OR Manager - August 2019 - 25

AMBULATORY
SURGERY CENTERS
that included making patients aware of
Deterra narcotic disposal bags.
To change the culture for pain management,
TCO developed a transparent
ranking system that conveyed data on
the prescribing habits of 46 physicians
for postoperative pain. Physicians were
briefed routinely, receiving monthly reports
of their progress. To gain provider
buy-in, " we never blinded the provider
names, " Uzlik told OR Manager.
Open discussions about results after
each phase of the project supported
group collaboration and buy-in for guidelines.
These discussions were intended
to promote a " healthy tension " dialogue
between leadership and physicians.
" Debates were encouraged and allowed
the team to understand why the
physicians were in the position they
were in, " Uzlik explains.
Phases of the investigation
The project's baseline phase sought
to gauge TCO prescribing practices by
procedure. Phone calls were made to
patients 2 weeks after surgery to get a
status report on their pain management
and to find out how many pills they'd
taken or if they had refilled or stopped
the medication.
Most of the 965 participants reported
wanting to hold off on, or even
decline, pain medication. On average,
patients were using just 54% of their
prescriptions, and 87% decided not to
take them because they didn't like the
effects of the drugs or had minimal pain.
The project's next phases addressed
the challenge of modifying prescription
practices and refill demands while reducing
adverse events and keeping patients
satisfied and pain-free.
Under one key measure, investigators
tracked the morphine equivalent
units (MEUs) of narcotics such as Percocet
and OxyContin (oxycodone), as
well as non-opioid pain regimens such
as Tylenol, for a host of procedures.
These included hip scope debridement,
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An American phenomenon
The US accounts for about 85% to 95%
of opiate prescriptions worldwide. In
2012 alone, physicians wrote nearly
260 million prescriptions for opioids.
Other industrialized countries have yet
to experience this type of health crisis.
Where did the American health system
go wrong? " You can't get an understanding
of where we are unless you look back
on where we've been, " says Gary Wyard,
MD, chief medical officer at Twin Cities
Orthopedics in Minneapolis. " If you
asked about opioids 5 years ago, doctors
didn't think about it. I'm an orthopedic
surgeon, and I know how this affects our
patients. But even I wasn't always aware
that there had been an epidemic. "
The epidemic was decades in the
making, Wyard says. Headlines and reports
from 40 years ago depict narcotics
addiction as a rarity despite their widespread
use in hospitals. The pharmaceutical
industry enabled the epidemic with
aggressive marketing to physicians in the
late 1980s and early 1990s. In 1996,
Purdue Pharma released OxyContin
(oxycodone), the most ubiquitous painkiller
that exists today. From the period
of 1999 through 2011, oxycodone use
would increase by 500%, and opioidrelated
deaths would rise fourfold.
In the late 1990s, pain became a new
priority among regulators. The Federaankle
scope with extensive debridement,
carpal tunnel release, laminectomy,
ORIF (open reduction and internal
fixation) distal radius and ulna, total hip
and knee arthroplasties, and lumbar
spinal fusion.
Modifications achieve results
Large variability existed in prescribing
habits. Some physicians, for example,
were prescribing four times more opioids
for carpal tunnel surgery than for
other procedures.
tion of State Medical Boards (FSMB) in a
1998 policy reassured physicians that they
wouldn't face punitive actions for prescribing
opioids, even in large amounts. Several
years later, FSMB called on state medical
boards to make undertreatment of pain
punishable for the first time. The Veterans
Administration and the Joint Commission
declared pain as " the fifth vital sign. " In
2001, the Joint Commission issued a standard
telling hospitals to regularly ask about
pain and to prioritize treatment for pain.
In 2007, the pendulum began to swing
in the other direction. Purdue Pharma
and three executives pled guilty to " misbranding "
of opiates as less addictive
and less subject to abuse than other
pain medications, paying $635 million in
fines. Several years later, opioids began
to dominate headlines, and federal agencies
began to document statistics and
issue guidance on opioid prescriptions.
In 2016, the Centers for Disease Control
and Prevention issued guidelines on
prescribing opioids for chronic pain. Although
this appeared to set some parameters,
the same guidance also suggested
prescribing opioids for acute pain.
The fundamental issue with pain is
there's no thermometer for it, Wyard says.
" Standards are unreliable. And no one
ever underestimates pain-they always
overestimate it. "
After this practice was discovered,
the number of pills prescribed per patient
across all procedures declined
considerably: from 41 to 16 pills on
average over the course of the project.
Overall, prescribing quantities and refills
decreased by more than 9% and
9.4%, respectively. At 2 weeks after
surgery, average pain levels for patients
declined by 13.6%. Patient satisfaction
remained high, with average scores of
Continued on page 26
OR Manager | August 2019 25
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