The Cleveland Clinic over the past couple of years also has developed a postoperative pain management initiative that examined the potential for using narcotic alternatives and it has shown promising results.
Cleveland Clinic’s approach relies on a greater use of narcotic alternatives before, during and after surgery, according to Dr. Eric Chiang, an anesthesiologist at the Clinic. The approach involves regional anesthesia (injecting a drug directly into the surgical site or pain area), and increasing the use of medications like acetaminophen and ibuprofen.
“The science behind it shows that opioids are not the best pain medicine,” Chiang said. “We’re probably not using Tylenol and nonsteroidals enough.”
Cleveland Clinic last year began a pilot program to change postoperative pain management protocols for patients who undergo cesarean sections, one of the most common surgical procedures in the U.S.
Chiang said C-section patients were traditionally prescribed Percocet or Vicodin while in the hospital only to receive more opioids upon discharge. Under the new protocol, patients got scheduled doses of either 1,000 mg of Tylenol or a large dose of Motrin every three hours even if they did not request pain medication.
Patients were informed they could still request an opioid if their pain was too great, but within the first month of making the change, opioid use among post C-section patients fell by 70%. Upon discharge most C-section patients are no longer prescribed an opioid, and those who do receive a prescription get an average of five pills compared with the 31 pills patients typically received in 2015.
“By minimizing and prescribing appropriate amounts of narcotic medicine—that’s how you fight the opioid crisis,” Chiang said. “It’s all those extra pills sitting at home that get diverted, and those pills in the community are what fuel the crisis.”
Dr. Candace Granberg, a pediatric urologic surgeon at the Mayo Clinic, said her department since at least 2012 has adopted an opioid-free pain management approach toward postoperative patients that has been successful enough for many patients to not require any pain medications while in recovery or after discharge.
She said a key part of her approach has been the focus on anticipating the need for treatment before the patient actually experiences pain, with patients receiving doses of acetaminophen and ibuprofen on an alternating schedule throughout their visit and having a nerve block applied to surgical areas prior to their procedure.
Prior to a procedure, the surgical team discusses the best ways to block patient pain during the operation and to control it during the patient’s recovery and at home.
Geisinger’s Martin said the system’s ProvenRecovery approach has been used with more than 2,000 patients since November. But he acknowledged the goal of eliminating opioids entirely from surgery has been difficult to achieve.
He estimated only about 20% to 30% of patients undergoing certain procedures are opioid-free. “There’s very few where absolutely no opioids are prescribed—that’s an aspirational goal for us,” Martin said. “But our No. 1 goal is to make sure patients’ pain is controlled.”
The goal of prescribing zero opioids is complicated by the fact that such drugs are still needed to control pain in a minority of patients. Further complicating matters, more people in general use opioids to treat chronic pain and may build a tolerance over time and so require stronger medications to successfully manage acute pain that’s common after many surgical procedures.
Martin said some surgery patients cannot easily be taken off such medications without going through physical withdrawal symptoms. “It’s a little more nuanced issue than just going for total opioid-free surgery,” Martin said.
While illicit drugs like fentanyl have overtaken prescription opioids as the primary driver of the opioid epidemic, prescribed opioids remain a significant contributor. Nearly a quarter of all overdose deaths and more than a third of all opioid-related deaths in 2017 were related to using prescription opioids, according to the Centers for Disease Control and Prevention.
Providers and lawmakers in recent years have worked to address opioid overprescribing through greater education for clinicians as well as through laws in several states limiting prescriptions to just a few days’ supply.
As a result the number of written opioid prescriptions fell from a record set in 2012 of more than 255 million to more than 191 million by 2017, according to the CDC.