Tools for managing pain in ASCs: AAAHC Institute's Dr. Naomi Kuznets on opioid use in the US

The question over how providers can effectively manage pain has taken on a more prominent role in the media over the last several years as the industry challenges providers to limit opioid use. Working with the AAAHC Institute for Quality Improvement for 18 years, Naomi Kuznets, PhD, the organization's vice president and senior director, has seen the opioid epidemic evolve and what factors have led to the growth in opioid use.

"The opioid epidemic has its roots in widespread use of opioids without providers' or patients' understanding of how addictive opioids are," Dr. Kuznets says. "It is not a sudden issue but one that has become much more widespread and the often severe or deadly effects of opioid use have become more well-known — thus the term 'epidemic' has been used."

The term 'epidemic' has taken hold in large part due to the gravity of opioid misuse and abuse. In 2014, 28,657 Americans lost their lives to opioid overdoses, with Ohio claiming the most lives that year at 2,106 state residents. 

Providers in all settings of care have an important role to play in reducing the number of opioid-related deaths and employing other methods to mitigate a patient's pain.

Resources for ASCs to manage pain
Effective pain management protocols have propelled growth in the outpatient surgery sector as surgeons can safely perform higher acuity cases in ASCs. However, surgery centers should have the proper anesthesia and pain control mechanisms in place to ensure patients are not walking out of the doors in an enormous amount of pain.

In the past, Dr. Kuznets explains, it was exceedingly difficult for providers to assess whether patients had a past prescription for opioids and many providers had reservations about discussing opioids' benefits or risks with patients. However, these conversations are happening more and more and surgery centers can employ new tools, such as state Prescription Drug Monitoring Programs, to assess whether patients have existing opioid prescriptions.  

"State databases, urine testing and frank discussions can be used so that ASC healthcare providers are aware of whether surgery/procedure candidates are current users of opioids or not," Dr. Kuznets says.

These tools can also help ASCs better decide which types of anesthesia are best suited for a patient as well as optimal pain management protocols following a procedure. Another key aspect of pain management is setting a patient's expectations. If a patient seeks more opioids than advised, ASC providers should articulate to patients the dangers of opioid addiction and recommend non-opioid pain relief alternatives such as acetaminophen or non-steroidal anti-inflammatory analgesic medication.

"Whether the patient is currently using an opioid or not, providers need to consider alternatives to both opioid-based anesthesia and opioid-based pain control post-procedure," Dr. Kuznets adds. "If post-procedure pain control prescriptions are for opioids, use of immediate release opioids, lowest prescribing daily dose and lowest number of days is important."

If a patient is taking opioids at the time of the procedure, there are certain protocols providers should follow. For instance, patients should take their opioid dose the day of surgery if they have a prescription. Additionally, current opioid use impacts the type and level of anesthesia and the type of pain management mechanisms post-procedure. Dr. Kuznets says current users may require additional analgesia during and post-procedure and ASCs should assess whether these patients will require an inpatient admission "to monitor pain control and titrate drugs to prevent overdose."

How AAAHC is helping practices manage pain
AAAHC identifies evidence-based best practices for surgery centers when managing pain in the outpatient setting. This year, the organization released a patient safety toolkit that includes information on opioid use as well as information regarding CDC guidelines on opioid prescribing and provider tools adapted from the CDC.

The toolkit is one step to limiting opioid use throughout the nation. Dr. Kuznets notes there is still work to be done, which entails provider education, public awareness and a dialogue between the provider and patient.

"This 'epidemic' did not develop rapidly and it will take time to bring this issue under control," she says. "I believe the more acceptable it is for providers to discuss opioids with patients, as well as test patients for opioid use, and consider alternatives to opioids, the greater there is a chance of us tackling this problem."

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