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    How to reduce opioid use in post-op patients

    The opioid crisis in the United States is widespread and affects many patients—including those undergoing major urologic procedures. In this interview, urologist Francis J. McGovern, MD, discusses the scope of the problem, outlines opioid-sparing strategies, and explains what the future holds in this area. Dr. McGovern is assistant clinical professor of surgery at Harvard Medical School, Massachusetts General Hospital, Boston. Dr. McGovern was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.

     

    What is the scope of the problem of opioid abuse?

    The scope of the problem in the United States is very, very serious and it’s widespread. The first statement I’d like to make is that pain is not a vital sign. In 1996, the American Pain Society trademarked the slogan “Pain: The Fifth Vital Sign.” Soon to follow, health regulatory agencies agreed with this declaration and it contributed to a significant rise in the use of narcotics. The United States alone uses more narcotics than all other countries on the planet combined. In 2016, there were over 50,000 deaths in the United States from drug overdose, and 30,000 of those deaths are directly attributed to opioids. In the 1960s, heroin was the most common gateway to opioid addiction. That has been surpassed by prescription opioids.

    U.S. studies have shown that 20% of the opioid prescription deaths can be traced back to a patient’s specific prescribing physician. In that same study, 54% of the opioids were obtained from a relative or friend. But when they traced back one step further, 80% of that 54% were, again, traced back to the prescribing pattern of a doctor.

    At Massachusetts General Hospital, we are now seeing collaboration with other departments within the department of surgery to address opioid use. We’re all trying to get a better sense for prescribing patterns, establishing norms, and looking at ways to prevent or reduce the need for opioids.

     

    How did you get involved in this area?

    It’s been a surgical evolution. At Mass General Hospital, I have a very active urologic/oncologic surgery practice. I’m often operating 4 days a week. As operating surgeons, we all know that complications significantly affect patient outcomes. Every surgeon wants their patients to do well.

    Read: How care process models can help your practice

    Back in 2000, I chaired a committee at our hospital on the development of clinical pathways for major urologic surgery. During the development of these pathways, we dissected every aspect of care: pre-op, intra-op, and post-op. Efforts were made to standardize the pathways for all major urologic procedures.

    We’re currently using these pathways and when we first executed them, we learned that this gave us a window into clearly seeing the issues that were contributing to post-op complications and increased length of stay. We learned that there are basically two main categories of surgical complications. One is directly attributed to surgical operative events. I would put bleeding, anastomotic leaks, anastomotic disruption, and infections in this category.

    But then there’s a second, broader category of complications that can be traced to side effects from medications, particularly opioids. Medical literature is now categorizing this as ORADES (Opioid-Related Adverse Drug Events). These are opioid-related side effects including confusion, respiratory issues, ileus, and retention. These are just a few of the very common complications we see. By reducing opioid need, we would also significantly improve patient care, reduce complications, and reduce length of stay.

    I credit our outstanding residents for pointing out that most of what they do in their shifts when they’re not in the operating room involves taking care of the side effects of opioids in post-op patients. This therefore became low-hanging fruit for improvement. It’s all been done in an effort to improve care, get more optimal results, and reduce length of stay.

    Next: Key strategies to avoiding opioids

    Stephen Y. Nakada, MD
    Stephen Y. Nakada, MD, a Urology Times editorial consultant, is professor and chairman of urology at the University of Wisconsin, Madison.

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