Opioid prescriptions have declined some in the past year, but remain triple the number prescribed two decades ago, according to a new report by CDC.1

At its peak in 2010, physicians prescribed 782 morphine milligram equivalents (MME) per person, up from 180 MME prescribed in 1999.1

In 2015, this amount had declined to 650 MME. The recent improvement was offset by a 33% increase in the average days’ supply per prescription, from 13 days in 2006 to 18 days in 2015, according to the report.1

The opioid data show that physicians continue writing too many opioid prescriptions at too high a dose for too many days, according to Anne Schuchat, MD, principal deputy director of the CDC.

To help prescribers halt the opioid epidemic, the Accreditation Association for Ambulatory Health Care (AAAHC) has developed a “Patient Safety Toolkit: Opioid Stewardship.”

The group is distributing the toolkit to more than 6,000 accredited organizations, and others can order it online for $10 a copy, says Naomi Kuznets, PhD, vice president and senior director at AAAHC.

The toolkit is an 11-by-17-inch poster with practical reminders and information about rating pain. On the flip side, it features information about why preventing opioid dependence is important, the clinical evidence, and references.

“It addresses the primary care chronic issues and procedural issues,” Kuznets says. “The idea was to make it brief and to the point and include tools that you could put on the wall and refer to as necessary.”

It’s not all-inclusive, but contains useful, evidence-based information, checklists, and guidance.

For example, the following is some of AAAHC’s guidance on dealing with opioid dependence:

1. Prevent ASC patients from developing opioid problems.

Ambulatory surgery centers (ASCs) can conduct pre-op testing, such as a urine test, to check for opioid dependence and benzodiazepine use. They also can check a state databank to discover if a patient has an active prescription for opioids, Kuznets says.

If patients do have active prescriptions, they should take their opioid medication to avoid excruciating pain, Kuznets says.

“You need to make sure they take their opioids the day of the procedure so they’re not in a withdrawal state,” she says.

Surgeons also should be aware of the potential for opioid dependence post-surgery. The toolkit cites the statistic that 36.5% of surgical/procedural providers’ prescriptions are for opioids. Also, 42% of orthopedists’ prescriptions are for opioids.2,3

Surgery patients who were not taking opioids prior to their procedures were at greater risk of chronic opioid use, including those who have undergone laparoscopic cholecystectomy, cataract surgery, transurethral prostate resection, and varicose vein stripping, the toolkit says.4,5

Only one in four ASC patients receive education on disposing of unused opioids.6

“People don’t dispose of the medication,” Kuznets notes. “They think, ‘I’ll keep this for when I have something that’s really painful,’ and you can’t do that with people around in your household that might abuse them.”

2. Calculate opioid safe dosages and prevent opioid dependence.

The first section of the toolkit notes how higher dosages of opioids are associated with higher risks of overdose and death, while demonstrating little benefit in reducing long-term pain. Then it provides guidance on calculating the total daily dose of opioids for safer dosage.

One strategy is to help set patients’ expectations about post-surgery pain, Kuznets says.

“Talking to patients about this before the procedure is so critical,” Kuznets says. “Have the patient consider other types of painkillers.”

For instance, a patient undergoing an orthopedic procedure might benefit from a COX-2 inhibitor to reduce pain and provide an alternative to opioids.

Clinicians should discuss alternative pain therapies, such as local anesthetic techniques, acetaminophen, and nonsteroidal anti-inflammatory drugs, with patients and caregivers. Also, some patients might be better suited for inpatient admission so they can be closely monitored.

“It’s really important for post-discharge prescribing to know how to calculate safe opioid dosages,” Kuznets says. “There are a lot of studies that show people have a lot of opioids left over after procedures.”

Until recently, physicians were unaware that patients would hoard leftover opioid pills or sell them, she adds.

“With surgery centers, it’s the post-procedure prescribing that’s important with regard to calculating,” she explains. “Just don’t do long doses of opioids, even for bone surgery, because within five days, most people are at the point where they should be weaning off the drug.”

The days of writing high dosages for two-week prescriptions are ending, Kuznets says.

3. Assess patients’ pain.

“Use an assessment tool for pain pre-op and post-op,” Kuznets suggests. “It’s a short tool that is fabulous for most clinicians.”

The pain assessment tool, recommended by AAAHC’s poster, offers clinicians three questions they can ask patients, including:

- What number best describes how, during the past month, pain has interfered with your enjoyment of life?

- What number best describes how, during the past week, pain has interfered with your general activity?

The answer choices are rated zero to 10.

Pain management goals for post-surgery patients should focus on helping them improve postoperative function and maintain their rehabilitation. It shouldn’t be to achieve a specific pain score, Kuznets says.

“There’s a trend of using non-opioid pain management — nonsteroidal anti-inflammatories — if you have a patient who can handle those,” Kuznets says. “There are lots of options that people are considering more proactively, including TENS [transcutaneous electrical nerve stimulation] units, which are units that interfere with pain signals to the brain.”

The whole idea is for surgeons to engage patients in discussions about non-opioid pain relief and to think about prescribing opioids in smaller dosages and for shorter periods, Kuznets says.

“Avoiding the discussion can lead you to some nasty issues and unrealistic expectations about pain control or prescriptions,” she explains. “There’s a lack of understanding about low-level, aching pain versus acute, distressing, up-from-the-level-of-pain-scale pain, and we really need to control the expectation about eliminating pain.”

Editor’s note: For more information about the AAAHC opioid toolkit, please visit: http://bit.ly/2w3R4y3.

REFERENCES

  1. Centers for Disease Control and Prevention. Opioid prescribing. Vital Signs, July 2017. Available at: http://bit.ly/2uveWLd. Accessed July 24, 2017.
  2. Ringwalt C, Gugelmann H, Garrettson M, et al. Differential prescribing of opioid analgesics according to physician specialty for Medicaid patients with chronic noncancer pain diagnoses. Pain Res Manag 2014;19:179-185.
  3. Levy B, Paulozzi L, Mack KA, Jones CM. Trends in opioid analgesic-prescribing rates by specialty, US, 2007-2012. Am J Prev Med 2015;49:409-413.

4. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low risk surgery: A retrospective cohort study. Arch Intern Med 2012;172:425-430.

5. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naïve patients in the postoperative period. JAMA Intern Med 2016;176:1286-1293.

6. Kumar K, Gulotta LV, Dines JS, et al. Unused opioid pills after outpatient shoulder surgeries given current perioperative prescribing habits. Am J Sports Med 2017;45:636-641