By Ms. Suzanne Ovel (Army Medicine)March 1, 2018
Residents at Madigan Army Medical Center at Joint Base Lewis-McChord, Wash., are reducing the use of opioids by surgery patients thanks to new quality improvement (QI) projects here.
When a resident brought a study on post-operation opioid reduction to the attention of the Department of Surgery's QI board last fall, they decided to implement a similar initiative at Madigan.
With the ongoing opioid crisis in the United States, the board was concerned about not contributing to it by overprescribing opiates.
"Seventy percent of people who start misusing opiates have either a valid prescription or a family member with a valid prescription, suggesting that opiate latency, or opiates just sitting around the house are a real problem," said Capt. (Dr.) Rowan Sheldon, a general surgery resident who runs the QI board. "So I want to treat your pain, I want to make sure you have enough pain medication, but I don't want to give you too much because it could be a danger to you or your family member."
The 2017 study from the Michigan Surgical Quality Collaborative, a partnership of Michigan hospitals, gave patients varying amounts of opiates and tracked how many they took, their pain levels and their satisfaction levels.
"People who were given more opiates, took more opiates, but there was no change in their pain score or their satisfaction score, suggesting that we could give them fewer as long as we educated them properly," Sheldon said.
While the opioid epidemic may be nationwide, some of the stats hit closer to home: 21.5 percent of Army active duty Soldiers reported misusing opioids over the last 12 months, according to the Military Medicine journal.
When the QI board dug into how post-operative prescriptions may contribute to long-term opiate use, they found that patients who took opioids for longer initial periods were more likely to use them long-term, according to the Center for Disease Control and Prevention. Sheldon stressed, however, that safe opiate use is a key part of many patients' post-operative pain management.
"They have a good reason for pain; surgery is not a normal state and we are intentionally creating trauma in order to heal them of a greater problem. Opiates are still our strongest pain medication. That said, their use is limited and needs to be done appropriately," said Sheldon.
The key is finding the right number of opiates to prescribe. The QI board decided to start by reviewing surgery's prescribing habits for laparoscopic removal of appendixes and gallbladders -- the top two most common surgeries in the United States. They found that while patients here were prescribed an average of 31.41 pills for appendectomies and 34.62 pills for cholecystectomies (gallbladder removals), the range of opioids prescribed fluctuated highly.
"(It) is incredibly variable … which was frankly unsurprising because in medical school you're taught pain is the fifth vital sign and you're taught that to alleviate people's pain, you give them pain medication," said Sheldon. "We know that opiates can be addicting; we're taught that they can be addicting, but we have a complete lack of good data of how long people should be on these medications for, and how much people typically need, and what the best way of doing that is."
Based off the Michigan study, and another study by Baylor University, the QI board decided to develop a standard protocol of giving all patients 10 opiate tablets as a starting point for home pain management after these surgeries. Patients are also given Tylenol and ibuprofen, and are encouraged to take these medications on a regular schedule to avoid "chasing the pain" while taking opioids as needed. In fact, education of both patients and staff is an integral part of this initiative.
"This was a comprehensive reform of how we do post-operative pain," said Sheldon.
Patients are educated at their pre-operative appointment, at post-op, and if they become inpatients, before they're discharged home. They're encouraged to take the smallest amount of opioid pills needed to reasonably control their pain.
However, "the education is not just for the patients. We took this on as a coordinated effort to make sure that we educated our providing staff as well as our ancillary (outpatient) staff so that we had a shared mental model as well as a shared goal throughout this," said Sheldon.
And the efforts are expanding outside of the general surgery department as orthopedic surgery later began a similar initiative.
"As a top five in the medical role prescriber, we have a role in helping to decrease the excess," said Capt. (Dr.) Taylor Mansfield, an orthopedic surgery resident who is leading their similar QI initiative for outpatient procedures.
Like orthopedic surgery, general surgery is surveying patients at follow-up appointments to gauge the effectiveness of the reduced prescriptions. So far, patients say they're satisfied with their pain management; in fact, many do not use all of the opioids they were given, even with the reduced prescriptions. Sheldon said that patients who find they have extra pills can return them to the Madigan pharmacy for disposal.
"Anecdotally, it's going fantastic. Actually per the nursing staff, they're receiving fewer calls on pain than they previously were," said Sheldon, who emphasized that the success of the initiative is due to the entire department to include research residents, providers and nurses, and nurses on the medical/surgical inpatient floor as well.
While they're still digging deep into the data, the first month of the QI results show an average of about 12 opioid pills prescribed per patient. Opioid prescriptions for appendix and gallbladder surgery patients decreased by 64 percent.
Orthopedic surgery is seeing positive results too.
"Despite what a lot of people felt was cutting back drastically, we're still seeing people with good pain relief," said Mansfield.
Both departments plan to continue and possibly expand their initiatives. Eventually, Sheldon hopes to work with other large military treatment facilities to encourage them to adopt similar programs.
"We want to try to push it to as many different patient populations as possible because we see opioids are a problem, and anything that we are adding into that, is our portion of that problem. The Department of Defense has a big push to decrease chronic opiates, and if we can help that at all, we'd like to," he said.