EXECUTIVE SUMMARY

When surgery patients already are taking opioids for chronic pain issues, the new goal is to get them to reduce their daily opioid intake — and prevent their suffering.

• It is important to prevent veteran patients from experiencing pain and emotional distress that could lead to suicidal behavior.

• Follow-up calls from case managers can help monitor their pain levels, symptoms, and emotional states.

• Hospital patients have been happier and better able to move around post-surgery when they are less reliant on opioids.


Some surgery practices have begun to require preoperative patients who take opioids for chronic pain to reduce their opioid prescriptions before surgery. Evidence-based outcomes suggest this helps them better deal with post-surgery pain and reduces their risk of opioid-related problems.

“We started a transitional pain service in January 2018,” 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.

“Our number-one goal is to take the best care of veterans that we can,” she says.

“We don’t want to see veterans suffer,” she adds. “And, in reducing the opioid epidemic, our biggest fear is [opioid-sparing strategies] might increase suffering, and we don’t want to see the suicide rate increase among our veteran population.”

Fortunately, the new strategy to taper off opioids preoperatively and to reduce overall reliance on opioids for post-surgical pain management has worked very well, Bayless notes.

“Our patients’ function scores are not worse — they’re actually improving, and our patients’ perceptions of pain have improved,” she explains. “Their pain intensity is what you’d expect after surgery, and we can prevent chronic or persistent opioid use after surgery among opioid-naïve patients.”

Before the transitional pain service, the institution’s results were similar to the national average of 5-15% of people developing persistent opioid use, she says. “Now that’s zero percent.”

The program collects data, including patients’ self-reported pain levels, and it shows that the tapering program does not increase their suffering. Instead, they are improving their functioning post-surgery and are stopping all opioids within 90 days, Bayless says.

“That’s a true testament to our nurse case managers, who do the majority of our follow-up phone calls,” she adds. “The service would not run without nurse case managers.”

They call patients, post-surgery, at two days, seven days, 14 days, 21 days, 30 days, 60 days, and 90 days. They also perform a chart review.

“If the patient is not off opioids or back to baseline within 21 days, then they’ll call them until they’re off opioids,” Bayless adds.

In one case, a man who was on opioids for chronic neck pain needed to reduce his medication before back surgery, says David Merrill, RN, transitional pain service coordinator at George E. Wahlen VA Medical Center.

The patient tapered down his opioid intake and underwent the surgery. Afterward, the team helped him wean off of opioids for a number of months.

“We worked with him through phone calls and helped him with withdrawal symptoms as he was winding down,” Merrill says.

The patient wanted to reduce his opioid intake because it caused him to be so lethargic that he could not spend time with his granddaughter. Once he was off opioids, he enjoyed babysitting his grandchild, Merrill explains.

But the patient returned to his community provider due to ongoing neck pain. The patient was prescribed opioids again, although at a lower dose than what he had been taking before surgery, Merrill says.

“He’s not back to his baseline and probably is taking half of what he was when we met him,” he adds. “This coincides with where we have great success, winding people down, and then they go back on pain medications — but with reduction.”

In other cases, patients might report they have stopped taking opioids when they are continuing with a prescription. The transitional pain service team will compare patients’ self-reported opioid use with prescription drug monitoring program data.

The focus on reducing opioids pre- and post-surgery includes changing hospital staff perceptions of pain management, as well. For instance, the VA hospital holds monthly inservices on the surgical floor about pain medication, Bayless says.

“This has empowered nurses on the floor,” she says. “This helps nurses better take care of post-surgical pain, and nurses have seen better outcomes: The patients are happier and getting out of bed more.”

From the nurses’ perspective, the reduction in opioid use has been very positive, she adds.