As legislators roll out opioid-related requirements with major implications for ASCs, Tampa, Fla.-based Laser Spine Institute is fighting the epidemic with its own prescribing protocol.
Laser Spine Institute Chief Medical Director and Co-Founder Michael Perry, MD, spoke with Becker's ASC Review about new legislation and how Laser Spine Institute is expanding its opioid-reduction policy — potentially to all seven of its U.S. centers.
Note: Responses have been edited for style and length.
Question: How could new opioid legislation impact physicians and patients?
Dr. Michael Perry: Most every state has now passed — or is passing — legislation that will limit the usage of opioids. From an ASC perspective, it's going to limit physicians' ability [to prescribe] narcotics beyond a specific period. In Florida, we're only allowed to prescribe seven days' worth of postoperative pain medication. Most people don't require narcotics for an extended period, but [occasionally] patients do. [Laser Spine Institute has] a lot of patients that travel. The patients either have to come back and see us [or] follow up with their primary care physician to continue [receiving opioids]. I think that's the biggest burden on providers in an ASC setting: maintaining the patient's medications if they're needed.
Q: Florida's seven-day requirement went into effect July 1. How did LSI address the legislation?
MP: Prior to the legislation being signed, we initiated opioid-free procedures [over several months]. Our program was started for patients that have obstructive sleep apnea. If you give them narcotics, that increases their risk for apneic periods postoperatively, so [we try] to refrain from using opioids in these patients. We place patients on a TLC protocol — or Tylenol, Lyrica and Celebrex — preoperatively. Postoperatively, we give medications like anti-inflammatories. Intraoperatively, our surgeons may use [Exparel]. We also use the Iceman for lumbar spine [procedures], a machine that circulates cold water. Intraoperatively, we use ketamine and other non-narcotic medications, again to [avoid] any sedative effects postoperatively.
We've been [following this protocol] for a number of months. A significant number of patients — 70 percent of them — have done quite well without narcotics. The ones that do require narcotics use a significantly decreased number postoperatively. This is being done in Tampa, but we're talking about initiating that companywide.
Q: The U.S. House of Representatives passed a bill incentivizing postsurgical injections as opioid alternatives. What are your thoughts on the legislation?
MP: I think it would benefit patients. Especially when we're dealing with spine, sometimes you can get postoperative nerve irritation, in which case a patient undergoing an epidural injection to calm the nerve by diminishing inflammation by the use of a steroid can be a significant benefit. This would obviously decrease the prescribing of further narcotics. From a provider's standpoint, [there's] less narcotics being written [and] an increase in referrals to pain management for these injections.
Q: Is there a tension between decreasing opioid use and improving patient experience, in terms of pain?
MP: They go hand-in-hand. Physicians trying to use the medications that affect different pain pathways is the best approach for patients. Most people with discomfort from pain can be treated with non-opioid medications. It's a win for the patient and provider because a patient's getting the best relief without the risk of addiction to opioids, and the provider has the satisfaction of knowing he's helping [his] patient without increasing that patient's risk of addiction with the use of opioids.
Q: What are some challenges physicians might encounter when switching prescribing habits?
MP: Some [potential challenges are] if insurance companies don't approve injections or certain medical disciplines or patients run out of [the insurer's allotment for] physical therapy. As far as medications are concerned, I don't think there would be any hurdles. A lot of medications you can buy over the counter. [For] the prescription ones, different manufacturers make similar types of medications — there's certainly a lot of [medications] out there that are not very expensive and are very accessible.
Q: Is there anything else providers should know?
MP: In the future, I think all ASCs are going to be looking at non-opioid use of medications preoperatively and postoperatively for patients. The attention for research would be trying to find other modalities or medications that don't have the same risks as opioids. I think it's just a matter of time before we're able to stumble upon that particular molecule or entity. Legislation is trying to limit the use of narcotics in patients and thereby decreasing the number of people addicted, [but another] issue is the people that already are addicted. We really can't overlook them. There need to be programs in place on the state and federal levels where people can be helped to get off these medications.