A transitional pain service at George E. Wahlen Department of Veterans Affairs Medical Center in Salt Lake City helps patients reduce their opioid use before surgery, and it helps patients taper off post-surgery opioids for pain management.
This approach is a big change in culture, says Kimberlee Bayless, DNP, APRN, FNP-BC, director of the Transitional Pain Service and an acute pain service nurse practitioner, anesthesia department at the VA Medical Center.
“We’re changing the culture of nursing and of our surgeons and staff at the VA,” Bayless explains.
The program uses different approaches for patients who already are taking opioids vs. those who would receive their first opioids after surgery.
“We look at patients that come in opioid-naïve and those that are on opioids differently because they have different risk factors,” 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.
“One-third of our patient population has been on opioids. When you’ve been on opioids chronically, it’s hard to get off the medication,” Brooke says. “We have been able to wean off 45% of our people who were chronic opioid users.”
One big opportunity has been to help patients wean off opioids after surgery.
“Sometimes, the surgery relieves what was causing their chronic pain,” Brooke adds. “For the opioid-naïve patients, we have been able to achieve nearly perfect success in not having them need opioids three months after surgery.”
The program’s strategy is to reduce opioid use at each stage.
“We want to give patients an adequate supply of narcotics if they need them, but also teach them how to taper,” Brooke says.
“Instructions say to take one tablet every four to six hours for pain, but do not distinguish between a pain level of 10 vs. a one or two,” he explains. “We say, ‘You don’t need to take opioid medication unless your pain is at a higher level; for the lower level, take Tylenol, ibuprofen, and nonopioid analgesics, which can be used just as effectively.”
For instance, knee surgery patients used to be discharged with 180 tablets, 5 mg, of oxycodone. Now they might receive 30 to 60 tablets, 5 mg, Bayless says.
The pain service uses a standardized multimodal pain treatment that includes Tylenol and anti-inflammatory medication.
“Things are becoming more standardized, and surgeons are becoming more thoughtful on how they’re prescribing,” she says.
And the results have been positive. “The nursing staff has commented that pain is better controlled and patients are happier,” Bayless says. “The nurses’ satisfaction also is improved, overall.”
Part of the reason the program is successful is because case managers work closely with patients, helping them cope with the pre-surgery opioid reduction and with their pain management after surgery.
Nurse case managers and a care team can assist with opioid-tapering strategies, employing this process:
• Have a conversation with patients about opioid tapering.
At intake, surgeons and staff let patients know that their elective surgery will not be scheduled until they have reduced their current opioid prescriptions, Bayless says.
“If they have decreased their opioids, there is less risk of having respiratory depression,” she says.
When case managers meet with patients to discuss their current opioid use and how this needs to be reduced by 50%, they help patients set up a plan, says David Merrill, RN, transitional pain service coordinator at the VA Medical Center.
“Through coordination with other services, the nurse practitioner, the nurse, and physician, we all work to set up a plan to help motivate the patient,” Merrill says. “We make monthly calls and follow up on a taper plan for the patient, checking in and giving encouragement.”
Occasionally, patients are overzealous in their desire to reduce opioid use — and this can cause problems.
For instance, one patient had been on a high dose of opioids before he met with the case manager to discuss tapering off his prescription, Merrill says.
“He wanted his surgery so badly that he went against our advice and basically did a 50% reduction overnight,” he recalls. “That never works because withdrawal symptoms kick in.”
The team helped the patient return to his baseline opioid prescription level and then slowly tapered off the amount until he reached 50% of the baseline dosage.
“We’d call him each day to make sure he was doing OK,” Merrill says. “We got him back on a normal program we set up for him.”
The patient underwent surgery and was able to sustain using only half the dose of opioids he needed before he entered the program.
• Case managers call the prescriber.
The nurse case manager discusses with the opioid prescriber how the patient has agreed to a 50% taper of opioid medication, starting with the next prescription renewal. The case manager suggests the prescriber can refer to case notes on the patient or call the surgery center physician for any additional information, Bayless says.
“We can write out the opioid taper prescription for patients,” she says. “We go over withdrawal medication and any other nonopioid medications that we would recommend they take.”
The goal is a warm handoff to the prescriber, and that usually works well, Bayless says.
• Check back with the patient.
“One of the novel things about our program is we have a dashboard, a health information technology tool that was developed by our medical informatics pharmacist,” Bayless says. “Our smart template has unique health factors imported into a dashboard, and it is able to track all of our patients.”
Case managers will see patients’ names with a list of their next appointments and alerts about which patients to call and check on.
“Every day, they can print out a unique list for that day,” Bayless says. “The dashboard shows which patients are in pre-op and post-op and helps case managers prioritize their day.”
Based on the dashboard data, a case manager can call the patient to talk about opioid tapering and to see how he or she is doing.
“The patients usually say, ‘Things are going OK, but I’m having withdrawal symptoms like you said, and I’m not sleeping as well, and the medications you gave us are either helping or not helping,’” Bayless says. “We ask how we can address this and see if they are taking their medications as prescribed. Then the nurse case manager puts a note in the electronic medical record about what’s happening.”
Case managers might check back with patients weekly, asking, “Is a week follow-up okay? Or do you need me to call you sooner?” Bayless says.
Some patients might want a call the next day, so they drive the pace of the case manager calls.
This level of connection between case manager and patient continues throughout the tapering period, which lasts four to eight weeks in most patients, she adds.
“When they’re done, the nurse case manager will alert the surgical team and say the patient has done the 50% taper and they can schedule surgery,” Bayless says. “They call the patient and say, ‘You’ve done a great job, and we’ll schedule you for surgery.’”
• Meet patients at pre-op appointments.
“They will see the patient again at the pre-op appointment to make sure everything stays OK,” Bayless explains. “We ask if they have any more questions or concerns, and we go to the surgery appointment with them, touching base with the surgery team and answering any questions the team has for us.”
The goal is another warm handoff. Case managers might discuss the patient’s expectations once his or her surgery date is set.
• Set patients up with a psychologist, as needed.
“Our team works closely together, and the psychologist sees patients, initially,” Bayless says. “If patients are at high risk for chronic opioid use, then the psychologist will do an individual session with them and a two-hour class, and see them as needed as they go through the opioid taper.”
Psychologists lead a surgical expectation class and work with patients on cognitive-behavioral interventions before surgery, Brooke says.
“We found that having the class before surgery is the most effective way to do it, and those interventions can be reinforced while the patient is in the hospital,” he says.
Psychologists have tried models that are validated for patients with addiction issues, including mindfulness and acceptance therapy, he adds.
The team encourages patients to use relaxation strategies, such as mindfulness, meditation, or hypnosis, to help them cope with the opioid medication reduction.
For example, one opioid-naïve patient who underwent shoulder surgery was still taking his post-surgery opioids a month after the procedure, Merrill says.
“We brought him back in, educated him, and had him work with our clinical psychologist,” Merrill says. “Through the course of multiple visits, we found that his underlying problem was anxiety, and he’d never been treated for it.”
With help from his case manager and the psychologist, the patient discovered that he was attracted to opioids because they numbed his anxiety. The team provided him with antianxiety medication and helped him taper off opioids, he adds.
Case managers build trusting relationships with patients, Merrill notes.
“We build a sense of trust with them,” he says. “They’re able to be open with us.”
Once the patient trusted his case manager, he was able to answer questions honestly about why he still needed his pain medications and how he was feeling. Those answers led to a referral to the clinical psychologist and the anxiety diagnosis, Merrill adds.