A transitional pain service nurse program that uses case management can help reduce opioid dependency and provide better pain management, following these techniques:
• Identify at-risk patients. “We try to identify patients on chronic opioids as soon as they’re indicated for surgery,” says Michael J. Buys, MD, anesthesiologist and section chief for acute pain service at the George E. Wahlen Department of Veterans Affairs (VA) Medical Center in Salt Lake City. Also, they identify patients with severe anxiety or depression and a history of active or prior substance abuse. These patients tend to struggle with pain after surgery, Buys adds.
• Educate extensively about pain presurgery. “We meet with patients to educate them about what to expect with surgery and pain after surgery,” Buys explains. “We discuss pain medication and opioids and set up the expectation that opioids are only to be used for severe breakthrough pain.”
Staff also educate patients on alternative pain treatment. Patients meet with the psychologist, who provides support with pain coping mechanisms, identifies underlying issues related to pain, and helps with nonpharmacological solutions and pain therapy.
“We don’t do pain scores anymore,” Buys says. “We talk about pain function and how it’s important to get rest to heal and to do physical therapy and, if they have thoracic surgery, to take deep breaths and cough.”
The transitional pain service team’s goal is to help patients understand they will not be pain-free right after a procedure. Still, opioids must be used only in the short term. “If patients are struggling after surgery, we remind them what we told them before,” Buys adds. “So much is going on, it’s hard for patients to take it all in at one visit. We contact them and reinforce the education.”
• Require opioid taper before surgery. The team helps patients taper opioid use before surgery. “We require a 50% reduction in opioids prior to doing surgery on them,” Buys says.
At the time of surgery, the program includes a multimodal analgesic approach: preoperative Tylenol, anti-inflammatory medication, and Lyrica. Patients receive anesthesia and a nerve block during surgery, and then continue with a nonopioid multimodal medication after surgery.
“Opioids are for breakthrough pain,” Buys says. “They should take opioids for severe pain, and then stop it, depending on the kind of surgery, usually 10 to 14 days after surgery.”
• Provide consistent follow-up. After a procedure, the transitional pain care team calls patients two days after, one week after, three weeks after, and then monthly for three months.
“We make the first call at two days after discharge, whether they’re hospitalized or go home the same day,” says David Merrill, RN, BSN, nursing care coordinator for transitional pain service at George E. Wahlen VA. “We feel like the second-day call and the seven-day call are extremely important. We provide an RN to phone the patient and answer questions about their post-discharge instructions. What we mainly find is what patients hear and what they’re taught are not the same thing.”
For instance, some patients will take their pain medication every six hours, regardless of whether they need it, instead of every six hours, as needed, Merrill says. “We give them education and guide them to a better outcome right from the beginning,” he adds. “We’re also successful in following up with questions they have.”
Usually, the team will know if the patient is struggling by the third week after surgery, he says. “If we see a patient not yet coming down or tapering off opioids, appropriately, then we’ll involve one of our nurse practitioners or consult the clinical psychologist for help, as well as Dr. Buys,” Merrill explains. “We meet weekly as a group to talk about the case and to understand where patients are.”
The calls and follow-up continue. Those with chronic opioid use are contacted more frequently. “If they’re struggling with pain and not off opioids, we call them weekly,” Buys says. “If they’re off opioids, we follow up with them at least monthly.” Initially, the transitional pain care program was for orthopedic patients undergoing total joint procedures. “After we saw the success we had with these patients, we brought in surgical specialties, any elective surgery,” Buys reports. “It’s a mixture of inpatient and outpatient surgery.”
• Meet weekly to discuss cases. “From the very beginning, we established a weekly interdisciplinary pain board meeting to talk about pre-op patients and post-op patients,” says Kimberlee Bayless, DNP, FNP-BC, APRN, nurse practitioner in acute pain service and director of transitional pain service at the George E. Wahlen VA. “We talk about pain plans and discuss the post-op patients that have not started to taper medications at that 21-day postsurgery.”
The team also discusses patients who report chronic pain. For instance, some patients who come in for total knee replacement might also experience chronic back pain, she notes. “We address other pain complaints for them,” Bayless explains. “Anesthesiologists, certified in chronic pain, have started to address what other modalities and medication could help with pain, without opioids.”
The team talks about provider appointments for which the transitional pain service team needs to be involved, Bayless adds. Sometimes, the team might make suggestions to primary care providers about interventions that could help patients. “We have developed a dashboard that helps with our tracking patients and providing care coordination,” Bayless notes.
(Editor’s Note: For more information on this topic, please read the June 2019 issue of our sister publication, Case Management Advisor, at this link: http://bit.ly/2RHOF8I.)