Pain Is Personal

Most patients who are hooked on opioids know exactly when they started down the slippery slope of addiction, and many think back to heading home from surgery with a pocket full of pills to overpower post-op pain.

The Duke University Health System in Durham, N.C., may have been unwittingly contributing to the nation's prescription drug abuse epidemic by sending patients home with excess amounts of opioids — they typically used only 30% of the pills they received and most did not dispose of the leftovers.

"Patients received stock prescriptions for pain medications at discharge because there was no infrastructure in place to assess their condition and adjust their care plan," says Padma Gulur, MD, executive vice chair of operations and performance at Duke Anesthesiology. "We saw a real opportunity to examine the surgical episode of care and explore ways we could do better."

Two years ago this month, she helped launch a perioperative pain care clinic with the goal of personalizing post-op pain management, minimizing the use of opioids, reducing the amount of time patients spend in recovery and increasing their overall satisfaction. Her large health system had the means and need — it treats 60,000 surgical patients each year — to launch a dedicated post-op pain clinic, but you can implement a similar program on a smaller scale. The key is to focus on the unique pain management needs of your patients weeks before procedures instead of relying on a cooker-cutter approach on the day of surgery that's often ineffective and unsafe.

Dr. Gulur and a team of anesthesiologists, who are fellowship-trained in pain management, run Duke's clinic. A member of the team meets with patients as soon as possible after surgeries are scheduled and is available to support their recoveries for up to 90 days post-op.

During pre-op appointments, they ask patients about their health histories, lifestyles, medication use and expectations of surgery and recovery. It's during those initial meetings with patients that they establish personal connections, learn about their specific pain management needs and begin implementing the 3 essential elements of the program:

• Medical. Dr. Gulur says chronic opioid users must be gradually weaned off of the painkillers before surgery because it's often necessary to escalate the post-op doses of chronic opioid users to achieve an analgesic effect. And that dose escalation puts them at risk of suffering a host of opioid-related side effects and complications.
• Psychological. Patients learn about the benefits of music therapy, which can have a positive impact on their perception of pain.
• Physical. Patients are instructed to participate in a basic exercise program in the weeks leading up to surgery. "Prehabilitation has not been definitively shown to lessen post-op discomfort, but patients feel more engaged in their care and more confident heading into surgery," says Dr. Gulur.

"It creates a positive mindset that potentially leads to patients feeling less pain during recovery."

Patients are also told to avoid foods that inflame muscles — including white bread and pastries, fried foods, soda, red meats and margarine — and instead reach for food that fights inflammation such as fruits, nuts, leafy greens and fish.

After the initial pre-op appointment, the Duke team creates individualized patient care plans, which include patient-specific, opioid-sparing prescribing recommendations that the surgical team can access and refer to on the day of surgery. They include information about the morphine equivalent daily dosage chronic opioid users are taking, medication compliance issues that could affect a patient's post-op care and physical or mental factors that could impact the effectiveness of the medications a patient is prescribed.

Dr. Gulur says it's also important to counsel surgeons on how to set reasonable expectations for post-op recovery — surgery will hurt, at least a little — and emphasize the importance of using multimodal, opioid-sparing pain management techniques. For example, combining 200 mg of ibuprofen and 500 mg acetaminophen is at least as effective, if not more effective, than popping 2 Percocet to relieve post-op pain.

Patients should be sent home with customized discharge prescriptions based on their specific pain management needs, says Dr. Gulur. Patients who undergo surgery at Duke Health typically receive NSAIDs and acetaminophen for comfort and a limited number of opioids for managing breakthrough pain.

Schedule follow-up appointments with patients 10 to 14 days after surgery and adjust pain medication prescriptions as needed. Also make sure your team is available at any time if patients have questions about their pain levels, suggests Dr. Gulur.

She says that availability limits the number of calls patients make to surgeons and primary care physicians, who are often unfamiliar with treating post-op pain and end up sending them to emergency rooms for care that could have been avoided with a quick call to one of your providers.

Proof positive

Patients at Duke Health are now discharged with personalized prescriptions. The result, says Dr. Gulur, has been a significant reduction in the amount of opioids used to control post-op pain.

"But it's not just about writing fewer scripts," she points out. "We also need to ensure patients are doing well." They are. Rates of medication-related harm have decreased while patient satisfaction scores have improved.

Says Dr. Gulur, "We've been prescribing fewer opioids and our patients are happier because we're treating them with personalized care plans that address their specific needs." OSM