Solving the opioid problem in ASCs — 11 leaders discuss strategies 

ASCs are well-positioned to lead the fight against opioid abuse. Here, 11 ASC administrators and thought leaders from across the U.S. discuss how their centers reduce opioid use and improve pain management. 

Read the first part of the series where 12 administrators discussed how opioids affected their communities. 

Note: Responses were edited for style and clarity.

Question: What strategies should ASCs use to tackle pain management and prevent opioid abuse?

Amanda Franta, BSN, RN, Administrator of Cedar Orthopaedic Surgery Center (Cedar City, Utah): Understanding not only that this is a national health issue, but that the side effects of opioids can significantly impact recovery for patients, we have changed our focus to greatly decrease opioid use in our ASC. Being an orthopedic specialty center, pain management is an important aspect of surgery for all of our patients, but especially with regard to our outpatient total joint replacements. While we have been performing outpatient total joint replacements since 2004, over the last 10 years we have implemented progressive anesthesia techniques, including: 

  • Preoperative pain management 
  • Stopping intraoperative administration of narcotics 
  • Using intraoperative pericapsular local anesthetic blocks placed by the surgeon
  • Using non-narcotic medications postoperatively

[These changes] lead to happy patients without pain or nausea who are consistently ready for discharge within a few hours. Early mobility is important with any surgery and decreasing opioid use has made a significant difference in that regard for our patients postoperatively. Most of our patients do still get a prescription for a short-acting narcotic pain medication, but our surgeon has decreased the quantity of medication on each prescription significantly for every surgery. In most cases patients are prescribed an amount that will last for the first two to three days. Patients are educated to only use the narcotic medication if needed and encouraged to use alternative analgesic medications, first or in combination, with the narcotic to decrease the amount of narcotic needed overall. Decreasing opioids intraoperatively, encouraging early mobility and patient education have been key for our pain management strategy. 

Gary Richberg, BSN, RN, Administrator of Pacific Rim Outpatient Surgery Center (Bellingham, Wash.): Our surgeons and physicians have been motivated to reduce the amount of controlled medications prescribed to their patients and have encouraged the use of Tylenol and [nonsteroidal anti-inflammatory drugs] for pain relief. The pharmacies also have been proactive in the identification of opioid-abusive behavior and drug seekers and have notified doctors of their concerns [when appropriate].

Andrea Lessner, BSN, RN, Total Joint Coordinator at North Valley Surgery Center (Scottsdale, Ariz.): Many of our patients receive zero narcotics while in our care. This is accomplished by our non-narcotic multimodal pain management protocol. Our protocol starts in [the preoperative process] with a non-narcotic medication bundle followed by non-narcotic spinal anesthetic and a nerve block. When appropriate, patients receive [total intravenous anesthesia] intraoperatively. Most patients do not require any IV or parenteral narcotics while in our care and are discharged home within two to four hours. 

Roger Franck, Administrator for the Endoscopy Center and Gastroenterology Associates of North Mississippi (Oxford): As an administrator of our ASC and [a gastroenterology] practice, [we've done several things]. Our ASC has elected to use nonopioids since this crisis began, and, in fact, we started the use of propofol for patients even before [the epidemic]. We saw that a large number of patients coming into our center had a difficult time being sedated and being comfortable with the typical conscious sedation drugs that are opioid-based, due to their use already. [We currently use] propofol, [which] is not only in step with averting the crisis, but [provides] a better experience for the patient. The odd thing today is that some insurers are still unwilling to pay for this method and are seemingly pushing [for] the continued use of opioids [with] their current policies. Perhaps it is time for them to get in step with the rest of the country and state as well.

James Adkins, CEO and Co-founder of Modern Ambulatory Surgery Centers (Phoenix): The anesthesia team and surgeons have changed their cocktails to utilize gabapentin, pregabalin and Tylenol to some degree. We still perform a fair amount of high-acuity outpatient spine surgery that necessitates collaboration between our pain intervention physicians and surgeons, as these patients often require pain medicine, at least initially. 

Tammy Stanfield, Administrator and Director of Nursing at North Pines Surgery Center (Conroe, Texas): Our surgeons are skilled and abreast of the current trends in pain management and they have trained on many progressive procedures [including]: dorsal root ganglion stimulators, NuTech's SIFix implant, Vertiflex's Superion Implant, and injection of stem cells into joints (major and spinous processes). What we also see is patients now using CBD oil and rubs to lessen the amount of opioid needed. … These shops are popping up all over Texas. Also, our spine surgeon is using a mixture of medications to close the incision, and the patients are doing very well. He uses: bupivacaine with epinephrine, ketorolac 30 milligrams, morphine 4 milligrams & Exparel (bupivacaine liposome) 20 milliliters. [With this,] the patients want to go home within two hours.

Jeffra Kinniard, BSN, RN, Director of Operations at Parkview SurgeryONE (Fort Wayne, Ind.): Our philosophy is team-oriented. As an orthopaedic specialty ASC, most of our patients receive regional anesthesia. This has been a major strategy to decrease the need for large numbers of opioids. Our nurses spend extra time during the scheduling process, in the preoperative bays and in the postoperative bays educating patients on realistic expectations about postoperative pain and how to best take their prescribed medications. Our surgeons e-scribe whenever possible and are very mindful about the dosage and amount of medications that they prescribe. Changes in prescribing patterns have evolved greatly from five years ago. In addition, non-prescription modalities are encouraged, including ice, breathing techniques, mindfulness, aroma therapy, etc.

Tony Mira, President and CEO of Anesthesia Business Consultants (Jackson, Mich.): The key to the management of any crisis is to assess its impact and identify strategies to address it. It is not clear to what extent a patient's surgical experience in an ASC can potentially trigger opioid dependence because the average patient is relatively healthy and most surgical procedures are short. Historically, orthopedic procedures are more painful and involve higher narcotic use. The use of narcotics in an ASC must be monitored closely, and clinical protocols should also be established that minimize the need for narcotics.

Tom Wilson, CEO of Monterey Peninsula Surgery Center (Monterey, Calif.): MPSC has adopted policies restricting postoperative opiate prescriptions to five days or less for breakthrough pain only. Anti-inflammatory and over the counter pain relief medications are usually sufficient to manage our patients' pain and are our preferred method of controlling post-surgery pain. 

Todd Chapman, MD, Orthopedic Surgeon at OrthoCarolina Spine Center (Charlotte, N.C.): Education and time spent with patients discussing expectations is a front-line therapy that many of us as providers could dedicate more time to. Setting expectations that pain associated with surgery and orthopedic conditions is temporary is important. Utilizing other non-opioid medications to address the pain associated with injury and surgery is a parallel strategy we should continue exploring and implementing aggressively. 

Bradford Curt, MD, Neurosurgeon at Mayfield Brain & Spine (Cincinnati): The statistics examining the opioid epidemic serve to highlight the negative social and economic impact that opioid misuse and overdose has had on our country. Multiple factors have led to the current opioid crisis, and I believe tackling the current problem will require the cooperation of physicians, patients, companies, healthcare systems, government and the local community.

We physicians need to recognize and appropriately diagnose a patient's underlying conditions, such as depression, which make pain management more complicated. Treating these pain-magnifying conditions will improve overall quality of care and pain management. Effectively identifying and treating the underlying cause of a patient's acute pain will shorten the need for pain management. 

Patient education and a strong physician-patient relationship allow early communication of arising problems and possible medication abuse. Early detection and treatment will hopefully minimize abuse, dependence, and overdose risks. We need multidisciplinary approaches wherein a pain treatment team expands its focus on acute and chronic pain in a patient-centered fashion. Current systems have focused on the supply side aspect of the crisis by monitoring prescribing habits and reducing prescribed amounts.  

The demand aspect of opioid misuse needs to be addressed as pharmaceutical companies innovate pain management options that include non-opioid as well as opioid medications and medications to combat opioid use disorder. As genetic testing improves, I hope to be able to choose more effective medications for individual patients while avoiding drugs that present more risk to the individual patient. Sole reliance on opioid pain medications must decrease as other less addictive or less easily abused options become available. Healthcare systems have and will need to continue to track medication usage and warn providers of possible abuse behaviors. These systems will need to connect our patients into an effective treatment and recovery program with local and government support.  

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