Taking Action Summit: Postoperative Narcotic Prescribing
Hello everyone. Thank you for joining us here if you are in person and thank you for joining us in our virtual component. My name is Catherine Connolly and it is an honor to facilitate for today's session, which is going to be "Post-Operative Narcotic Prescribing," and that is going to be held by Dr. Jacob Moalem.
He is a Professor of Surgery and Endocrinology, and the Director of Quality Improvement for the Department of Surgery at the University of Rochester Medical Center. Dr. Jacob Moalem is Professor of Surgery and he also serves as the Director of Quality Improvement for the Department of Surgery at the University of Rochester Medical Center. Along with his clinical work, Dr.
Moalem has authored many peer reviewed publications and textbook chapters, and presented research at national meetings. A recent study he led of an opt-in prescription system for patients undergoing certain ambulatory procedures, found that empowering patients successfully reduced the need for postsurgical narcotic prescriptions. Dr. Moalem continues to lead work in the area of postsurgical prescribing and is implementing an innovative program to systematically reduce opiate prescribing.
If you could please join me in welcoming Dr. Moalem to the stage and give him a round of applause. (Catherine claps) (audience claps) Thank you.
- Thank you so much. Good morning and thank you so much for the privilege of this podium and for the opportunity to share our team's work on opioid stewardship. It's a real honor to participate in this program and a privilege to discuss our efforts to date. I think it's really noteworthy that our president concluded his most recent State of the Union address with a very carefully crafted four-point unity agenda.
In this plan, the president and his team selected out for discussion, really the only issues that they believed that our entire country could unite around that needed to be addressed immediately, and how fitting is it that opioids made the top of this list? The reason for that is that we have a massive problem in this country. There's an incredible number of Americans who suffer from opioid use disorder, a disorder which now accounts for more than two-thirds of all overdose deaths in this country. We also know that the overwhelming majority of heroin users began their addiction story by abusing prescription opioid medications, and that only a minority of these victims were actually the legitimate recipients of the original prescription.
The vast majority of these individuals actually received these medications through diversion, most often from very well-meaning family members, friends, relatives, neighbors, anyone that these people would have access to, but the one thing that they all had in common is they all had a few extra pills from a recent operation, which is an experience that I think anyone can relate to, myself included. This story is very, very complicated, and I don't mean to summarize the history of it in one slide, but it really does all begin in the early 1990s, when we all started paying much more attention to postoperative pain: monitoring it, measuring it, and being evaluated by it.
In 1996, pain became an official vital sign, first adopted by the American Pain Society, but then later by the Joint Commission as we heard about before, and this led to a marked explosion in direct-to-physician and direct-to-patient advertising by drug companies that often hid data related to addiction potential of these medications. Some of the data that they shared with us regularly at all these lavish lunches and dinners, were just outright falsified, but this led to an incredible rise in prescriptions. And when you couple that with the explosion of pain centers and pill mills, particularly in the southeastern and southwestern United States, access to these medications was incredibly easy.
You could easily get prescriptions for 100 or 200 pills of oxycodone without any form of a physician-patient relationship and without any oversight and without any accountability. So the number of addicts across this country began to skyrocket, and then when you mix in the fact that these brand new, novel fentanyl analogs, some of which were incredibly potent, were flooding the streets, these were much cheaper than prescription medications, but what addict could control effectively and dose accurately, a medication that is 10,000 times more potent than morphine? So young Americans are literally dying by the thousands, and that trend continues today.
Just to balance out the politics, I have to bring old President Trump onto the scene, and when he declared the opioid crisis to be a public health emergency, this was not a hyperbolic statement by any means at all. This was a reflection that for the first time, the United States enjoyed the dubious distinction of having the lowest survival rate among all wealthy, high income developed countries in the world. The other thing that you see on this graph here is that America in the red line, as compared to all of the other highly developed countries, is beginning to see a dip in the life expectancy.
This is a national trend and here's why. In the rest of the world, there was a little bit of an increase in the death rate among the elderly individuals in their populations. This was because of a flu which was particularly virulent during this time period. But in America, you saw a different thing.
What you started seeing is young Americans dying, typically in their twenties and thirties, and this is because of opioid overdoses, to the point where now opioid overdoses is the leading cause of death in young Americans, particularly young males, typically dying in their twenties, and it's this rising death rate that is responsible for a decrease in the overall life expectancy of all of us Americans, which is a catastrophe. I think I can comfortably say that most of the conversation, most of the funding, most of the attention focuses on the right side of this, on treatment of opioid use disorder, but there's actually been precious little attention paid to the left half of this, and it's my job here today to convince you that primary prevention of this problem is actually where you get the best bang for your buck, because if we can prevent people from accessing opioids in the first place, then we can stop the entire train before it leaves the tracks.
This is one of the most influential studies. It was actually published only five years ago, a study done by the CDC, which shows that among 1.3 million opioid naive individuals who were exposed to opioids for as little as one day, there was a very real likelihood of persistent opioid use at one year and at three years. So one year after the initial exposure, the incidence of continued opioid use was actually 6%, and at three years it's 3%.
And not surprisingly, the longer the exposure to the drugs initially, the higher the likelihood of maintaining opioid use after the initial exposure. That study and a few others have prompted the development of opioid reduction initiatives across the country, and by far, the most well developed is in the state of Michigan, where the Michigan OPEN Network is a very large public-private collaboration with hospitals, insurance agencies, payers, and treatment centers, and this consortium has now generated a massive amount of very, very high quality data, but also benchmarks and prescribing recommendations nationally, which we all can use and make reference to in our own practices.
And a lot of what I'm gonna present to you is gonna come from this Michigan group, like this study, which looked at patients, close to 60,000 patients, that underwent inguinal hernia repair, a very common and ostensibly innocuous operation that all of us know someone who's had a hernia fixed. Well, we now know that 1.5% percent of all of these patients continue to use opioids even a year later after this operation. And what these authors various duly discovered was that the biggest risk factor of continuing to use pain medications more than a year out was having the prescription given to the patient before the operation even takes place.
So the physician, and unfortunately, it's most commonly the surgeon, is setting an expectation that, oh yeah, you're absolutely gonna require the pain medication, so let me make sure that you have it before the operation even takes place. Another study looked at slightly more invasive surgeries, or much more invasive surgeries in the form of cardiothoracic surgery, and you see that the more prescription medication the patient receives upfront or immediately after the surgery, the higher the likelihood of opioid use disorder even a year out from from the operation, and all of this is summarized in this slide, which unequivocally shows that no matter how big or small the operation, no matter if the operation is on the GI tract or on the colon or on the biliary tract, on a child or on an adult, for cancer or for benign disease, there is a real population of patients that are going to continue to use narcotic medications for far longer than their surgeon anticipates or expects, and that's something that we all need to pay much, much more attention to.
This study also out of Michigan is probably the highest level of evidence that we have about why, although multiple other studies have replicated these findings. What the investigators did is they called back 2,400 patients who underwent 12 representative procedures to see what they actually required and used after their surgery. And when you compare what they received in the green bars to what they actually needed and used in the lighter green bars, you see that there's an enormous discrepancy. Way less than half of the pills that we prescribed were necessary for these patients, and about one out of five patients took the entire prescription, which actually makes you wonder why they did, because you look at the size of the gap in between what most patients received and needed, that gap is massive.
The other major finding out of this study was that it wasn't the kind of procedure that the patients had or the approach, whether it was open or minimally invasive, or even what their pain level after the surgery was that best predicted how much narcotic the patients took. The single best predictor of how much pain medication a patient takes after an operation is how much pain medication they receive from us. Again, strongly speaking to the power that we have as surgeons in setting proper pain expectations and putting them in a frame of mind where they might actually need much more than they actually do.
This is a fascinating study. This consortium looked at very common operations like appendectomy, cholecystectomy, which is removal of the gallbladder, and an inguinal hernia repair, that were done in any of 18 major academic medical centers, three of which were in the United States. One was at the Mass General Hospital, another was in Johns Hopkins, and the final one was at the University of Arizona in Tucson. And what they did was compare the amount of narcotic medications the patients were going home with after these very common operations in the U.S. versus everywhere else in the world.
The results were shocking. Non-American patients all across the globe after these operations were going home with less than one oxycodone pill on average after these operations. You have that exact same operation here in the United States, and the average prescription in these major medical centers is 23 pills for the same exact surgery. They took it a step further.
They looked at the pain scores of the patients, and here in America after these operations, the average American will perceive their pain level to be a four after the surgery. But you ask that same question of a non-American and their average pain score after this is one. Whoops. Firing away.
One. A subsequent paper written by the same group focused on the relationship between the amount of pain that patients report and the prescriptions that they receive. If you look at the bar on the left, non-Americans who report no pain after surgery get no medicine after surgery. But four outta five American patients did receive a pain medication prescription after an operation from which they said that they had no pain.
And if you look at the two bars in the middle and on the right, you see the degree to which the patient reported pain influenced the kind of prescription that they get. Here in America, almost no relationship, that is almost a straight line across. There are no statistically significant differences in any of those four bars, whereas in the rest of the world, the more pain you have, the more medication you get. But if you look at the scales, you see that even with severe pain, non-American patients are receiving pain medications for a day or two max.
Here in America, the scale goes up to 40 tablets. That's enough for a week. It breaks my heart to say that I don't have an explanation for that at all, other than to say that here in this country, we do have a culture of over-treating every complaint. And very often, there needs to be a pharmacological solution for something that is actually physiologic and normal, and that's something that we're here to change as part of this conference.
So my own involvement in this and my own interest in this started many years ago when I learned, and actually when I proved, that I was part of this problem. We led a study together with our colleagues in the University of Washington-Madison, not the University of Washington, the University of Wisconsin-Madison, where we can essentially just, we tracked our own prescribing behavior and what our patients needed. And what we found was that the two institutions were wildly different. I was giving all of my patients 20 pills after a thyroidectomy and parathyroidectomy, the folks in Madison really didn't have a protocol across multiple surgeons who were doing the same types of procedures, but we learned very clearly that the majority of the patients didn't require anywhere near what we were giving across both institutions.
You see 70% really took zero to three pills, and from my patients, almost half took no pills. But the other thing that was really shocking to me is we asked patients why they took the pain medication, nearly half of them took them for reasons that you would never consider using pain medications for. Like taking it just in case to make sure you have a good night's sleep. Like taking it because usually it's women having the surgery, so the husband says, you know, oh, just take it and make sure you have a good night's sleep.
You'll have a sore throat. Discharge instructions sometimes indicate that you should take it for mild pain. And so back in 2017, we set out to really change our prescribing habit, and we thought that if we educated our patients enough about the findings from the previous study, at least some patients would opt to not take any narcotic pain medications to home. And without belaboring the nuances of the study and the methodology, I'll bring you right to the results.
I was blown away, I am still blown away now when I look at these data that show that 96% of patients when given a choice after these kinds of surgery chose to go home with no narcotic medications whatsoever. 96%. So we went from this pattern, where here you see in blue, every patient going home with 20 pills of narcotics after surgery and the green is what they actually took. So you see there's very little green shading on that bar on the left, and maybe 75% of the pills were taken, to then doubling the number of patients and sending home a fraction of the narcotic medications, as you can see on the bar on the right.
Putting it all together, we were able to reduce our prescribing by 97% just by giving patients a choice. And so in six months, we saved 4,100 and some odd pills from hitting the medicine cabinet shelves here in Western New York, and leaving them in the pharmacy where they should probably stay. So there are multiple takeaways from this and you can read them for yourself, but the main takeaway for me was that as I was talking to patient after patient about the benefits of potentially going home with no narcotics, they all would shut me down because actually none of them wanted it in their home in the first place.
And they would just tell me to save my breath because if they had a choice, even before the conversation ever started, they would do anything to avoid having these drugs in their medicine cabinets if they could. So I'm very proud to say that our department, about three or four years ago, set out to reduce narcotic prescribing across the entire department, and right around that time, I was asked to take over the quality improvement effort for the department, and so this sort of became my project. And in thinking about how I was gonna structure this, it became very, very clear to me that there was not gonna be any way to meaningfully do this unless we really understood the prescribing behavior of all of our surgeons across our network.
I thought right up front that a good place to start would be to help prioritize the prescription of non-narcotic medications, and I suspected that we would find significant variability across prescribing behaviors of different surgeons, and so standardizing was gonna be a big part of it, because a big premise in quality improvement efforts across the board is to define variability, and as you bring people closer to the mean, invariably, you improve performance and you also reduce waste. In this case, it's not really cost, although it is cost of lives. So what we did is over many, many months, we were able to cobble together two major databases.
And so we created this clinical pharmacologic database that had about 750,000 data fields for patients that were treated over a calendar year. This included demographic information, the information on the prescription that they had, who the surgeon was, who discharged the patient, all of their prescriptions that they received in the hospital, as well as their pain scores. I personally cannot express enough gratitude to Alexa Melucci who's on the right, and Olivia Lynch who's on the left. Alexa is one of our research residents who is absolutely outstanding, and Olivia is outstanding in her own right.
She recently just graduated from our medical school and is actually now already in Boston. She will begin her general surgery residencies at the Brigham and Women's Hospital in Harvard. These two superstars really undersell their contribution to this. Took one look at this database and realized very, very quickly that we were not gonna be able to make any heads or tails of this unless we really tried to focus in on some representative procedures.
And so with their advice and in consultation with some of the divisional leadership in the hospital, we settled on 18 representative elective procedures that we could really focus on and analyze deeply, and leave the rest of it on the outside, understanding that if these were truly representative, which we later proved that it was, the findings from these operations would be translatable across the rest of the department. And so we focused on adult patients who were opioid naive before this intervention. And in total, this amounted to procedures representing six of our divisions in the hospital and nearly 1,500 patients.
From there, we branched out and they analyzed data for hundreds and hundreds of other patients, as I'll show you in a minute. And the first question that they asked was, was there a drug of choice in the department? And very quickly we saw that oxycodone five milligrams was by far the drug of choice, and that it, and its derivative, so maybe 10 milligrams or with or without Tylenol, accounted for nearly 90% of all the opioid prescriptions from our department. And so what we did from this point on is converted everything, all of the narcotic prescriptions, IV and otherwise, to the language of oxycodone five milligrams, which we, as surgeons, can really understand, as opposed to morphine equivalents and things like that, which most people who aren't in this business don't really relate to very well.
The next thing that we did is we looked at the actual prescription behavior, and here is a snapshot of the entire department. And what you see right away with a number of prescriptions of pills that patients are going home with after surgery, is there a laser? You can see that the spread is massive, but you also see that the number that is most commonly represented, the mode here, is actually zero pills. So we're doing a great job in some cases of sending patients home with nothing, but you also see that the difference between open and laparoscopic surgery, for example, is actually not that large.
And then we did these kinds of analyses according to every possible predictor that we could think of that might drive this prescribing behavior. We'll focus on laparoscopic cholecystectomy, which is the most common operation that we do as surgeons. It's interesting because this is an operation that at Strong, well, in our department, we do in three different environments in three different divisions, and you see that, again, for a very standardized operation that is typically very quick, outpatient, you see the patients are going home with anywhere from zero to 75 pills over that calendar year, and depending on where you have it, the prescribing behavior of the different individuals, the surgeons, the residents, and APPs who are sending the patients is all over the map.
And then you compare this graph to what we know from the very high quality data from Michigan that shows that more than 50% of patients do not require more than three pills, and that their recommendation for discharge is actually no more than 10 pills, and you superimpose those recommendations on our prescribing behavior, you see that a full third of our patients are going home with much more than the maximum that is recommended by these national benchmarks. So there's a significant low-hanging fruit here, a real opportunity to save thousands of pills with just one operation, and that's if we shoot for a low bar.
What if we shoot for the bar that would satisfy, we know, 75% of our patients and make that the median of our prescribing? Now we're approaching 10,000 pills that we might be saving just by making one shift in education. Another piece of very low-hanging fruit that they identified, or we identified together, was that of the original 1,400 patients, nearly 300 reported pain scores of zero in the last 48 hours of their admission. Those same patients also required no narcotic medication during that same 48 hours just prior to discharge.
Inexplicably, about half of the patients went home with a prescription for narcotics, often decent amounts of medications as well. You can see here, up to the equivalent of 75 pills for one patient. And so from very extensive analyses, and I've shared only kind of the tip of the iceberg with you, we've learned that there's very significant heterogeneity in the discharging behavior of surgeons, which is exactly what we expected to find, but we also found significant opportunities for improvement here, and so that drove us to take this to the next step, and we did that in the division of colorectal surgery.
And the reason why I picked colorectal surgery is because here, we have four different procedure categories that have actually decent number of patients. It was interesting that even at baseline, this division was performing better or at the standards that were recommended by the Michigan Consortium. And the reason that was very important to me was because I didn't wanna realize gains in a division that was not high-performing at baseline because that could be easily discounted, but if we could achieve reductions in a division that is already doing a very, very good job according to national standards, then that would be something that we could hold onto and easily, more easily take to the rest of the department.
And so what we did was we used those medians from our initial analysis and just simply set those as prescribing targets for our surgeons and for our APPs. We then made these badges that go on the back of the ID tags for all of the residents and for all of the advanced practice providers as a reminder that those were the prescribing targets, and on a monthly basis, Alexa would make a dashboard for the surgeons and for the staff in this division. And really the place to focus on is over here, is using this stoplight type of a model, what we see here on the left is that just prior to the launch of this trial, what you see is a nice bell-shaped distribution here, with about a roughly equivalent number of patients that were going home with fewer than the target prescription, there's a good number of patients that are going home with more than, and then a small number of patients that are going home with a prescription that is right on target.
But you see as that panel scrolls over to the right, that there is a rapidly decreasing number of patients that were going home with more than what the recommendation became. Very, very simple intervention. When we put it all together, you see that over the course of a calendar year, we reduced the number of narcotic medications that were prescribed by this already high-performing division by 50%. And we increased the number of patients that were going home with no narcotic medications whatsoever, and this is after resections of the colon, resections of the rectum, or procedures that involve the creation or the manipulation of colostomies and ileostomies.
We increased the number of patients that were going home with absolutely nothing by way of narcotic medications, again, by another 50%, all without an increase in refill requests, just by patient education. If you look at the individual procedures in the table on top where you look at the all patients line, which is kind of bolded for you, you see that the median across all patients went from 10 to two-and-a-half or two-and-a-quarter pills per patient. And so we're now taking this to the entire department and I'm very proud to say that the initiative that we actually just began launching this month is incredibly comprehensive in that it addresses the patient, it addresses our nurses, it addresses the surgeons, and the residents, in a very comprehensive package that includes very extensive educational initiatives, intervention tools, a lot of tracking methodology, and we've overcome a large number of barriers, and I'll take you through some of this already in the next few slides.
In the middle of the screen here, you see is a poster that actually was just delivered to my office yesterday. These are going to be mounted in every patient care environment that we, as surgeons, have. So patients will begin to see these in our clinics, they'll see them throughout perioperative services and in the recovery room, they'll also see them in the hospital rooms. And what these do is they begin the conversation around expectation management after surgery.
They emphasize that some pain is a normal finding after surgery and is to be expected. They also emphasize that our target for pain management is not a pain-free world. It is a pain level through which patients can comfortably function. It emphasizes the importance of over-the-counter medications like Tylenol and ibuprofen, and then finally, explains the appropriate role that narcotic medications can have.
And on the bottom of this, there's a reminder that these medications are never to be shared, that they're to be disposed of safely, and then this QR code. And that QR code will lead patients, their support network, their family, and their loved ones, to this video which we produced a little earlier this year. (upbeat music) - Comforted.
- Cared for.
- This is what we strive to deliver for every patient.
- As a surgical department, and also as an institution and healthcare system, we are all committed to keeping you comfortable and safe, both inside and outside of the operating room.
- A few years ago, the prevailing philosophy in medicine was to try to completely eradicate pain, often using large amounts of strong narcotic medications.
- But many recent studies, including some done by members of our department, have revealed that most of the narcotics prescribed to surgical patients were unnecessary.
- We now also know that narcotic medications may actually delay your recovery from surgery by causing nausea, delaying the return of bowel function, and making you feel groggy.
- Even worse, we also learned that across our country, those excess medications actually increase our risk of narcotic addiction and dependence, not just our patients themselves, but to other members of the community who gain access to these drugs through various means.
- It's our responsibility as your surgeon.
- As your inpatient surgical team.
- As your outpatient surgical team.
- As your nurse.
- As your pharmacist.
- As your advocate.
- To reduce all these risks, while continuing our efforts to keep you comfortable after surgery.
- Surgery causes pain, but with the appropriate mindset and tools, we can manage it very effectively, while minimizing need for strong narcotic medication.
- The first step is to acknowledge surgery will cause some discomfort and that some amount of pain after surgery is normal and to be expected.
- Both in the hospital and after discharge, we should not aim for a pain score of zero, or take narcotic medications just in case.
- Our goal is to reduce your pain to a level which allows you to function normally. For most people, this is the equivalent to a three or four on a 10 point pain scale.
- Various non-narcotic medications like Tylenol and ibuprofen are very helpful in treating postoperative pain and reducing your narcotic requirement, and should be preferentially used in patients who do not have liver or kidney dysfunction.
- Patients who are taking blood thinners after surgery should ask their surgical team if it's safe for them to take ibuprofen or a similar non-narcotic medicine.
- Local pain control tools such as use of lidocaine patches, ice, or heat, can also be used in some cases.
- For severe pain that's not manageable by these other approaches, we'll, of course, prescribe narcotic pain medications to you.
- It is important to emphasize that nearly all of our patients who have surgery will require at least some narcotic medicines during their care, and that appropriate and judicious use of these medicines is critical to your recovery and is not harmful.
- Our goal is to work with you to minimize excessive narcotic prescriptions and to give you the right amount of these medicines such that your pain can be reduced to allow for normal function, but not be completely eliminated.
- If you have unused narcotic pills after recovering from your procedure, we strongly encourage you to safely dispose of them.
- You can bring your unused pills back to some pharmacies, including our pharmacy at Strong Memorial Hospital, and drop them off no questions asked.
- Throwing medicines, including narcotics, directly into the trash or flushing them down the toilet is not the safe or proper way to dispose of extra pills of any kind.
- We thank you for allowing us to care for you. Working together, we can keep you comfortable and safe, and also do our part to reduce narcotic overuse and over prescription. (upbeat music) - So that video and the clinging poster that you saw have been really the cornerstone of a massive educational program that we've deployed for all of our perioperative nurses, and we hope will extend out to patients and their families very, very quickly. The next thing that we did is we took all the data from all the analyses that we talked about, brought them back to the individual surgeons, and set new prescription targets across all procedures.
Those are way lower than they actually were, even after our analysis, and have now been printed on ID badge tags, which are distributed to all of our residents and advanced practice nurses. Finally, we've made four novel changes to the electronic medical record, which we believe are gonna be incredibly helpful for docs and prescribing providers to do the right thing. And the first thing that's gonna happen when a patient is being discharged on narcotic medications, is this reminder to discharge the patients with acetaminophen or ibuprofen as a first line agent, with just a single click. The
next thing that's gonna happen is the EMR will be queried and a summary table will be displayed of all of the narcotic administrations that this particular patient has required during their entire hospitalization. This will allow a discharging provider to make a much more informed decision about how much narcotic medications to send our patients home with. Additionally, we've prepopulated prescription amounts with amount targets, amount quantities that are consistent with our prescribing targets, as well as this reminder on top in red that patients that are gonna go home with a much larger amount than is typically required, that those patients should be considered for a prescription for naloxone, which I think will be an important reinforcer for discharging providers, that there is a dark side to giving patients just a few extras just in case.
And then finally, if the patient who is currently being discharged did not require any narcotic medications in the 48 hours prior to discharge, this best practice advisory will come up, which will require that the discharging person provide written justification for why they think that this patient that hasn't required any pain medication in the last two days, all of a sudden might when they go home. In addition, that same dashboard that Alexa painstakingly put together by hand every month for the colorectal surgery division is now being automatically populated, where we just need to set in the search criteria, and then this report gets automatically generated every month to be shared with divisional leadership, with individual surgeons, and with anybody who wants to know how they're prescribing behaviors compare to their peers, but also to national benchmarks.
And then finally, for patients who are going home with larger narcotic amounts than what we typically recommend, we're proud to start sending patients home with these Deterra enzymatic deactivation bags. These are essentially fancy Ziploc bags that have some coffee grounds and some other chemicals in them, that make for a very effective, very quick, very environmentally-friendly way of disposing of any prescription medication, including narcotics. And so this is a very confidential, inexpensive adjunct which we have now incorporated into our stewardship model. And so when you look at this thing in aggregate, there's several things that make it relatively distinguished, well, actually very distinguished.
First, it is by far the most comprehensive program that is out there. Most published initiatives that other departments have done have employed one or maybe two initiatives, we've got many that are being unrolled all simultaneously. The other things that make it very unique is that it addresses every single stakeholder in the chain from the patient themselves and their family, to our nurses and the surgeons. And finally, this is the only program across the country that I know of that begins to start the conversation before the patient ever comes in for surgery, continues the conversation through their time in the hospital, and follows them after discharge.
And so we're very, very optimistic that we will meet our goal of 20% very, very easily, and actually, far exceed that expectation. In terms of next stops, we're continuing to work with our colleagues in information systems to be able to harness even more powerful data. And so here is the view of our entire system, and you can see that over the last several years, we've prescribed 1.4 million tablets of narcotic medications with a couple of dips that correspond with COVID one and COVID two.
We can filter this by different specialties, and you can see that orthopedic surgery, as you might expect, is the highest user of narcotic medications, but we can also filter it by demographics so that we can begin to understand whether gender, socioeconomic status, the place where the patient lives, have any impact on prescribing behavior, and begin to intervene on those levels as well. Looking back to the individual specialty, so here is orthopedic surgery, we can see by these dot plots that there's some procedures that are high utilizers of pain medication and others that are lower utilizers, and if we click on that top dot, which corresponds to knee replacement surgery, you can actually even see the individual surgeons who are performing that surgery.
Some of them are way over on the left, prescribing much more than average, and others are over on the right, and so this is an opportunity to start sharing best practices and improve everyone's performance across the board. Beyond Strong Memorial Hospital, and I think of great interest to the attendees of this conference, is the fact that in rural America, the magnitude of this problem is actually much more severe. There's much greater need for interventions related to narcotic use. There's much fewer, or way fewer resources to deal with addiction problems, and this problem is almost entirely unstudied.
We're in the process of applying for an RCORP grant to help fund an initiative that will take a lot of these initiatives down to our three hospitals that are more rural, and we're hopeful that with these very intentional interventions, we will begin to make a dent, not only in the city of Rochester and the surrounding areas, but also heading a little bit further down into the region. I really have to acknowledge the medical faculty group of the U of R that supported the initial work on this study with a grant. Michelle, who is sitting here, who has been a real champion of this effort, and her entire team.
In the Department of Surgery, again, Alexa and Olivia have done an incredible amount of of work on this, but also a lot of support from Liz Levatino, who directs the QI effort, and a lot of inspiration from Doctors Linehan and Temple. Dave Linehan is our chair. The ISD Department at the university has been incredibly supportive in helping us create these dashboards and analyze this data. And finally, the Quality Institute at the U of R has also been very, very supportive of this work.
And so with that, again, thank you so much for this privilege and for the opportunity to share some of our work with you. (audience claps) - [Catherine]
Thank you so much, Dr. Moalem. We do have a few questions here, and, of course, if you have questions in the audience, feel free to step up to a mic. But our first question is, "How do you respond to people who are concerned that making it harder to get prescription medication will lead people to use illicit opioids?"
- I think that, well, there's two parts. First of all, no one is trying to make it harder for patients to receive the narcotic medications that they require after surgery. There is no intention here to restrict any surgeon or any resident's ability to prescribe narcotic medications when they need it or when their patients need it. The whole goal here is to define the gap between what patients actually require and what we have been giving patients, and that gap is very often very extensive, and to reduce it.
It's interesting to me that when we look at our own data, the prescriptions that were the greatest in size, and we're talking about several weeks worth of narcotic medications, were often given to patients that had the most contact with their physician staff in their immediate postoperative period. So it's not like this is someone who's being sent out of the hospital and not being seen again for two months. These are patients that we're seeing literally every three days or every week, so there's plenty of opportunities for longitudinal care and to continue to provide them additional pain medication if they need it.
And so that's our goal. And in terms of the idea that not having narcotic pain medication prescribed would lead to illicit use, I suppose that that's a possibility, but the reality of it is, is if we do our jobs right and help anticipatory guidance for our patients, that the likelihood that that would happen is actually extremely rare. I don't know that that's ever been formally studied, but that's my take on it.
Thank you. We have a question from the crowd. Michelle?
- This is phenomenal work.
- And very comprehensive work. And I just wanna remind folks, particularly those that may be online, that if they are interested in knowing more about the work or how to implement it in their community, that they can reach out to the UR Medicine Recovery Center of Excellence, but I wanna ask you another question. You talked a lot about surgery and there are a lot of prescribing that is going on in neurology and some of the more medicine-based areas around pain. How do we get the same message out to our medicine colleagues?
- I think that the message is out there. I think that it is being received. I am extremely fortunate to say that I have by far an easier job than they do because the insult that we inflict on our patients that causes pain is often very reproducible and also very finite. So you have an operation, you'll have some pain afterwards, but you know that that pain is going to improve.
Patients with chronic conditions that cause pain are an entirely, face an entirely different challenge, where often the best we can do is control the pain, but you expect that in many cases it'll be a chronic condition for which there is no cure. So I think that the best advice that I can give is that if there are patients, the interventions will have to go through a pain treatment center. Yeah, I just, this is...
We're talking about an entity that is so dramatically different than what we have been approaching. The U of R is very interested in working on this. There's a large task force that is dedicated to that. Far more challenging, far more challenging, but I will say that the understanding that we need to do better in reducing opiates is there.
There are certainly alternatives. Those alternatives don't work for everyone, but I am far from an expert on the chronic management of chronic pain conditions. That is just not my training or expertise.
All right, we have another question. "What obstacles have you faced when implementing this program and how did you navigate them?"
- So I thought that a big obstacle was gonna be the culture. When I was a resident, every patient that went home, went home with 40 pills of oxycodone to start for a gallbladder, and it went up from there, because god forbid, the surgeon would get a call in the middle of the night that their patient was in pain. That's how I grew up as a surgeon, and many surgeons grew up exactly the same way, but to my surprise, there was absolutely no resistance from the surgical staff, from any of the surgeons, or from the residents. The residents are actually even way ahead of us old guys.
The biggest challenge was actually making sure that the data that we had had appropriate fidelity. You know, anytime you use a large institutional database, and this one had nearly a million fields, being able to collect the data in a way that is meaningful, is accurate, and is actionable, was actually very, very difficult, and I am so grateful to my colleagues in ISD who really took this project and gave it the appropriate level of seriousness and attention so that we can get this job done.
Excellent, just one more here. "Could you tell us more about the methodology around the data analysis in the narcotic reduction pilot? Has this research been published, and if so, what is the publication information?"
- So both of those studies have been published. The more recent study was published in a journal called "Annals of Surgery," which is one of the highest impact factor journals there is in our field. The methodology was very, very simple. Once we had the results from the first study, which showed that that half of the patients took no narcotics, and most of those who do or many of those we did, took it for reasons that were not, we thought, valid, I held some educational sessions with the nurses in the recovery room so that they would begin giving the message to patients that there is a strong possibility that they're not gonna require any pain medication, which was a very different thing than they had been telling patients.
And then in the office, like I got a whole write up that I would give patients, my nurse practitioner would do the same, and we really tried to emphasize that this was an operation from which patients really had very little pain. We use a nerve block before we make the incision, and patient after patient are very surprised by how little pain they have postoperatively, but really, we found that all of this work to kind of reset expectations was superfluous because patient's eyes just would light up when you offer them a choice to go home with no narcotics. And that's not every patient, but it was a huge number of patients who just had no interest in taking this stuff home with them.
And on that same vein, "Does your data look at all prescriptions or just by the surgeons? Thinking about cancer patients who may need opioids after surgery, who may be getting a prescription from other clinicians."
- So these are all postsurgical patients who are discharged after being admitted to one of our services. So that was kind of the way we defined our patient population.
Okay. "And then as part of the pre-admission process, do you screen or ask patients if they have a history of substance use disorder? If not, do you screen patients for patterns of compulsive impulsivity or other related psychology factors related to addiction?"
- I have to expect that the rigor with which that kind of a screen is done is highly variable across our department. You know, those are fields, and when we do our analyses, we try to concentrate our analysis on patients who are opioid naive, but we have certainly in our dataset and the things that we look for, are history of anxiety disorder and other predictors of narcotic use. How accurate all that data is when you translate it to an entire surgical department and an entire population, I have no idea.
All right. And then you mentioned that rural areas may have fewer resources to implement some of these best practices. Do you think there's a possibility for these practices to be adapted to be less resource intensive?
- So the interesting thing is that these interventions, with the exception of capturing the data in the first place, are actually not resource intensive at all. For an entire year, my resident and I, and our medical student did it, you know, after hours and on Sundays. So, you know, the resource requirement for this is really just education and collecting the data. And as electronic medical record systems are being implemented across the country, and actually one of the main triggers for us being interested in doing this in our three hospitals in the region is Epic was just installed in all three of those hospitals in the last couple of months, so we now have the power to get the data.
It's just crafting a dashboard that will allow us to feed back the information to the discharging doctors.
And on that vein, my personal question that I'm fascinated by, with that said, do you feel that there are some cases where you have patients coming in who are, again, opioid naive, that may not be educated, that you're seeing come in for follow ups that might be asking for more medications? And do you have an intervention at that point where you can try to educate more and probably assess psychologically again?
- So that's a tough challenge and certainly there is a significant number of patients who come in the door already on pain medications. And I think at that point, you kind of have to assess the impact of the intervention that you're about to offer to that patient before surgery as compared to what their baseline pain medication requirement is. And so for my operations, that's pretty easy. I tell them that their pain medication for their back pain will be more than sufficient to treat anything related to the neck.
For other operations, it's not quite so straightforward in determining when the patient makes the shift from the acute pain environment, from the postoperative period, to their baseline chronic pain is sometimes very, very difficult, especially when these operations affect kind of the torso, the upper abdomen, or the chest. But I do think that, again, for patients who are chronic pain medication requirers, that a dedicated pain management team is really the answer because it's over that long-term relationship that real interventions can be made to try to reduce the requirement.
Excellent. Any other questions?
Jacob Moalem, MD, FACS
Professor of Surgery & Endocrinology & Director of Quality Improvement for the Department of Surgery, University of Rochester Medical Center