Better Post-Operative Prescribing Patterns and Education Reduces Opioid Use

BARRIE, ON - Post-operative pain management is undergoing a transformational change with a focus towards moving away from prescribing opioids as the primary mode of analgesia.  While the motivations for this practice change are many, the urgency has been accelerated by the emerging opioid public health crisis.
 
In Ontario, opioid-related mortality rates have increased by 161% over the last 5 years, with over 90% of these deaths due to unintentional overdose among young adults who were never prescribed opioids.  Prescription opioids represent a potential source of narcotic misuse, with surgery among the most common indications for opioid initiation.

In response, surgeons and anesthetists have been working together to study the effects of different post-surgical pain management strategies on reducing opioid use without compromising patient outcomes.  Many studies have now demonstrated that bundled peri-operative analgesic strategies not only reduce overall opioid use, but also have no adverse effects on post-operative pain experienced by patients.

In 2019, RVH general surgeon and critical care specialist, Dr. Ana Igric, organized a continuing medical education event for the departments of Surgery and Anesthesia, focusing on recent developments in peri-operative opioid prescribing practices. The speakers were a surgeon and an anesthetist from the London Health Sciences Centre who had just completed a prospective study, Standardization of Outpatient Procedure (STOP) Narcotics, using a bundled peri-operative pain management strategy on patients undergoing day surgery. The bundled intervention included an education component for all operative staff, intra-operative analgesia that included opioid-reduction strategies, and time-limited post-operative opioid prescriptions.
 
Their study demonstrated a reduction in overall opioid use, reduced variability in post-operative opioid prescriptions and good patient pain management outcomes.  Not only were the study results well received, but Dr. Igric realized there was no reason that a similar strategy could not be successfully implemented at RVH. 

Supported by a donor grant from the RVH Foundation, Dr. Igric organized a research committee to plan for a study involving implementation of the STOP Narcotics peri-operative pain management strategy for patients undergoing elective outpatient hernia repair and laparoscopic gallbladder surgery.  In addition to monitoring for the same outcomes as the STOP Narcotics study, the RVH research team also wondered if there were other relevant patient outcomes that might be affected by the opioid reduction strategy.  All the studies that had been published prior to this study had considered pain control as the only relevant clinical outcome.  Other clinical investigators had not considered asking patients if there were other outcomes that might be just as or more important than pain control.  

In collaboration with the RVH Centre for Education & Research, under the mentorship of Dr. Giulio DiDiodato, RVH intensivist and Chief Research Scientist, Dr. Igric designed a study that included a novel approach to measuring other patient-relevant post-surgical outcomes. Patient recruitment started in November 2019, and after 12 months, 184 patients had been enrolled in the study, which accounted for 36.1% of all eligible surgeries.  

Supported by a pain specialist research nurse, Mary Robertson, the study was able to demonstrate that patients rated outcomes such as the ability to return to work and the ability to resume usual daily activities as more important than pain control, a novel finding that had not previously been reported in the published literature.  Combining pain control along with these other relevant outcomes into a composite outcome, Dr. Igric demonstrated that implementation of the STOP Narcotics bundled pain management strategy resulted in reduced opioid prescriptions and patient use without causing unintended adverse consequences for either pain control or the other important patient-relevant outcomes.  The results of the study are currently being summarized and prepared for publication.