Fight the opioid epidemic with proactive education and care coordination

Too many Americans have been touched by the opioid epidemic, but hopefully that will start to change soon. Physicians can fight back against this epidemic and save countless lives in the months and years ahead thanks to a heightened awareness among patients and caregivers about the risks, a firm commitment by the medical community to increase adoption of non-opioid pain management options and better coordination across the patient care continuum.

The American College of Surgeons cites research that patient education is best provided in a personal, face-to-face encounter with culturally and linguistically appropriate support materials. To proactively address the issue of patient education, the California Society of Anesthesiologists (CSA) has taken the lead as one of the first medical societies to produce content directly aimed at educating patients and their caregivers about safe opioid use and alternate pain management options.

The new CSA video, “How to manage your pain after surgery,” is available in both English and Spanish, with clear graphics and easy to understand messaging. The video content was developed based on the latest research and policies from nationally recognized medical organizations, including the American Medical Association, Centers for Disease Control and Prevention (CDC) and the U.S. Department of Health and Human Services.

While substance use disorders are complex and multifaceted, long-term opioid misuse often begins with treatment for acute pain, including patients who are recovering from surgical care. That’s why patient education is so critical at this key moment in their treatment.

Although surgery represents the first exposure to opioids for many patients, a recent report showed that 12 percent of patients who had a soft tissue or orthopedic operation became addicted or dependent on opioids in the year following surgery. But that means that 88 percent do not.

It’s important to keep in mind that surgery and untreated pain are in and of themselves harmful and must be treated appropriately. Physicians and other healthcare providers must strike the right balance to treat pain safely and effectively, using opioids where appropriate and incorporating other methods whenever possible.

Physicians should continue to advocate with insurance companies, other healthcare professionals and patients to use opioids as necessary, while encouraging (and funding) the use of other techniques to help with analgesia. Data from the National 2012 National Health Interview Survey revealed that an estimated 23.4 million adults (10.3 percent) experience “a lot of pain.” For these individuals, including those who are recovering from surgery, pain therapy serves an important purpose, especially given research that identified a link between discontinuation of opioids and suicidal acts. 

But for most post-operative patients, pain management with opioid medication is not needed for extended periods. Therefore, the period before surgery represents a window for proactive intervention through patient education about post-operative pain. A Bulletin from the American College of Surgeons notes the importance of the preoperative encounter, including using the time to remind patients that “zero pain is an unrealistic expectation.”

Clinicians can start with a discussion of treatment goals, pain management expectations and duration of post-procedure pain. This should include a discussion of options for pain management other than opioids, such as over-the-counter medications like NSAIDS, occupational and/or physical therapy, acupuncture, chiropractic care, stress management, exercise, cold, heat and massage.

There is also an opportunity for enhanced coordination among all providers on a care team to ensure a “One Team” approach with greater oversight of post-operative patient pain management, where one provider may unknowingly undermine another’s efforts to reduce patient prescriptions. For example, a large retrospective study on postoperative prescribing published in 2018 in the Journal of General Internal Medicineobserved, “Among surgical patients who developed new persistent opioid use, surgeons provide the majority of opioid prescriptions during the first three months after surgery. By nine to 12 months after surgery, however, the majority of opioid prescriptions were provided by primary care physicians.”

A multidisciplinary team that includes the primary or treating physician/provider, the surgeon, the anesthesiologist, pain physicians, nurse practitioners, physician assistants and others can work collaboratively on transitions of care. For example, the team should all have access to a preoperative and a post-discharge plan that focuses on specific functional and pain management goals and engages patients and their support teams. The post-operative plan should include detailed instructions regarding opioids - dose, indication and target stop date - that are captured in a discharge summary and accessible across the continuum of care.

This care coordination will help all members of the health team manage patients’ pain while preventing long-term dependence, misuse and avoiding preventable adverse events.  A similar process could be instituted for patients undergoing dental surgery or other procedures that may require opioids for pain management.

There is hope that we are getting in front of the opioid epidemic. A recent CDC report found opioid prescribing declined substantially across the United States between 2014 and 2017, correlating with a drop in overdose deaths. With a greater focus on proactive education and care coordination, providers can continue to reduce the human suffering of opioid misuse.

Shalini Shah, MD, is vice chair of the Department of Anesthesiology & Perioperative Care and enterprise director of Pain Services at University of California Irvine Health. She is also the chair for the Committee of Pain Medicine at the California Society of Anesthesiologists and energized by advocating for excellence in pain care for both patients and physicians.