EXECUTIVE SUMMARY

Case managers in surgical practices can help fight the opioid epidemic by working with patients to reduce any current opioid use and prevent persistent opioid misuse.

• A Veterans Administration medical center started a transitional pain service for surgery patients to help them find alternative strategies to reducing surgical pain.

• The old model of giving patients more pills if they experience any pain post-surgery is giving way to a new model, allowing that some pain is acceptable.

• Care coordination is important to ensure patients do not fall through the cracks.


Healthcare professionals across all disciplines, including case managers, are doing their part to end the opioid epidemic. Opioid abuse and misuse have contributed to more than half a million overdoses nationwide in the past two decades, and problems have continued. Federal data show that more than 56 million Americans filled at least one opioid prescription in 2017. (For more information, visit: http://bit.ly/2GzCtkL.)

Recognition that some surgical patients could benefit from case management services to help with pain has led one organization to develop a transitional pain service for surgery patients.

“This is a strategy that is fairly new,” says Benjamin Brooke, MD, PhD, FACS, associate professor of surgery and an adjunct professor of bioinformatics and population health sciences at the University of Utah in Salt Lake City. Brooke also is the chief of the division of vascular surgery and director of the Utah Intervention Quality and Implementation Research group.

Before the opioid epidemic, physicians were taught to think of patient pain as a fifth vital sign. They were supposed to ask about it and help reduce it as much as possible. Doctors would prescribe opioids for patients who reported pain at a level two or three, Brooke explains.

“So patients expected to get medication if they had any pain at all,” he adds. “What we’ve realized now is that patients don’t need opioids unless they have severe breakthrough pain, and we can give them a lot of nonopioids and nonmedical interventions, like acupuncture.”

This evolution away from opioid prescriptions for all pain has led to the need for a more holistic program that includes case management.

“Every institution’s environment is different,” Brooke says. “You have to do an assessment of barriers and facilitators to make sure it will fit within your own institution and the providers executing the model.”

When patients with complex medical needs are given opioids at the time of surgery, there is a need for better care coordination, Brooke says.

“We’ve taken a couple of different models for the concept of integrative case management and tried to put these in this program,” he adds. “We’ve also looked at a lot of evidence for what causes people to continue opioids and tried to develop a program that uses the evolving evidence.”

Research shows that post-surgery opioid treatment has served as a significant gateway to continued opioid use and misuse. One recent study found that 8.3% of opioid-naïve patients given opioids after shoulder surgery had developed new, prolonged opioid use.

Another study found that 14% of opioid-naïve patients that received opioids for pain after lung resection continued to fill their opioid prescriptions three to six months post-surgery.1,2

In the traditional surgery model, patients would be sent home with opioid prescriptions and would be seen in one or a few follow-up visits. After that, community providers would take over the opioid prescriptions, so surgeons rarely knew whether patients developed persistent opioid use.

But the new model of transitional pain service addresses this care gap, says Kimberlee Bayless, DNP, APRN, FNP-BC, director of The Transitional Pain Service and an acute pain service nurse practitioner, anesthesia department, at George E. Wahlen Department of Veterans Affairs (VA) Medical Center in Salt Lake City.

“We thought we should formulate a transitional pain service and start taking care of veterans in a more well-grounded, holistic approach,” Bayless says. (See story on how pain program works, in this issue.)

“Our goals are to reduce pain suffering, improve functional outcomes, stop new chronic opioid use, and help chronic opioid users to reduce or eliminate use of opioids,” she says.

Patients are stratified based on risk factors, such as surgery type, current chronic opioid use, substance abuse, mental health concerns, and medical history. They are placed in groups of low, moderate, and high risk for the development of new, persistent, chronic post-surgical pain.

“Involve nurse care managers in the process of identifying these patients,” she says. “Nurses can do detailed chart reviews and also meet with the veterans to get a detailed history from them about their chronic pain, social history, and family history.”

The transitional pain service is a team, including an anesthesiologist, psychologist, and nursing case manager, Brooke says.

“The team is very integrated in terms of following patients [and] meeting on a daily basis to ensure all patients are being followed, and there’s a clear plan to prevent patients from being dropped or falling through the cracks,” Brooke adds.

“We started this program with orthopedic patients and now are expanding it to all surgical specialties,” he says. “When we started the program, we had a very intensive follow-up after surgery of at least weekly and then once a month. Now, we’re trying to taper back and say, ‘What is the right amount of follow-up that patients need?’”

The follow-up provides patients with reassurance that they can handle their post-surgery pain even if they do not use opioids. And they try to reduce the trend of patients going to other providers to renew their opioid prescriptions, he says.

“We reinforce that there are other options than taking medications,” Brooke says. “We have clinics set up for people who are chronic opioid users, and after a three- to six-month window, if the team feels patients are still at risk of having opioid misuse or abuse patterns, then we can refer patients to these other specialty clinics.”

REFERENCES

1. Gil JA, Gunaseelan V, DeFroda SF, et al. Risk of prolonged opioid use among opioid-naïve patients after common shoulder arthroscopy procedures. Am J Sports Med. 2019;47(5):1043-1050.

2. Brescia AA, Harrington CA, Mazurek AA, et al. Factors associated with new persistent opioid usage after lung resection. Ann Thorac Surg. 2019;107(2):363-368.