Opioid Safety, Patient Safety, Respiratory Compromise

We Need to Focus on Patient Safety to Battle the Opioid Epidemic: 5 Key Steps to a More Balanced Approach

Though much of the attention to end the opioid epidemic is centered on the improper use of opioids in the community (misuse, diversion, etc), the truth is that opioid harm exists across a continuum of care. The safe use of opioids begins with the safe use of opioid analgesics in the hospital setting and the prescription of opioids upon discharge of the patient from a healthcare facility. We must first and foremost make sure that opioids provided to patients are done so in a safe manner both during administration and upon discharge.

By Michael Wong, JD (Founder and Executive Director, Physician-Patient Alliance for Health & Safety)

Opioid-related deaths are a leading national and community concern. Unfortunately, reports of opioid-related deaths occur with astonishing regularity in our daily news feeds.

Though much of the attention on opioid-related harm is centered on the improper use of opioids in the community (misuse, diversion, etc), the truth is that opioid harm exists across a continuum of care. The safe use of opioids begins with the safe use of opioid analgesics in the hospital setting and the prescription of opioids upon discharge of the patient from a healthcare facility. We must first and foremost make sure that opioids provided to patients are done so in a safe manner both during administration and upon discharge.

Make sure that #opioids prescribed to patients are done so safely. Click To Tweet

So, how do we do that?

First, we must recognize the critical role of physicians in the lives of patients and the impact that they can play in the opioid epidemic. On August 25, 2016, the Surgeon General issued a letter to physicians urging them to take a part in combating the opioid epidemic. On the Surgeon General website, healthcare providers are encouraged to help solve the opioid epidemic:

“Our nation faces an opioid crisis. Health care providers are uniquely positioned to help communities and their patients #TurnTheTide on the opioid epidemic. Providers can be the solution. Join the movement. Sign the pledge.”

To gauge whether clinicians would answer this call and how clinicians and the public felt about the Surgeon General’s recommendations to fight the opioid epidemic, the Physician-Patient Alliance for Health & Safety (PPAHS) conducted a survey of our readers (most of whom are clinicians, hospital executives or risk managers) to examine perceptions about the Surgeon General’s appeal to physicians to play an active role in stemming the opioid epidemic.

The survey results highlight that the majority of doctors and clinicians agree with the Surgeon General’s letter, with 7 in 10 respondents having, or will, take the pledge.  However, respondents were divided in what has caused the “opioid epidemic”; while over-prescribing of opioids and an overly aggressive emphasis on pain treatment were popular choices, a significant percentage (35%) chose to indicate other reasons.

What was clear was the sentiment that doctors, rather than government or communities, should be the captains leading the efforts to curb opioid harm.  In order to do so, respondents indicated that an expanded toolset, comprised of educational and screening resources, was needed.

The second step is to answer this call by providing clinicians with the necessary tools and information they need to make informed and safe treatment recommendations.

What might be contained in these tools and information? For information that should be provided to clinicians, please see steps three, four, and five below.

The third step in achieving this more balanced approach is to consider other pain management alternatives before immediately prescribing an opioid and to make sure that physicians have the tools that they need to prescribe appropriately.

Consider other pain management alternatives before immediately prescribing an opioid Click To Tweet

The American Pain Society (APS) recently released Clinical Practice Guideline for Post-Surgical Pain Management, which set forth 32 recommendations. Roger Chou, MD, lead author and head of the Oregon Evidence-based Practice Center, says that the guideline targets all clinicians involved with post-surgical pain:

The intent of the guideline is to provide evidence-based recommendations for better management of postoperative pain, and the target audience is all clinicians who manage pain resulting from surgery,

The APS guideline asks clinicians to stop and consider the best pain alternatives for each patient. Dr Chou emphasizes the need for a multimodal approach:

The guideline strongly advises use of multimodal anesthesia that target different mechanisms of actions in the peripheral and central nervous systems. Randomized trails have shown that multimodal anesthesia involving simultaneous use of combinations of several medications — acting on different pain receptors or administered through different techniques — are associated with superior pain relief and decreased opioid consumption compared with use of a single medication administered by one technique.

The recently pronounced guidelines from the American Association of Oral and Maxillofacial Surgeons (AAOMS) also set forth guidelines for managing a patient’s acute and postoperative pain. The AAOMS guidelines emphasize the need for a balanced approach to the prescribing of opioids and highlight:

  • “Prescribing ibuprofen, and/or possibly acetaminophen, as a first-line analgesic therapy for postoperative pain (rather than starting with opioids)
  • Advising a long-acting local anesthetic to delay onset and severity of postoperative pain.
  • Carefully documenting instructions for patient pain management.
  • Accessing state prescription drug monitoring programs as required.
  • If necessary, using only short-acting opioids at the lowest dose possible for the shortest duration possible.”

The fourth step is monitor all patients receiving pain medications, and particularly opioids, to ensure that these patients are safe.

Monitor all patients receiving pain medications, and particularly #opioids #patientsafety Click To Tweet

The APS strongly recommends that clinicians continuously assess and monitor their patients receiving pain medication, particularly if it involves opioid administration:

  • Conduct a preoperative evaluation, including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, and substance abuse;
  • Adjust the pain management plan on the basis of adequacy of pain relief and presence of adverse events;
  • Use a validated pain assessment tool to track response to postoperative pain treatments and adjust treatment plans accordingly;
  • Appropriately monitor sedation, respiratory status, and other adverse events in patients who receive systemic opioids; and
  • Provide appropriate monitoring of patients who have received neuraxial interventions for perioperative analgesia.

Unfortunately, the AAOMS guidelines fail to discuss the need to monitor to ensure that all patients receiving sedatives or opioids are safe. This is, I believe, a major oversight. Appropriate and balanced prescribing must be accompanied with adequate monitoring; otherwise, it would be like telling someone to put a parachute on before jumping out of the plane, but not making sure a parachute was actually worn. Both are necessary.

The fifth step is to make sure that patients understand physician-recommended treatments.

Make sure that patients understand physician-recommended treatments Click To Tweet

ISMP Canada, the Canadian Patient Safety Institute, Patients for Patient Safety Canada, the Canadian Pharmacists Association and the Canadian Society for Hospital Pharmacists have collaborated to develop a set of 5 questions to help patients and caregivers start a conversation about medications to improve communications with their health care provider. Clinicians should make their patients know the answers to these five questions:

  1. Have any medications been added, stopped or changed, and why?
  2. What medications do I need to keep taking, and why?
  3. How do I take my medications and for how long?
  4. How will I know if my medication is working, and what side effects do I watch for?
  5. Do I need any tests and when do I book my next visit?

To download the 5 Questions to Ask about your Medications, please click here.

The attention given to the opioid epidemic has resulted in a negative-opioid prescribing environment. However, it must be remembered that there are some patients and medical procedures that require the use of opioids and that when this happens we need to make sure that these patients receiving opioids are adequately monitored to ensure their safety. The Physician-Patient Alliance for Health & Safety recommends that all patients receiving opioids should be monitored with pulse oximetry for oxygenation and with capnography for adequacy of ventilation.

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