As providers in all disciplines, including surgical settings, look for strategies to be part of the solution when it comes to opioid prescriptions, one Veterans Administration model provides a blueprint.
The team educates patients about nonopioid methods of post-surgical pain reduction, including taking Tylenol, using ice machines, and following their physical therapists’ instructions, 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 follow up with patients, calling them within two days to answer any questions or concerns,” she says.
The following is how the program works:
• Screening process. For surgery patients at the Salt Lake City VA, there is a screening algorithm that asks these questions:
- Is the patient at high risk for opioid misuse?
- Does the patient have a history of substance abuse?
- Has the patient been on opioids previously or currently?
- Does the patient have a mental health history of anxiety, depression, or post-traumatic stress disorder (PTSD)?
- Does the patient lack social support?
“All of those are risk factors we’ve identified and that are evidence-based,” 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.
Patients who are at risk of prolonged opioid use are contacted and offered enrollment in the program.
The program uses PROMIS (Patient-Reported Outcomes Measurement Information System) scores. (For more information, visit: http://bit.ly/2VzMAj4.)
PROMIS is a program developed with funding from the National Institutes of Health and is available for public use. It includes a subset of instruments that can be used to assess pain. Its other instruments assess alcohol use, social roles, anger, anxiety, asthma, depression, emotional support, psychological stress, smoking, substance use, and many others categories.
Case managers also might assess a patient’s pain catastrophizing scale. The catastrophizing scale is used to predict which patients might experience worse or prolonged pain, leading to greater opioid use. If patients catastrophize their pain, then they might use more medication or develop chronic pain post-surgery, Bayless explains.
“We’re trying to see if that score can predict outcomes postoperatively,” she adds. “If they say, ‘I don’t think my pain will be any better’ or ‘the pain always will be bad,’ then that’s a valid pain measure.”
• Preoperative education. Sometimes, patients do not know what to expect with post-surgery pain and treatment, Brooke notes.
“A pre-op education course can give patients information on what their expectations would be and set the stage for saying, ‘You’re not going to need as much opioids as was previously expected for a lot of patients,’” he says.
Nurse case managers can start a conversation with patients. Patients also can view a one-hour surgical expectations course.
“One thing we focus on is patient-reported outcomes and patient-reported assessments of their pain intensity, pain interference, and pain catastrophizing,” Brooke says. “Nurse case managers interview patients to assess baseline scores, and then after the operation, the nurses will reach out to patients at regular intervals about whether their pain scores have improved the way they should.”
A pre-surgery expectation class run by psychologists can help patients change their attitude about surgical pain.
“The psychological component includes talking about opioids and medications that can be used with surgery,” Bayless says. “Psychologists introduce mindfulness in that class.”
• Pre-op case management. “A lot of the role of the case manager is being a liaison between veteran and surgical services, the go-to person for veterans for anything related to their surgical questions,” Bayless says. “Developing a relationship with the veteran is one of the most important roles.”
Case managers spend an hour with patients at the initial intake and are available afterward to answer any questions.
“They build a real relationship with veterans preoperatively,” Bayless says. “Veterans find that case managers are quick to respond and answer their questions.”
Case managers also explain the program’s policy that patients who are currently using opioids for pain management must taper off their opioid medications by 50% prior to scheduling the surgery. (See stories in this issue on pain control and opioid tapering.)
“Nurse case managers do care coordination with veterans with our recommendations for how to taper pain medications, monitor withdrawal symptoms, and get medications to 50% before the surgery is scheduled,” Bayless explains. “Our case managers coordinate with primary care providers, doing follow-up with prescription renewals, and follow-up weekly to see how the taper is going and whether they have any side effects.”
The program and case management approach has had a very positive impact on individual patients, Bayless notes.
“Just today, I was stopped in the canteen by one of our veterans that we served,” she says. “She told me that she just finished with yoga and she is one year out from her total knee replacement.” The former patient told Bayless that she often thinks about the transitional pain service team and gives the team credit for how she was able to regain her functional life. “I enjoy hearing about the struggles and successes of our veterans,” Bayless says. “I feel blessed and honored to serve those that have so valiantly served our country.”