How much pain medication should you send your patients home with? Do patients use opioids post operatively? The short answer is that most do not. Greater than sixty percent of patients do not completely use opioids prescribed for post-operative pain. How can physicians and facilities use this information to have a positive impact on the opioid crisis? How is your facility determining quantities prescribed? Are there alternatives to opioids? In this post we will discuss recent trends in the use of opioids as well as steps prescribers and facilities can take to reduce risks and liability.

In a recent study published in JAMA Network Open, researchers at the University of Pennsylvania Perelman School of Medicine followed more than 900 patients who underwent orthopedic and urological procedures to determine their use of opioids prescribed for pain control. What they found was eye opening. More than 60% of the opioids prescribed for post-operative pain management went unused. Not only does it appear that we are sending patients home with too much medication, we are also potentially contributing to the ongoing opioid crisis.

The majority of opioids prescribed for acute pain after surgical procedures are not used and these excessive quantities have been associated with conversion to long-term use, overdose, and opioid use disorder. By now we know that opioid abuse is a pervasive problem and prescription medications are often a starting point for those who abuse them. Limiting prescribing quantities and teaching patients how to safeguard and dispose of extra medication can be starting points to limit availability to those who might divert and abuse.

What can facilities do?

We often hear about antibiotic stewardship, and now we are also starting to hear about opioid stewardship. How can we be better stewards of opioid use? Here are some steps facilities/prescribers can take to achieve a balance between good pain management and at the same time minimizing the number of medications that are available for abuse.

1. Implementing a multimodal perioperative pain management system: There is mounting evidence that multimodal analgesia can effectively treat post-operative pain while also minimizing side effects and the use of opioids. Options here include things like acetaminophen, nonsteroidal anti-inflammatory drugs, gabapentinoids (e.g. gabapentin), alpha-2 agonists (e.g. clonidine), and regional and topical anesthetics (e.g. bupivacaine). The choice for each patient will be based on the procedure, patient comorbidities, hemodynamic stability, and the adverse effect profile of the chosen agent.
2. Limiting the number of opioids prescribed on discharge: How much pain medication should you send your patients home with? As usual, there is not a blanket answer that will work for every patient and every circumstance. Tailoring the choice of medication, as well and the quantity to the specific patient will always be required. Although state policies will have an impact on quantities prescribed, each patient experiences pain and responds to analgesia in differing ways. Planning ahead and having a conversation with the patient ahead of time goes a long way to help them better tolerate the hours and days immediately after surgery.
3. Inform your patients about how to get rid of excess opioids: DEA Drug Takeback Days, which happens twice annually, are a perfect opportunity for patients to get rid of unused medications. The next one is April 24, 2021. There are also local places designated to take back these medications. Your patients can find the location closest to them by using the DEA website for Controlled Substance Public Disposal Locations. Educating our patients should always be part of the transition of care process. Disposal of unused medications is something that is often overlooked but could have a large impact on the opioid crisis. Remember that unlike in our facilities where all controlled medications are secured, unused medications are often left unsecured and not supervised. This provides an entry point for someone who is looking to misuse and can have many unintended outcomes.

As is the case with other challenges we face in safe medication management, this is a potentially dangerous situation that can be mitigated or eliminated by a little pre-planning. Developing a system to ensure each patient gets the best care possible (including minimizing post-operative pain), should start long before the patient is being discharged. If you have questions about this topic or need help setting up a system to enhance patient safety and regulatory compliance, let us know.

The Consultant Pharmacists at OctariusRx provide guidance on safe medication management, survey readiness and cost savings to ambulatory healthcare facilities/surgery centers, senior care facilities and pharmacies. We also help individual patients optimize their medications to improve their quality of life and save money. Contact us for assistance.