Opioid Reduction Initiative

The opioid epidemic in the United States has become a leading cause of death1. As a result of vigorous research, we now know that approximately one in sixteen patients provided a prescription after surgery will become a chronic user of opioids2. This chronic use, combined with the fact that only 3 in 10 pills prescribed are used by the intended recipient3, has resulted in the fact that one in 3 opioid-related deaths can be attributed to prescription pain killers.

As hernia surgeons, we are committed to partnering with our patients to:

  • Set realistic expectations about postoperative pain and pain management
  • Reduce opioid prescribing
  • Reduce opioid consumption
  • Measure outcomes related to hernia surgery and opioid use.

We are committed to continuous quality and process improvement and are providing our patients with an informational brochure that should be read carefully by anyone who is given a prescription for opioid analgesics after hernia surgery.

The brochure: “Learn the Facts: opioids & pain management” sets forth the medical community’s developing concern about opioid use. The brochure presents medically accepted information about opioid use, but is general in nature and should not be understood as making any claim concerning the diagnosis, treatment, cure, or prevention of any disease or condition of any particular person. You should consult with your doctor about your need for opioids and your experience and concerns with opioids prescribed by your doctor.

In addition to this brochure, we appreciate your participation in the ACHQC patient-reported outcome survey before and after surgery.

Download Brochure

References:

  1. https://www.cdc.gov/opioids/data/analysis-resources.html
  2. Chad M. Brummett, MD; Jennifer F.Waljee, MD, MPH, MS; Jenna Goesling, Ph.D.; Stephanie Moser, Ph.D.; Paul Lin, MS; Michael J. Englesbe, MD, New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults, JAMA Surg, doi:10.1001/jamasurg.2017.0504
  3. Howard R, Fry B, Gunaseelan V, Lee J, Waljee J, Brummett C, Campbell D Jr, Seese E, Englesbe M, Vu J Association of Opioid Prescribing With Opioid Consumption After Surgery in Michigan, JAMA Surg. 2018 Nov 7:e184234. doi: 10.1001/jamasurg.2018.4234
 

Reducing Opioid Use & Prescribing: Lessons Learned from the Abdominal Core Health Quality Collaborative

Webinar Resources

Optimal Postoperative Pain Management Strategies after Hernia Repair

MULTIMODAL PAIN MANAGEMENT

For the last 2 years, the ACHQC has worked to identify opportunities to impact the opioid epidemic.  To that end, the Opioid Reduction Task Force was formed and has worked with the ACHQC leadership to develop a comprehensive postoperative pain management strategy.  Importantly, this new protocol focuses on alternative strategies for postoperative pain reduction and encourages opioids as second-line therapy.  Below is a summary of the work of the task force, national guidelines and an ask of all ACHQC surgeons.

Goal: Influence and motivate all ACHQC surgeons to use best practices in managing postoperative pain after ambulatory inguinal and umbilical hernia repair. 

Task Force Work to Date:

  • Created and implemented optional tool within the ACHQC to measure: opioid prescribing, multimodal pain management, patient opioid consumption and risk factors for chronic use
  • Analyzed above data within the task force
  • Implemented a pilot study in November 2019 - Multimodal treatment of postop pain including acetaminophen, ibuprofen, ice and 10 or less opioid tablets
  • Presented initial data at QI summit in Denver - Dec 2019
  • Obtained consensus on postoperative pain management treatment plan and commitment to reducing opioid prescribing including adoption of a multimodal pain management strategy with opioids as 2nd or 3rd line “rescue” medications

Findings:

  • ACHQC Surgeons had various preoperative, operative, and postoperative pain control regimens
  • Task force patients used significantly fewer tablets than were prescribed (see attachment)
  • November pilot of prescribing 10 or fewer tablets of any opioid after inguinal and umbilical hernia repair resulted in no callbacks for prescriptions refills

Recommended Best practices for Optimal Postoperative Pain Reduction Strategies:

Preop evaluation

  • Patients to fill out preoperative patient-reported outcome (PRO) form and surgeon to enter data into ACHQC

Perioperative

  • Discuss pain expectations and discuss medications in preop holding
  • Provide ACHQC opioid education handout with discharge instructions 
  • Educate, prescribe or recommend to patients: Acetaminophen, Ibuprofen, Gabapentin, ice 
  • Provide opioid Rx for no more than 10 pills

Follow up

  • Patients to fill out post-operative PRO form and surgeon to enter data into ACHQC
  • Surgeons or staff to input opioid prescribing data in ACHQC at 30-day follow up visit

Commitment obtained at QI meeting:

  • Incorporate multimodal, non-opioid pain management strategy as a first-line approach and opioids as a “rescue” medication - please refer to the attached note card
  • Agree to prescribe no more than 10 opioid tablets for routine open and MIS inguinal and umbilical hernia repairs (this can be adjusted for outlier patients)
  • Surgeons will implement best practices and input data into the ACHQC
  • Outcomes data will be reevaluated in 6-12 months to determine if any modifications are necessary

Tips to success:

  • Standardize your workflow – assign time/person to input data into the ACHQC
  • Standardize your prescriptions to reduce variability
  • Take pride in knowing that you’re helping your patients and impacting the opioid epidemic with prevention
  • Motivate yourself and your staff with the importance of reducing patients’ pain and opioid usage
  • Ask for help from task force members

Next Steps:

  • Continued analysis and dissemination of data obtained through the ACHQC
  • Create educational video for surgeons to discuss optimal pain management techniques and how to talk to patients about multimodal pain management

References & current prescribing recommendations for opioids after hernia repair:

  • Michigan-OPEN: 0-10 tabs [1]
  • Johns Hopkins: 0-15 tabs [2]
  • Mayo Clinic: 0-20 tabs [3]
  • Dartmouth Hitchcock: 15 tabs [4]

​Download Note Card

References:

[1] https://michigan-open.org/prescribing-recommendations/
[2] Overton HN, Hanna MN, Bruhn WE, Hutfless S, Bicket MC, Makary MA; Opioids
After Surgery Workgroup. Opioid-Prescribing Guidelines for Common Surgical
Procedures: An Expert Panel Consensus. J Am Coll Surg. 2018 Oct;227(4):411-418.
[3] Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann EB. Results of a Prospective, Multicenter Initiative Aimed at Developing Opioid-prescribing Guidelines After Surgery. Ann Surg. 2018 Sep;268(3):457-468.  http://links.lww.com/SLA/B477
[4] Hill MV, McMahon ML, Stucke RS, Barth RJ Jr. Wide Variation and Excessive Dosage of Opioid Prescriptions for Common General Surgical Procedures. Ann Surg. 2017 Apr;265(4):709-714.
http://nationalacademies.org/hmd/~/media/Files/Activity%20Files/MentalHealth/OpioidRxGuidelines/Feb%202019%20workshop/Presentation/Barth%202.pdf

 

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