Opioid Reduction Through Postoperative Pain Management in Pediatric Orthopedic Surgery

OBJECTIVES Our goal with this initiative was to reduce discharge opioid prescriptions while maintaining optimal pain management through the use of standardized pain prescribing guidelines for pediatric patients after orthopedic surgical procedures. METHODS Through analysis of established yet inconsistent prescribing practices, we created a 4-tiered guideline for pediatric orthopedic postoperative pain management prescription ordering. Following the Model for Improvement methodology including iterative plan-do-study-act cycles, the team created an electronic medical record order set to be used at discharge from the hospital. The provider compliance with this order set was monitored and analyzed over time by using provider-level and aggregate control charts. A secondary measure of opioid prescriptions (morphine milligram Eq [MME] dosage per patient) was tracked over time. The balancing measure was the analysis of unanticipated opioid prescription refills. RESULTS Greater than 90% compliance with the guidelines was achieved and sustained for 20 months. This resulted in a 54% reduction in opioids prescribed during the improvement period (baseline = 71 MME per patient; postintervention = 33 MME per patient) and has been sustained for 12 months. The percentage of unanticipated opioid prescription refills did not significantly change from the period before the institution of the guidelines and after institution of the guidelines (2017 = 3%; 2019 = 3%). CONCLUSIONS The creation of these guidelines has led to a significant reduction in the number of opioids prescribed while maintaining effective postoperative pain management.

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Postoperative Narcotic Prescription Practice in Orthopedic Foot and Ankle Surgery

Foot & Ankle Orthopaedics ◽

10.1177/2473011418775947 ◽

2018 ◽

Vol 3 (3) ◽

pp. 247301141877594

Author(s):

Thomas M. Hearty ◽

Paul Butler ◽

John Anderson ◽

Donald Bohay

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Postoperative Pain Management ◽

Pain Medication ◽

Foot And Ankle ◽

Prescribing Practices ◽

Nerve Blocks ◽

Opioid Prescription ◽

Health Crisis ◽

Ankle Surgery

Background: The misuse and abuse of opioid pain medications have become a public health crisis. Because orthopedic surgeons are the third highest prescribers of opioids, understanding their postoperative pain medication prescribing practices is key to solving the opioid crisis. To this end, we conducted a study of the variability in orthopedic foot and ankle surgery postoperative opioid prescribing practice patterns. Methods: Three hundred fifty orthopedic foot and ankle surgeons were contacted; respondents completed a survey with 4 common patient scenarios and surgical procedures followed by questions regarding typical postoperative pain medication prescriptions. The scenarios ranged from minimally painful procedures to those that would be expected to be significantly more painful. Summaries were calculated as percentages and chi-square or Fisher exact tests were used to compare survey responses between groups stratified by years in practice and type of practice. Results: Sixty-four surgeons responded to the survey (92.8% male), 31% were in practice less than 5 years, 34% 6 to 15 years and 34% more than 15 years. For each scenario, there was variation in the type of pain medication prescribed ( scenario 1: 17% 5 mg hydrocodone, 22% 10 mg hydrocodone, 52% oxycodone, and 3% oxycodone sustained release [SR]; scenario 2: 15% 5 mg hydrocodone, 13% 10 mg hydrocodone, 58% oxycodone, and 9% oxycodone SR; scenario 3: 11% 5 mg hydrocodone, 13% 10 mg hydrocodone, 56% oxycodone, and 14.1% oxycodone SR; scenario 4: 3% 5 mg hydrocodone, 5% 10 mg hydrocodone, 44% oxycodone, and 45% oxycodone SR) and the number of pills dispensed. Use of multimodal pain management was variable but most physicians use regional nerve blocks for each scenario (76%, 87%, 69%, 94%). Less experienced surgeons (less than 5 years in practice) supplement with tramadol more for scenario 1 ( P = .034) as well as use regional nerve blocks for scenario 2 ( P = .039) more than experienced surgeons (more than 15 years in practice). Conclusion: It is evident that variation exists in narcotic prescription practices for postoperative pain management by orthopedic foot and ankle surgeons. With new AAOS guidelines, it is important to try to create some standardization in opioid prescription protocols.

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An Interactive Pain Application (MServ) Improves Postoperative Pain Management

Pain Research and Management ◽

10.1155/2021/8898170 ◽

2021 ◽

Vol 2021 ◽

pp. 1-12

Author(s):

Richard Gordon-Williams ◽

Andreia Trigo ◽

Paul Bassett ◽

Amanda Williams ◽

Stephen Cone ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Nursing Staff ◽

Pain Control ◽

Standard Care ◽

Severe Pain ◽

Postoperative Pain Management ◽

Pain Scale ◽

Opioid Prescription ◽

Patient Reported

Background. Most patients have moderate or severe pain after surgery. Opioids are the cornerstone of treating severe pain after surgery but cause problems when continued long after discharge. We investigated the efficacy of multifunction pain management software (MServ) in improving postoperative pain control and reducing opioid prescription at discharge. Methods. We recruited 234 patients to a prospective cohort study into sequential groups in a nonrandomised manner, one day after major thoracic or urological surgery. Group 1 received standard care (SC, n = 102), group 2 were given a multifunctional device that fed back to the nursing staff alone (DN, n = 66), and group 3 were given the same device that fed back to both the nursing staff and the acute pain team (DNPT, n = 66). Patient-reported pain scores at 24 and 48 hours and patient-reported time in severe pain, medications, and satisfaction were recorded on trial discharge. Findings. Odds of having poor pain control (>1 on 0–4 pain scale) were calculated between standard care (SC) and device groups (DN and DNPT). Patients with a device were significantly less likely to have poor pain control at 24 hours (OR 0.45, 95% CI 0.25, 0.81) and to report time in severe pain at 48 hours (OR 0.62, 95% CI 0.47–0.80). Patients with a device were three times less likely to be prescribed strong opioids on discharge (OR 0.35, 95% CI 0.13 to 0.95). Interpretation. Using an mHealth device designed for pain management, rather than standard care, reduced the incidence of poor pain control in the postoperative period and reduced opioid prescription on discharge from hospital.

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Less is more: Postoperative pain management using restrictive opioid protocols in all surgical services in a comprehensive cancer center.

Journal of Clinical Oncology ◽

10.1200/jco.2021.39.15_suppl.103 ◽

2021 ◽

Vol 39 (15_suppl) ◽

pp. 103-103

Author(s):

Jason Ricciuti ◽

Steven Gallo ◽

Deanna Argentieri ◽

Paul Visco ◽

Kristopher Attwood ◽

...

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Patient Experience ◽

Postoperative Pain Management ◽

Comprehensive Cancer Center ◽

Cancer Center ◽

Control Group ◽

Prescription Database ◽

Opioid Prescription ◽

Surgical Services

103 Background: Opioids are routinely given for postoperative pain management with limited evidence on the amount needed to be dispensed. Prescribed opioids increase the risk of chronic use, abuse, and diversion, which contribute to the opioid epidemic. We sought to demonstrate that postsurgical acute pain can be effectively managed across different surgical specialties with a markedly reduced number of opioids. Methods: A prospective case-control study of restrictive opioid prescription protocol (ROPP) was implemented in all surgical services from February 2019 through July 2019 at a tertiary comprehensive cancer center for all patients undergoing a surgery for which opioids would be routinely prescribed at discharge (n = 2,015). Data from surgeries performed by the same services from August 2018 through January 2019 were used for comparison (n = 2,051). At discharge, patients did not routinely receive opioids unless they had a maximally invasive procedure or if they required multiple doses of opioids during hospitalization (maximum 3-day supply). Compliance with the protocol was tracked by pharmacists daily. Patient demographics and surgical details were collected. State-run opioid prescription database was used to determine the number of opioids prescribed to all surgical patients within a 120-day surgical window. Validated patient satisfaction surveys were used at postoperative visits to assess patient experience. Results: After implementation of the ROPP, 45% less opioids were prescribed after surgery for all participating patients (323,674 morphine milligram equivalents (MME) vs 179,458 MME, p < 0.001). The majority of services complied with the ROPP in more than 95% of cases. There was no difference in postsurgical pain intensity between cohorts. Patients in the ROPP cohort had less refill requests compared to the control group (20.9% vs 17.9%, p value = 0.016). Surveys were completed by 338 patients in the control group (16.5%) and 360 in the ROPP group (17.9%). There was no significant difference in patient reported satisfaction with postoperative pain control or on the impact of pain on daily activities between the cohorts. Conclusions: Implementation of a ROPP by multiple surgical services at a tertiary cancer center was feasible and resulted in substantial decrease in the number of opioids prescribed while not compromising patient experience. Patients did not require more prescription refills despite being provided no opioids or a limited supply. This study provides evidence to support reducing the number of opioids routinely prescribed after surgery.[Table: see text]

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Limited use of nonopioid analgesics after pediatric ambulatory surgery

Journal of Opioid Management ◽

10.5055/jom.2021.0620 ◽

2021 ◽

Vol 17 (2) ◽

pp. 101-107

Author(s):

Nhi Ho, MD ◽

Anjali A. Dixit, MD, MPH ◽

Christina Inglis-Arkell, MD ◽

Solmaz P. Manuel, MD

Keyword(s):

Pain Management ◽

Postoperative Pain ◽

Ambulatory Surgery ◽

Tertiary Care ◽

Postoperative Pain Management ◽

Opioid Prescription ◽

Tertiary Care Medical Center ◽

Management Plans ◽

Nonopioid Analgesics ◽

Nonopioid Analgesic

Objective: This study sought to determine the rate at which nonopioid analgesics were utilized in postoperative pain management plans after pediatric ambulatory surgery in patients who were also prescribed postoperative opioids.Design: Retrospective cohort analysis.Participants: Patients ≤ 21 years old who were prescribed opioid medications after undergoing ambulatory surgery at a tertiary-care medical center. Methods: Postoperative day 1 (POD1) opioid prescription and use survey data along with electronic medical record data were extracted and analyzed for patients meeting inclusion criteria between April 2017 and December 2017. Main outcome measure: Recommendation to take nonopioid analgesics after discharge.Results: A total of 849 (63.2 percent) patients responded to the survey and 275 (32.4 percent) of these cases were prescribed postoperative opioids. Of the 273 cases included in this study, 137 (50.2 percent) received recommendations to take at least one nonopioid analgesic as well, and 164 (60.1 percent) reported using their prescribed opioids on POD1. Opioid use did not vary significantly with nonopioid analgesic recommendations. There was significant variability in opioid and nonopioid analgesic prescribing and recommendation patterns across surgical subspecialties.Conclusions: There was limited use of nonopioid analgesics in postoperative pain management plans after pediatric ambulatory surgery. This leaves many patients with only opioid-based agents as the first-line medication for postoperative pain management. These findings highlight an opportunity to educate prescribers and patients on the importance of step-wise multimodal analgesic plans.

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