How 3 ASC leaders are managing opioid use

The Ambulatory Surgery Center Association asked members to share what they're doing to counter the national opioid crisis.

Three responses provided to ASCA:

Rick Bushnell, MD, chief of anesthesia at Shriners Medical Center for Children in Pasadena, Calif.: In Pasadena, we have written a preemptive pain protocol that starts patients on three non-opioid medications 48 hours in advance of surgery. We start and continuously dose acetaminophen, gabapentin and celecoxib according to first-order pharmacokinetics (five half-lives to reach maximal sustained blood levels), and we continue those medications on the day of surgery and into the postoperative period. We monitor the performance of this protocol in each surgery with a Patient Reported Outcomes Measures data collection tool detailing each day's postoperative pain score and the number of doses of postoperative opioid they consumed. The result of our first three years of data collection is 89 percent of our postoperative opioids remaining unused at the end of the treatment's period. Medically/legally, each returned PROM demonstrates that each patient titrated themselves off opioid medications.

Stan Plavin, MD, ASCA board member: As Enhanced Recovery After Surgery techniques continue to be finely tuned and value-based solutions and alternative payment models proliferate, clinicians have a tremendous responsibility to prescribe fewer opioids. At our ASC, we create a patient care experience where we engage our patients in a manner that provides education and sets expectations for care. We identify and develop care plans that show the inherent value of reducing opioid use not only before, but also during and after the episode of care. We let our patients know that limited prescriptions will be given with respect to their post-surgical pain expectations. Setting these parameters is an important step in helping our patients understand the process and goals associated with their care. The anesthesia team is involved from the beginning, as the members of that team are the link that connects all the parties and can coordinate this effort. I call this process "Standardization with Individualization." Providing alternatives to opioids is just part of the solution; engaging, educating and empowering patients to be accountable will be paramount in their experience, and ultimately, the success of their care.

Maura Dent Cash, RN, director of clinical applications for HSTpathways: To facilitate a patient's transition from the postoperative area to home without delay, ASCs often use less long-acting anesthesia and fewer opioids during surgery and the immediate postoperative period than hospitals. Toward this end, I am seeing more and more ASCs using adjunct pain relief methods as a matter of routine. Instead of waiting for pain to start in the post-anesthesia care unit, anesthesia providers often give doses of acetaminophen IV and other non-opioid medications to certain surgery patients at the end of the procedure in the operating room. Having been at the forefront for finding alternatives, ASCs have used creative ideas to combat pain because of the necessity for short stays and concerns for the safety of patients (i.e., not just loading them up with opioids and sending them out the door).

ASCs also achieve effective analgesia using regional anesthesia techniques in conjunction with non-opioid therapies. These postoperative pain blocks give patients immediate pain relief that will wear off gradually over several hours, decreasing the need for opioids in the immediate postoperative period. Hospitals are less focused on these alternatives since patients will not be discharged home immediately postop. Non-medication remedies cannot be overlooked. Ice packs, positioning and positioning aids, breathing and meditation techniques, and distraction should also be included in postoperative care and discharge instructions.

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