A surgeon on the opioid crisis: Why we need prescription guidelines

rasbachn — Thu, 23 Nov 2017 15:47:05 +0000

A surgeon on the opioid crisis: Why we need prescription guidelines rasbachn Thu, 11/23/2017 - 10:47

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Surgeons vary widely in their approach to opioid prescriptions and some patients use opioids for prolonged periods post-surgery (photo by Shutterstock)

Tola Afolabi

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City & Culture

Munk School of Global Affairs & Public Policy

opiods

The Conversation

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The Conversation with Tola Afolabi

Of all the possible ways of alleviating the opioid crisis, one has so far garnered far less attention than it deserves: prescription guidelines for surgeons.

Surgeons are the third-biggest prescribers of opioids, often choosing them to help patients who have undergone hysterectomies, gall bladder removal, tendon repairs and other procedures where pain relief is a critical part of the recovery process.

And research shows that patients who are given opioids to treat surgical pain are at significant risk of dependence on the painkillers. One study estimates that every year in the United States, more than two million patients become addicted to the opioids that their surgeons prescribed.

According to a national report, prescription opioid deaths are climbing, and Canadians are the world’s second-highest users of prescription opioids per capita. Our use of opioids is rising faster than in the U.S. And over half of Ontario patients who suffered an opioid overdose were given an opioid prescription within four weeks of their death.

And yet, while detailed guidelines are in place for dentists and for doctors who prescribe opioid-based painkillers for long-term pain, there are none for surgeons.

Prescribing with caution

As a plastic and reconstructive surgeon, I often treat and prevent surgery-related pain. I sometimes prescribe opioids for patients who have had surgery. But I try to take care to prescribe only enough to help with the most severe pain that cannot be relieved by ibuprofen (Advil) or acetaminophen (Tylenol).

I also insist that these medications should only to be used if other pain-avoidance techniques – like resting and elevating the area – have failed. Or, I give it in the smallest possible doses to patients who can’t tolerate ibuprofen or acetaminophen.

My prescriptions last for only a few days, and I caution patients to use the drug only if their pain is keeping them up at night. I came to this approach because I was trained to be conservative with opioids, and I have seen many patients whose pain was managed successfully without opioids.

Federal Minister of Health Ginette Petitpas Taylor announces new federal activities to address the opioid crisis during a recent speech in Calgary (photo by Jeff McIntosh/The Canadian Press)

But not all surgeons are the same. For example, while I do not prescribe opioids after carpal tunnel surgery, some of my colleagues give Tylenol #3, which contains codeine, an opioid.

And although I give breast reduction patients a small prescription for hydromorphone, another opioid, a colleague recommends only acetaminophen and ibuprofen. He tells me that he hasn’t “prescribed opioids in a long time for almost anything.”

Dangers of post-surgery addiction

This anecdotal evidence is supported by research. Studies show that surgeons have different approaches to how they treat pain stemming from surgery. An April 2017 study of general surgeons in New Hampshire revealed that “there was a wide variation in the number of opioid pills prescribed to patients undergoing the same operation.”

A wrong move can have grave consequences. If pain is not treated, the patient may suffer unnecessarily, and end up in the doctor’s office or the emergency department. I’ve known desperate patients to use a relative’s leftover pain medication, or even buy drugs on the street.

Persistent opioid use

Pain typically disappears a few weeks after surgery; the worst is usually over within the first week. But a June 2017 study by doctors at the University of Michigan noted that some patients continued taking opioids for more than three months after surgery. The researchers concluded that “persistent opioid use is more common than previously reported and can be considered one of the most common complications after elective surgery.”

They added that “there has been little attention placed on post-operative prescribing,” and “the effect of post-operative use on the opioid overdose epidemic has been less recognized.”

A mural encourages people to pick up the overdose antidote Narcan at a nearby safe injection site in Vancouver, in this June 2017 photo (photo by Jeremy Hainsworth/AP)

In Canada, many aspects of the opioid crisis have been closely analyzed by agencies such as HealthcareCAN and the Canadian Centre on Substance Use and Addiction.

In May 2017, guidelines for long-term pain were released by the DeGroote Pain Research Group at McMaster. These were updated from 2010 guidelines following a scientifically rigorous process that involved the input of numerous clinicians, researchers and patients.

We don’t yet have anything comparable for surgical pain. The Ontario Ministry of Health and Long-Term Care is developing quality standards for opioid prescribing for both acute and chronic care. These quality standards may not meet the rigour of an official guideline, however, notes Dr. Buckley, who is also DeGroote’s scientific director.

Managing patient expectations

Guidelines for surgeons are critical to addressing the opioid crisis.

They would improve communication between physicians and nurses. The profession increasingly favours a multi-disciplinary approach to prescribing medications to ensure that the family doctor, emergency physician, nurse, surgeon and even patients are all on the same page.

Sometimes the insights of non-surgical colleagues play a role in a surgeon’s decision to prescribe opioids.

Guidelines would also help manage patients’ expectations. Some patients fear becoming addicted to opioids; others fear not having enough medication to relieve their pain.

As one colleague noted: “It’s tricky. Most people expect to be prescribed something after most procedures so Tylenol #3 isn’t uncommon, but I prefer to avoid it if possible.”

Tola Afolabi is a Munk global journalism fellow at the University of Toronto

This article was originally published on The Conversation. Read the original article.

Training is key to ending opioid epidemic, says U of T expert

lavende4 — Tue, 18 Oct 2016 14:09:17 +0000

Training is key to ending opioid epidemic, says U of T expert

lavende4 Tue, 10/18/2016 - 10:09

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(Photo by John Moore/Getty Images)

Liam Mitchell

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Liam Mitchell

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In 2014, more than 700 people died in Ontario from opioid-related causes, making it the third-leading cause of accidental death in the province.

In response, the Ontario government has just announced a new comprehensive opioid strategy to develop new, evidence-based training modules and academic programs in conjunction with educational institutions, which will provide modernized training to all health-care providers who prescribe or dispense opioids.

The University of Toronto has been at the forefront of the battle against opioid abuse. For the past four years, U of T's Faculty of Medicine has offered an innovative and award-winning course for physicians and other health-care providers on the safe prescribing of opioids. By the end of 2016, 480 participants will have completed the program offered through the continuing professional development office in the Faculty of Medicine.

Dr. Abhimanyu Sud, the course’s director and a lecturer in the department of family and community medicine, says the focus needs to be on delivering effective education.

“There is a huge demand from physicians for better education on prescribing opioids. You can see genuine worry about how to deal with this issue. But we should use the best educational methods available to deliver that information.”

The U of T course is delivered through a hybrid of online learning and in-person training. It begins with three live webinars that allow learners to respond in real time to questions posed by course instructors. Participants build their base level of knowledge on topics like the assessment of chronic pain and details about opioids themselves and then review complex case studies. Finally, they participate in a one-day workshop where they role-play scenarios they might confront in their practice, such as assessing for addiction.

Sud, who is a family physician with a specialized practice in chronic pain, initially came upon the field by surprise.

“I found that when I came out of medical school, I really hadn’t received a lot of training in prescribing opioids. And it was at a time when there was a shift from broadly prescribing opioids for treating chronic pain, because we thought they were harmless, to starting to see the negative consequences. We were all looking for clearer information and more guidance,” he says.

A large part of that guidance came in 2010 when the Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain was first released. A new set of guidelines is expected to be released in 2017.

“Our participants get a thorough understanding of the guidelines, which forms the basis of our course. It’s a complex document, so we walk them through it to ensure they have the confidence of what it says and how best to use it,” says Sud.

The course is offered three times per year with the next session beginning in January 2017.

While most participants are family doctors, the course has drawn other medical specialists as well as nurse practitioners and addiction workers from across Canada. Five faculty members are helping to lead the course and plans are underway to offer the in-person workshops outside of Toronto.

“Our aim isn’t just to impart knowledge, but we really want to change how people conduct their practice. When we see practices change, that’s when we know we’re having an impact,” says Sud.

opiods

A surgeon on the opioid crisis: Why we need prescription guidelines

Prescribing with caution

Dangers of post-surgery addiction

Read more on The Conversation about solutions to Canada's opioid crisis

Persistent opioid use

Managing patient expectations

Training is key to ending opioid epidemic, says U of T expert