Opioid use in America — 13 ASC leaders discuss how opioids affect their community

The opioid epidemic continues to be among America's most critical issues. In this piece, ASC administrators and thought leaders from across the U.S. discuss how opioid use has affected their community in the first part of a two-part series.

Note: Responses were edited for style and clarity.

Question: How is opioid use and abuse affecting your community?

Amanda Franta, BSN, RN. Administrator of Cedar Orthopaedic Surgery Center (Cedar City, Utah): In 2017, HHS declared the opioid epidemic a national public health emergency and with this increased awareness nationwide we have seen a shift in treatment and prescribing guidelines that are steps in the right direction. This epidemic has been a significant issue here in Utah, [so much so the state formed] the Utah Opioid Task Force in 2017 to combat it. According to the Utah Opioid Task Force, Utah is ranked seventh in the nation for drug overdose deaths between 2013-16, opioid deaths in Utah have outpaced deaths caused by firearms, falls, and motor vehicle crashes. I have seen [the effect of the epidemic] in our southwest corner of Utah. Iron County, where we are located, had the third highest rate of opioid prescriptions in the state of Utah at 90 prescriptions per every 100 people, according to the CDC's 2017 US County Prescribing Map.

Gary Richberg, Administrator of Pacific Rim Outpatient Surgery Center (Bellingham, Wash.): Across the country and in my community, opioid addiction has plagued in various degrees every community in the U.S. leading to addiction and abuse. With the awareness of opioid abuse, some patients have unfortunately sought after illegal street drugs as a replacement. One such drug that is cheap and easily available is heroin. Our community has seen increases in heroin usage for the replacement of the euphoric experience some patients experience from long-term opioid use.

Joleen Harrison, BSN, RN, Administrative Director of Mankato Surgery Center (Mankato, Minn.): The community has experienced a few cases in our area and a number of them resulted in death or accidents due to opioid abuse. Minnesota, too, has had its share of issues with opioids.

Minnesota legislators have teamed up with the Minnesota Board of Pharmacy making changes in the prescribing regulations this month. The way providers were prescribing in the past will no longer be accepted. [The state made several changes including:] a set number of days per patient a script can be written. In the acute surgical setting, the pharmacist has the authority to allow more tablets if the provider has written such, based on their professional judgement or contact the surgeon for changes before dispensing. Many of the insurance carriers have also followed suit to set guidelines on number dispensed following either the CDC or MN Board of Pharmacy guidelines.

We have done an opioid quality improvement study around this topic to collect data to find out how many tablets per provider were being dispensed. The data found that providers were prescribing five to 90 tablets of narcotics for a similar case, however providers were rarely prescribing an amount that were consistently high or questionable. We redid the study in December of 2018, and found a decrease in the amount prescribed per provider for similar cases. We did not find any prescriptions in the 90 pill range from the year before. We feel the national attention to this epidemic and provider-based education may have had an impact on their prescribing amounts.

Since the Minnesota Board of Pharmacy [implemented its] recent changes, we now have an increased number of calls from larger pharmacy chains asking to have the provider change the order. These pharmacies are concerned over the amount of narcotics the patients would receive in a 24 hour period of time and with the new regulations, they need the providers to make the prescription changes to meet new guidelines.

We are educating our physicians, our nursing team now and discussing the opioid prescribing changes with patients ahead of time. If the prescription is not written according to the changes, the pharmacy may delay filling the prescription as it waits for clarification between from the provider. At Mankato Surgery Center, we have taken an active approach to do what we can so patients are educated before and after leaving our care.

Roger Franck, Administrator for the Endoscopy Center and Gastroenterology Associates of North Mississippi (Oxford): It is as big a problem in Mississippi as it is in other states. Our community and state has the issue on high alert, and the medical community has taken several steps at the state level to reduce the use drastically. It almost has become difficult to prescribe an opioid at all, but, of course, I am exaggerating a bit. In our state, there are state-developed protocols that must be met in order to prescribe opioids.

James Adkins, CEO and Co-founder of Modern Ambulatory Surgery Centers (Phoenix): Sadly, patients have suffered and it has made it very difficult for legitimate patients to get access to therapy. Furthermore, it has placed an incredible burden on pain providers and the patients we serve. We actually went so far as to hire a retired DEA agent to screen patients per the providers direction and randomly in the clinic. Subsequently, the patients are under surveillance constantly by the entire team.

Tammy Stanfield, Administrator and DON at North Pines Surgery Center (Conroe, Texas):
We see a large population of pain management patients that are on some type of opioid. We perform procedures in an attempt to allow the physician to be able to decrease the amount of opioid or discontinue it. Some patients report that family steal their medications, which does not help the epidemic. We encourage patients to lock up their medications to protect themselves and others. Our procedures will hopefully help the patient [alleviate pain] or we attempt to find one that does like spinal cord stimulator, SI fix or superion implant.

Jeffra Kinniard, Director of Operations at Parkview SurgeryONE (Fort Wayne, Ind.): Northeast Indiana is vastly affected by opioid abuse. It seems to know no boundaries. The local Department of Health, healthcare professionals and the hospital systems have banded together in a conscious way to develop short-term and long-term strategies.

Tony Mira, President and CEO of Anesthesia Business Consultants (Jackson, Mich.): The opioid crisis is the major topic of conversation among anesthesia providers. Among pain management physicians, the use of opioids is a big issue but now has also become a concern among anesthesiologists in their management of patients in the operating room. This is part of the inspiration to use more nerve blocks for acute pain management. By giving a targeted dose of a local or a narcotic targeting a specific nerve plexus the objective is to minimize the need for additional opioids for the management of the patient's pain.

Suzi Cunningham. Administrator of Advanced Ambulatory Surgery Center (Redlands, Calif.): It is definitely an epidemic in our community, just like it is in most. I do think the awareness is key. Our surgeons treat our patients conservatively and have found that there are very good alternatives to prescribing opiates.

Tom Wilson, CEO of Monterey Peninsula Surgery Center (Monterey, Calif.): Through the efforts of the Monterey Peninsula Surgery Center (MPSC) and our local hospital, the number of individuals developing an opiate abuse problem post-surgery has decreased substantially.

Robert L. Masson, MD, Medical Director of the Masson Spine Institute (Ocoee, Fla.): We have had an opiate policy that was progressive for several years, multifactorial approach across several methodologies.

I am not going to address this from the perspective of recreational narcotic use and addiction. We have no role in that. On the other hand, for years, we have sensed an iatrogenic opiate dependence and expectation in people with chronic pain. Our ASC is focused on complex orthopedic and spine surgery, and I think that we had identified the problem within our patient population long before it became popular to talk about the crisis. Normal law-abiding people, who have little interest in drug use, have for years been insidiously treated for chronic and mechanical pain with narcotics, too often ending up with legitimate addiction despite their best intentions. There is too much attention on 'patient satisfaction' and pain scores and we have taken a hard position on not enabling that pattern nor the abuse, and in many cases at the risk of angry relationships when our reluctance to enable the narcotic merry go round is met with great resentment, anger and anxiety. We do not believe that orthopedic and spine mechanical disorders need end of life palliative, chronic narcotic treatment except in extreme cases. There is no end point to this strategy and it had become far too easy and common to prescribe. We consider major narcotic addiction a severe co-morbidity and I believe it is a major risk for the outpatient surgery environment, unless there is a clear and present joint venture between patient and healthcare provider team.

On the other hand, we have set up a tiered strategy that couples empathy, support, education, diagnosis and mental health support when available. [We incorporate those elements into] surgical strategies that are minimally invasive, rapid recovery-focused, and that require minimal short-term narcotics. We have a strong preoperative messaging platform that focuses on prehabilitation, physical and mental preparation, judicious use of narcotics specifically towards the goal of functional preparation, coupled with rest and recovery, and less towards 'pain relief'. We try to teach our patients what to expect during the recovery period, and address the mechanical triggers in a way where a slow postoperative wean is part of the surgical goal structure. We are fairly specific [with patients stressing] that the patient needs to 'buy in' to the goal of weaning the narcotics as part of their treatment plan. We have embraced better anesthetic techniques and started the use of exparel or 72-hour liposomal bupivacaine for postoperative analgesia.

We also encourage biofeedback, natural anti-inflammatories, best nutrition and normal rehab, rest and recovery cycles, which reduces the need for self medication.

My personal opinion is that as a healthcare provider, I am best able to give clarity, hope and a compass towards physical improvement and recovery, towards a quality of life solution, but that it is a joint venture with the patient. I have zero empathy or tolerance towards enabling narcotic abuse and I encourage all providers in the treatment chain to take a unified, consistent approach towards eliminating 'pain free' goals. We truly aim to change the goal structure from 'pain free' to more functional, more independent, happier and more mobile goals by creating pain patterns that are more conducive to a meaningful life, and aggressively resist the urge to offer a 'pain free' existence.

No one strategy solves the problem, but a cohesive, disciplined, multimodality and empathetic approach clearly creates the most functional strategy for our most severe cases and our practice profile and results have benefited substantially, on behalf of a healthier, happier patient population because of the decade of being proactive.

Joy Taylor, COO of Polaris Spine & Neurosurgery Center (Sandy Springs, Ga.): Not only is opioid use and the often-resultant abuse highly problematic, but it also has virtually no upside. In many settings, routine analgesics are just as effective, if not more so, than opioids.1, 2 The impacts of opioids on the brain are still being explored, but we already know that exposure to opioids for as short a period as one month can reduce gray matter.3

Helping our patients avoid the risks of opioid use and getting them back to their lives, families, and friends is central to our mission at Polaris Spine & Neurosurgery. Our Director of Nursing, Denise Crocker, BSN,RN, has put together a program with a foundation in educating patients through our Spine Surgery Class. More informed patients are less anxious and better able to deal with their surgical pain, knowing it is only temporary. We emphasize what pain is expected, and teach patients and their caregivers to fully utilize comfort measures, such as warm packs to relax muscles, ice packs to reduce inflammation at the surgical site, repositioning, and ambulating.

With the help of our Director of Anesthesia, Nikki Wiley, MD, we also have put together a comprehensive medication protocol that includes the use of exparel injections, as well as calibrated pre- and postoperative doses of Lyrica, steroid dose packs, and muscle relaxants. We also encourage the use of Tylenol, as general analgesics are extremely effective, especially in conjunction with these other methods.

All of this is discussed at length in our pre-op class and in our education booklet, in addition to being revisited before discharge with the caregiver, and included in our discharge packet.

We believe that our patients' long-term health is built upon returning to their fullest lives as soon as possible, and minimizing the use of opioids is critical to that.

Vance Gardner, MD, medical director of Hoag Orthopedics, the research unit of Hoag Orthopedic Institute (Irvine, Calif.): A significant increase in opioid deaths in Orange County, Calif., was documented in an October 2018 report by the Orange County Health Care Agency. Emergency department visits and overdose deaths showed a significant jump, especially in the southern and coastal cities. Ages 45 to 54 accounted for nearly half of the deaths.

This information, coupled with federal government data showing prescription opioids playing a larger role in initiating the use disorder (and in overdose itself), and our own data documenting significant leftover prescription opioids following arthroscopic surgery4, prompted us to take action. We have begun a practice of relying on multimodal therapy instead of opioids, when possible. In addition, improved preoperative blocks and more accurate prescription amounts are utilized. Our surgeons are beginning to use enhanced tools for recognizing patients at risk and distributing educational materials about the opioid crisis preoperatively. Proper methods of discarding unused pills are also being made available.

Since increasingly complex surgery is being safely performed at our ASCs, pain will always be an important factor that needs to be compassionately addressed. However, we believe the present crisis prompts us to be proactive with solutions that reduce the risk of persistent use potentially leading to an opioid use disorder in our patients, as well as lessen the amount of unused opioids that can possibly harm others.

References
1 https://media.jamanetwork.com/news-item/no-significant-difference-pain-relief-opioids-vs-non-opioid-analgesics-treating-arm-leg-pain/
2 https://www.sciencedaily.com/releases/2018/04/180417181101.htm
3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3138838/

4 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6400509/

Tomorrow, the administrators and thought leaders discuss strategies they've implemented in their ASC to tackle pain management and prevent opioid abuse.

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