prescribed opioids within three months prior to surgery, 8 out of 13 patients who underwent GBP and 12 of the 96 patients who underwent cholecystectomy were still prescribed opioids 6–12 months after surgery (OR 11.2; 95% CI 3.1–39.9, p=0,0002). Affective disorders were common among “long-term” users of opioids and prior benzodiazepine and amitriptyline use were significantly associated with “long-term” opioid use. Conclusions The proportion of patients that used opioids 6–12 months after cholecystectomy or GBP was low. Patients with preoperative opioid-use experienced a significantly higher risk of “long-term” opioid use when undergoing GBP compared to cholecystectomy. The indication for being prescribed opioids in the “long-term” were mostly unrelated to surgery. No patient who was naïve to opioids prior surgery was prescribed opioids 6–12 months after surgery. Although opioids are commonly prescribed in the preoperative and in the early postoperative period to patients with gallbladder disease, there is a low risk that these prescriptions will lead to long-term opioid use. The reasons for being prescribed opioids in the long-term are often due to causes not related to surgery.

Efficacy of a password-protected pill-dispensing device to enhance disposal of unused opioids after cancer surgery.

2021 ◽  
Vol 39 (28_suppl) ◽  
pp. 264-264
Author(s):  
Jacob Cogan ◽  
Melissa Kate Accordino ◽  
Melissa Parsons Beauchemin ◽  
Sophie Ulene ◽  
Elena B. Elkin ◽  
...  
Keyword(s):  
Pain Control ◽  
Cancer Surgery ◽  
High Rate ◽  
Smartphone App ◽  
Opioid Use ◽  
Structured Interviews ◽  
Health Crisis ◽  
Patient Reported ◽  
After Cancer ◽  
The Impact

264 Background: Opioid misuse is a public health crisis. Initial opioid exposures often occur post-operatively, and 10% of opioid-naïve patients who undergo cancer surgery subsequently become long-term opioid users. It has been shown that 70% of opioids prescribed post-operatively go unused, but only 9% of unused pills are disposed appropriately, which increases the risk of unintended use. We evaluated the impact of an inexpensive, password-protected dispensing device with mail return capacity on retrieval of unused pills after cancer surgery. Methods: Adult patients scheduled for major cancer-related surgery were eligible. Enrolled patients received opioid prescriptions in a password-protected, pill-dispensing device (Addinex) from a specialty pharmacy. The mechanical device links to a smartphone app, which provides passwords on a prescriber-defined schedule. Patients request a password when they are in pain, enter the password into the device and receive a pill if the prescribed time has elapsed. The smartphone app provides clinical guidance based on patient-reported pain levels, and suggests tapering strategies. Patients are instructed to return the device in a DEA-approved mailer when opioid use is no longer required for pain control. Unused pills are destroyed upon receipt. The primary objective was to determine the feasibility of device return, defined as > 50% of patients with device return. We also explored patterns of device use, patient reported outcomes, and device satisfaction via surveys and semi-structured interviews. Results: Between October, 2020 and April, 2021, 13 patients completed the study; 4 patients are currently enrolled. Among the initial 13 patients, 7 underwent abdominal hysterectomy, 4 underwent mastectomy and 2 underwent cutaneous tumor resections. The majority of these patients (n = 10, 77%) returned the device, and more than half (n = 7, 54%) returned the device within 6 weeks of surgery. Only a minority of patients (n = 5, 38%) used the device to obtain opioids; most (n = 8, 62%) used no opioids at home, and all of these patients returned the device and the unused pills. Of 11 patients who participated in semi-structured interviews, most (n = 7, 64%) said they felt safer having opioids in the device instead of a regular pill bottle. Among device users, the majority (n = 4, 80%) reported an overall positive experience. All non-users reported having no opioid requirement for pain control. Conclusions: Our early findings suggest that use of an inexpensive, password-protected, pill-dispensing device to assist with opioid dispensing and return is feasible, with a high rate of device and unused opioid return to the pharmacy. This strategy may be effective for reducing opioid diversion. Analyses and recruitment are ongoing to evaluate the benefits of reducing post-operative opioid consumption.

scholarly journals THE OPIOID EPIDEMIC IN LONG-TERM CARE: A STAFF PERSPECTIVE

2019 ◽  
Vol 3 (Supplement_1) ◽  
pp. S709-S709
Author(s):  
Rachael Hemmert ◽  
Gabriella E Dull ◽  
Linda S Edelman
Keyword(s):  
Pain Management ◽  
Long Term Care ◽  
Adverse Drug Events ◽  
Well Being ◽  
Educational Needs ◽  
Opioid Use ◽  
Term Care ◽  
Opioid Prescription ◽  
The Impact

Abstract Opioid-based analgesic therapy is a common treatment for moderate to severe pain among long term care (LTC) residents. It has been estimated that 60% of LTC residents have an opioid prescription. Of these, 14% use opioids as part of a long term pain management strategy. LTC residents are particularly vulnerable to opioid misuse, exhibiting higher rates of adverse drug events. However, addressing pain, polypharmacological needs and resident well-being in the LTC setting is challenging. More research and education regarding opioid use in LTC is needed. The Utah Geriatric Education Consortium conducted interprofessional focus groups with LTC partners to 1) determine educational needs of staff regarding opioid use, and 2) gather qualitative data about the pain management experiences of staff when working with residents and families. Staff identified the following training needs: pain manifestation and assessment; certified nurse assistant education on opioid use; non-pharmacological options for pain management. Review of staff’s perception of the intersection of opioids, family and staff in a LTC setting revealed that 1) family is concerned about opioid use; 2) conversely, staff may not see opioid use as a problem; and 3) non-pharmacological options for pain management are often costly and unavailable to those in LTC. Identifying educational needs of LTC staff will help guide the development of educational materials and provide baseline data for future assessments of the impact of opioid education on long-term care patient outcomes.

Evaluation of the Efficacy of Liposomal Bupivacaine in Total Joint Arthroplasty

2019 ◽  
pp. 089719001987257
Author(s):  
Francis J. Zamora ◽  
Rani P. Madduri ◽  
Ashmi A. Philips ◽  
Nancy Miller ◽  
Mini Varghese
Keyword(s):  
Knee Arthroplasty ◽  
Pain Control ◽  
Standard Of Care ◽  
P Value ◽  
Opioid Use ◽  
Post Surgery ◽  
Likert Score ◽  
Average Pain ◽  
Hip And Knee Arthroplasty ◽  
The Difference

Background: Appropriate pain control is one of the cornerstones necessary to promote positive clinical outcomes. A new bupivacaine liposomal formulation was designed to extend its analgesic effect for up to 72-hours post-surgery, reportedly leading to significant opioid-sparing. Method: Retrospective and prospective chart review conducted in a 178-bed academic institution between January 2013 to December 2013 and August 2014 to November 2014, in 115 patients that receive hip and knee arthroplasty. The primary outcome was the measurement of average daily pain score on post-operative days 1 and 2. Secondary outcomes included length of stay, overall opioid use post-surgery and pain control satisfaction using Press-Ganey® scores. Results: The average pain scores in the HCl group were 4.64 and 4.38 (Likert score: 0-10) for POD 1 and POD 2, compared to 4.72 POD 1 and 4.2 POD 2 in the liposome group (POD 1: p = 0.413; POD 2: p = 0.303). The difference in LOS for knee arthroplasty was statistically significant [HCl group: 1.94 days (± 0.66) versus liposome group: 2.27 days (±0.77) p-value = 0.038)] favoring the standard of care. For hip arthroplasty or bilateral knee arthroplasty the differences in LOS were not statistically significant ( p = 0.052 and p = 0.484 respectively). 93% of the patients in the HCl group, pain was well controlled, versus 88.5% in the liposome group with similar oxycodone IR use among groups. Conclusion: Liposome bupivacaine did not offer a notable benefit compared to the HCl formulation in our study.

Improving transitions of care through implementation of a standardized handoff at a comprehensive cancer center.

2016 ◽  
Vol 34 (7_suppl) ◽  
pp. 242-242
Author(s):  
Diane C. Bodurka ◽  
Mohamed Ait Aiss ◽  
Helene P Phu ◽  
Lakeisha R Day ◽  
Varkey Abraham ◽  
...  
Keyword(s):  
Pediatric Oncology ◽  
Medical Errors ◽  
Gynecologic Oncology ◽  
Skills Training ◽  
Illness Severity ◽  
Transitions Of Care ◽  
Comprehensive Cancer Center ◽  
Cancer Center ◽  
Post Intervention

242 Background: Communication failures cause two-thirds of sentinel events in hospitals. These adverse occurrences are often both fatal and preventable. Consequently, improving the quality of handoffs has been identified by multiple accreditation constituents as a top priority patient safety goal. This project was part of an institutional initiative to standardize handoffs among physicians, trainees, and midlevel providers. Methods: Four subgroups were identified as pilot areas: Gynecologic Oncology (Gyn Onc) fellows to nocturnalists, Surgical Oncology fellows, Pediatric Oncology residents and fellows, and Emergency Center attending staff to inpatient hospitalists. This abstract focuses on the Gyn Onc and Pediatric Oncology services. All teams used a PDSA cycle (Plan, Do, Study, Act) to conduct its pilot study. A gap analysis, root cause analysis, and process mapping were performed in each area to identify specific handoff issues. A validated standardized handoff tool, I-PASS (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, and Synthesis by receiver), was selected. Of note, “Illness severity” highlights patients identified at higher risk for complications and denotes their status as “watcher” or “unstable.” Interventions included I-PASS skills training and utilization of the I-PASS mnemonic. Each service developed a standardized definition to identify patients classified as “watchers.” Medical errors, ICU transfers, and provider satisfaction were assessed pre- and post-intervention. Results: Results from 40 handoff surveys showed communication errors dropped by 10% (16.49 vs 14.93). Minor harm as result of a problematic handoff decreased by 45% (2.55 vs 1.39), with a 55% reduction in ICU transfers. There was an overall increase in handoff satisfaction using I-PASS and 100% standardization of handoffs across the Gyn Onc and Pediatric Oncology units. Conclusions: Implementation of I-PASS, a validated standardized handoff was associated with reductions in medical errors and improvement in communication. Our institution is moving toward implementing I-PASS across all units to increase the safety and quality of patient care.

Improving the assessment and documentation of constipation at UF Health Cancer Center through mandatory prompts.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 263-263
Author(s):  
Brian Hemendra Ramnaraign ◽  
Bilal Farooqi ◽  
Priya Kadambi Gopalan ◽  
Merry Jennifer Markham
Keyword(s):  
Hospital Admissions ◽  
Medical Oncology ◽  
The Other ◽  
Cancer Center ◽  
Intervention Period ◽  
Opioid Use ◽  
Academic Hospital ◽  
Post Intervention ◽  
Chart Abstraction ◽  
Oncology Practice

263 Background: Opioids are commonly prescribed to patients for management of pain and the most common and persistent side effect from opioid use is constipation. Opioid-induced constipation (OIC) affects 52% of patients with advanced cancer and 87% of terminally ill patients. In the Spring 2017 Quality Oncology Practice Initiative (QOPI) chart abstraction round, UF Health Cancer Center’s Medical Oncology clinic notes documented the assessment of constipation in only 45.45% of charts. This is below the academic hospital aggregate documentation rate of 55.61%. Methods: Our objective was to improve the rate of documentation of assessment of constipation in the Thoracic Oncology Clinic at UF Health Cancer Center by 33% to a goal rate of at least 60% by 3 months. We used a Plan-Do-Study-Act model in order to design our project. We worked with the EPIC developers to include a mandatory prompt at the end of the assessment/plan section of the clinic template notes for the Thoracic Oncology practice. Our prompt was “Constipation was addressed and @HE@ {DOES/DOES NOT} have symptoms” where the author chooses from a drop down list to select whether the patient “does” or "does not” have symptoms. We planned to assess a total of 60 random charts in the 3 month post intervention period. Results: At the end of our study, a total of 48 out of 60 charts (80%) documented constipation thus surpassing our goal of 60%. Of the 12 charts assessed that did not address constipation, 11 did not use our revised templates and were notes that were “copied forwarded” from previous encounters. Conclusions: Given that our intervention was a success, we plan to expand these revised templates to the other medical oncology subspecialties in order to better document assessment of constipation for all cancer patients. While our mandatory prompt was shown to lead to increased documentation of constipation, further studies to show whether or not this leads to decreased complaints of abdominal pain, decreased incidences of bowel obstructions, and/or decreased hospital admissions, would be interesting to pursue.

Improving patient-centered oral chemotherapy at an academic cancer center.

2018 ◽  
Vol 36 (30_suppl) ◽  
pp. 212-212
Author(s):  
Charles Henry Lim ◽  
Jennifer Petronis ◽  
Sabrina Mellor ◽  
Monika K. Krzyzanowska
Keyword(s):  
Patient Education ◽  
Treatment Plan ◽  
Patient Survey ◽  
Satisfaction Score ◽  
Cancer Center ◽  
Average Score ◽  
Post Intervention ◽  
Care Plans ◽  
The Impact ◽  
Single Question

212 Background: Despite established standards for prescribing and monitoring oral anti-cancer medications (OAC) and validated tools supporting OAC patient education, substantial quality gaps remain. Methods: To identify local gaps in care for patients receiving OAC, we used a patient survey in the GI and Endocrine medical oncology clinic. Providers were also interviewed. The survey consisted of 23 questions addressing three domains (treatment plan (T) education, self-management (S) education and health team communication (C) as well as a single question overall satisfaction score. A composite average score encompassing all 23 questions was generated. Questions were derived from ASCO chemotherapy standards and validated patient communication instruments and scored on a 5-point Likert scale. Subsequently, individualized drug-specific written care plans guiding patient education were developed and tested in iterative PDSA cycles. The aim was to improve the composite average patient survey score by 10%. The same patient survey was used to assess the impact of the change ideas. Results: We collected 32 patient surveys, 21 pre- and 11 post-intervention. Baseline surveys indicated lowest scores in the C domain. Providers reported variation in education content and communication techniques used. Care plans with standardized content for 8 OAC agents were tested in simulated and clinic settings in a stepwise fashion, with implementation beginning in Feb 2018. Providers received training on integrating the care plans into clinic workflow. The composite average score for all 23 items improved from 4.18 to 4.29. The single question overall satisfaction score improved from 4.17 to 4.45. Improvement was noted across all 3 domains (T: 4.31 → 4.41, S: 4.26 → 4.36, C: 4.00 → 4.15). For balancing measures, provider teaching time per patient initially rose following implementation before returning to baseline. Conclusions: The intervention led to improvement in the patient experience when starting OAC. Standardized content and a framework guiding provider communication were key elements of the change ideas. To meet the study aim, further PDSA cycles integrating teach back methodology and proactive phone follow up are ongoing.

2 Impact of Multimodal Analgesia on Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S5-S5
Author(s):  
Sierra R Young ◽  
Jeremiah Duby ◽  
Erin Louie
Keyword(s):  
Pain Control ◽  
Total Body Surface Area ◽  
Oral Morphine ◽  
Multimodal Analgesia ◽  
Power Calculation ◽  
Opioid Use ◽  
Icu Discharge ◽  
Opioid Medications ◽  
Oral Morphine Equivalent ◽  
The Impact

Abstract Introduction Opioids are considered the cornerstone of treatment for post-operative burn pain. However, detrimental adverse effects of opioid use include over-sedation, respiratory depression and dependence. Multimodal analgesia is an alternative method of pain control that utilizes a combination of opioid and non-opioid medications. Multimodal analgesia offers different mechanisms of action which may be beneficial in burn-injured patients. This study examines the impact of multimodal therapy for post-operative pain control in a burn intensive care unit (BICU). Methods This retrospective cohort study was performed at an academic burn center between 2012 and 2018. Consecutively admitted patients with burns greater than or equal to 10% total body surface area (TBSA) and BICU length of stay (LOS) greater than seven days were eligible for inclusion. Patients were excluded if they received an opioid continuous infusion greater than 48 hours. Patients treated with multimodal analgesia were compared to those treated with opioids alone. The total oral morphine equivalent (OME) dose was calculated for each 24-hour period for 5 days after a grafting surgery. Secondary endpoints included pain scores, BICU LOS, and ventilator days. Data analysis was performed with descriptive statistics. A power calculation determined that 60 patients per group were needed to detect a 30% difference in the primary endpoint. Results There were 100 patients in the non-multimodal group and 100 patients in the multimodal group. Mean cumulative OME dose was significantly lower in the multimodal group (1,028 mg vs. 1,438 mg, P &lt; 0.002). Patients with over 20% TBSA burns had a larger reduction in mean OME doses in the multimodal group (1,097 mg vs. 1,624 mg, P = 0.0049) compared to patients with 10% to 20% TBSA burns (949 mg vs 1,282 mg, P = 0.057). Utilizing more multimodal agents was not associated with lower OME doses. There was no difference in pain score on post-operative day 5 (5.5 + 2.3 vs. 6.2 + 2.2, P=0.07) or at ICU discharge (4.7 + 2.4 vs 4.7 + 2.8, P = 0.99). There was no difference in other secondary outcomes. Conclusions The use of multimodal analgesia significantly reduced cumulative OME doses without compromising pain control. Applicability of Research to Practice Multimodal analgesia may be a beneficial adjunct to burn pain management to mitigate opioid use without compromising pain control.

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