Opioids are cheap and effective in reducing post-surgery pain, but they’re also dangerously addictive for some patients. This is why some hospitals and doctors nationwide are reducing or eliminating opioid prescriptions. For ASCs, opioids still serve an important purpose. However, providers should ask whether an opioid prescription is what’s best for patients at risk of addiction to the drug.
“There need to be pointed conversations about pain and medication,” says Elisabeth Johnson, FNP, PhD, director of health services for the University of North Carolina (UNC) at Chapel Hill Horizons, a substance abuse treatment program for women and children. Johnson was a scheduled speaker on the topic of assessing and identifying patients at risk for substance use at the 29th Annual PACU and Ambulatory Surgery Conference, held March 10, 2018, in Chapel Hill.
“Sometimes, these questions don’t get asked because people are uncomfortable,” she says. “But if you keep asking the questions, then it becomes as normal as asking who a patient lives with and what their pain is, today, on a scale of one to 10.”
Physicians and ASC staff must remember that substance abuse is not a morality issue, Johnson says.
“It’s a brain disease, and pain is a naturally occurring thing,” she says. “People will have different responses, and these are complicated — physical and emotional responses.”
Johnson asks patients direct questions about whether they have a history of misusing medications or alcohol or whether anyone in their family has this history. She also asks whether they’ve had any psychiatric diagnoses.
“If you make it a routine part of what you do, then you are comfortable with this,” Johnson says. “It’s similar to asking about sexual activity when you’re screening for AIDS; if you ask everybody, it becomes as normal as asking if someone has high blood pressure or diabetes.” There’s an opioid risk tool that provides simple guidelines to assessing the potential opioid misuse (). It was developed by Lynn R. Webster, MD, to assess risk of opioid addiction. The opioid risk tool features a matrix with room to assess risk, giving each answer a number. The clinician would circle the boxes where a patient said “yes,” and then total those numbers. A total score of three or lower indicates low risk for future opioid abuse. A score of four to seven indicates moderate risk, and anything eight or above suggests high risk.
The questions concern the following information:
- Family history of substance abuse, including alcohol, illegal drugs, and prescription drugs;
- Personal history of substance abuse, including alcohol, illegal drugs, and prescription drugs;
- Age between 16 and 45 years;
- History of preadolescent sexual abuse;
- Psychological disease, including ADD, OCD, bipolar, schizophrenia, and depression. If a patient’s answers on the risk tool indicate a potential opioid abuse problem, then the ASC should consult with an expert on pain and substance use issues or talk with the patient about alternative ways to manage their post-surgical pain.
One strategy is to strictly limit the number of opioid pills a patient is prescribed. In North Carolina, a recent law called the STOP Act limits the number of days of medication that someone can be given for post-surgical pain or for acute pain, such as a broken finger, Johnson says.
“I think that sort of trend is happening across the country as people are trying to put in measures to guide people,” she says. “On the substance abuse side, I hear a lot of stories about people who get started on opioid medication that’s prescribed by well-meaning healthcare providers for back pain, dental pain, etc., and then they get a refill and things spiral down after that.”