Amidst the national opioid addiction crisis, a Utah nurse with a background in case management has collaborated with a team of doctors and nurses at a Veterans Administration hospital — and their program has gained attention from The Joint Commission (TJC).
“This should be the national standard for care,” a TJC auditor told hospital leadership at the VA Salt Lake City Health Care System where Amy Beckstead, RN, MSN, ED, is a nurse educator/manager of the Regional Centers of Innovation Specialty Care (COI).
Since the program was implemented in January 2018, Beckstead reports that no opiate-naïve patients seen through the Transitional Pain Service (TPS) have continued postoperative opioid use. TPS patients already using opioids preoperatively have experienced significant reductions in chronic opioid doses.
Beckstead and her colleagues are presenting their findings at multiple medical conferences, spreading the word that their approach has proven effective — albeit based on preliminary results.
Opioids are commonly prescribed for postoperative pain, says Beckstead. “Among the various pathways by which individuals are introduced to opioids, surgery is the third avenue.”
“Surgery is really an ethical time to address opioids,” she explains. “Of course, we should offer pain control to patients postoperatively. Opioid issues related to chronic pain could have started with surgery. But the problem has been that nobody really stopped to look at how did the pain become chronic. Where was the acute insult that led to chronic pain?”
Statistics show that, historically, between 5% to 12% of patients who were opiate-naïve going into surgery will develop persistent chronic pain and opioid use after surgery.
“Communication after surgery is too disjointed in discussing reasonable opioid use,” Beckstead explains. “Patients are typically instructed to take the medication PRN [as needed]. But most patients don’t understand what ‘PRN’ means, and they take it until the bottle is empty.”
Patients also were not getting much education about the opioid medication itself, she adds. “They may not have realistic expectations about their level of pain and the need for an opioid pain medication, but that aspect is never discussed.”
Another layer is that the postsurgical patient typically is “not in the best mental state” to understand what they’re being told about the medication, Beckstead adds.
These factors cause confusion for the patient, who likely will call the surgeon for a refill because of continuing pain. That surgeon may continue prescribing the opioid medication for what he or she thinks are valid reasons.
Once the patient returns to primary care, that dosage may be continued due to lack of communication and guidance about proper use and tapering of opioids. The patient might be ready to scale back to a non-opioid painkiller or other alternatives for pain control.
The TPS team intervenes before chronic pain becomes an issue, and helps patients manage their pain in a different way.
“In the past, patients were given the illusion that perhaps we can get rid of their pain with the medications, and that’s not always possible,” Beckstead explains. “We had to help the patients develop realistic expectations about the pain and about pain control.”
The team uses a multidisciplinary approach that starts before surgery, with the nurse educating the patient about pain he or she might experience after surgery.
Each patient in the study was identified as either “opioid naïve,” who had not taken opioids in the previous 90 days, or patients with chronic pain who were currently taking opioids — about 30% of patients.
Beckstead says the preliminary results are a “great success.” Of the 241 surgical patients monitored since January 2018:
• 72% were opioid-naïve prior to surgery; none of these patients were still taking opioids three months later, compared to 5-13% in published studies;
• 28% were taking chronic opioids prior to surgery; 43% were completely off opioids after surgery; 37% had reduced their usage; 12% returned to their baseline use after surgery;
• Only 8% increased their opioid dose after surgery.
How did the TPS team so successfully decrease unintended opioid misuse post-surgery — and decrease opioid use rates for veterans who were already taking them for chronic pain?
First, they screened patients for risk factors and targeted those who were more likely to overuse the medication.
“I feel most strongly that education was the key to the program’s success,” says Beckstead. Prior to surgery, a nurse took time to educate patients about their surgical procedure, the pain they might expect, and the types of pain medications they could expect to take.
Patients also were instructed on the length of time to take the pain medication. “We stressed that it wasn’t long-term,” says Beckstead. “We also talked to them about other approaches to pain control, like mindfulness. A psychologist could also see them to discuss alternative pain control methods.”
Each patient also learned a nurse would be following up with them for three months after discharge via phone calls on days two, seven, 14, 21, and 30. This was to ensure the patient was following the plan to taper the opioid dosage. When the patient was off opioids for five consecutive days, those calls would end.
However, the team would check in with the patient at six months and one year to monitor overall functioning.
The team used the National Institutes of Health PROMIS pain scale to determine if the pain medication was effective. They also used quality of life questions to help determine each patient’s ability to function without the opioids.
“All these touch points, where we see the patient before surgery and call them afterward, creates a relationship of trust between patient and nurse,” says Beckstead. “I think that’s the strength of this program, as it’s not only about helping people with pain medication, but because expert nurses were helping them and referring them to other services and specialists when necessary.”
With this trust, “the patient is willing to let go of pain medication and is more accepting of what the team tells them is in their best interest,” she adds.
Those who receive the regular calls are higher-risk patients who may have mental health issues. Also, if surgery is more invasive, those patients are more likely to experience more pain — and are at higher risk for unintended opioid misuse.
The calls to the patient come from a transitional care nurse who works closely with surgery, anesthesia, and the primary care doctor so that there is less risk of prescription refill.
Beckstead is starting the qualitative review process for the program. She, along with colleagues including a vascular surgeon, anesthesiologist, and nurse practitioner, are evaluating the patient education and dose-tapering process. The findings will be shared with nurses, residents, doctors, and primary care doctors.
Currently, no clear guidelines exist regarding how much pain medication to prescribe for patients after specific surgical procedures. “We hope to see patterns emerge that help us validate prescriptions guidelines for acute pain for other hospitals and providers,” Beckstead explains.
For example, with patients undergoing gallbladder surgery, what pain medication should the team recommend, and how long should the patient take it? Statistics show that even minor surgeries like these can lead to opioid misuse, compared to what might be expected with more invasive surgeries, like open heart surgery, that typically are more painful for the patient.
The program is “really gratifying,” says Beckstead. “We’re really helping patients; we’ve had stories from patients, how grateful they are.”
Some patients taking chronic opioids have stopped taking them altogether. “One patient said his daughter wouldn’t let his grandchildren come over because he was too ‘out there,’” she says. “One of his great triumphs was having the kids stay overnight.”
Another patient felt “clear enough” to drive his motorcycle. “That’s the quality of life we want to give patients,” says Beckstead.
How do they get patients to taper chronic opioid medications? “We’re telling them long-term opioid use doesn’t really help your chronic pain,” she explains. “Your body gets sensitized to the opioids, so you need more. You also get hypersensitive to pain when you take opioids.”
When opioids were first introduced, they were considered “wonder drugs,” she says. “They still are in certain situations like palliative care for cancer patients and end of life. But we’re changing the mindset and culture about opioids.”
“It’s exciting,” says Beckstead. “We want to be part of the solution. It’s very encouraging seeing these results.”