Pharmacists discuss the best methods for postoperative opioid prescription management.
In 2019, opioid overdoses were responsible for the death of nearly 50,000 Americans, according to the National Institute on Drug Abuse.1 These opioids- which include prescription pain relievers prescribed after surgical procedures—are part of a “serious national crisis” that has impacted everything from public health to social and economic well-being.1
Data show that both opioid-naïve and non–opioid-naïve surgical patients are at high risk for chronic opioid use following surgery, but it can be challenging to minimize these risks while appropriately managing postoperative pain. In fact, according to a recent report presented at the American Society of Anesthesiologists annual meeting, 1 in 5 opioid-naïve patients continue to use opioids 3 months after surgery,2 a statistic that many pharmacists are trying to change.
Joe Moose, PharmD, co-owner of Moose Pharmacy in Concord, North Carolina, and director of strategy and luminary development for CPESN USA, said that starting a patient on opioids comes with the responsibility of setting realistic expectations on what pain management should be and how it should be controlled.
“A patient should be continuously educated on their pain medicine instructions to ensure that they are only taking [the medication] for the necessary amount of time,” he said. “Education...is rarely provided to patients [in a comprehensive way].”
Another significant problem is the irregular, inconsistent enforcement of prescriber limits. Although policies are in place, for both providers and pharmacies, factors like auto-renewals and too-high-of-volume fills both contribute to prolonged, inappropriate use.
Anna Legreid Dopp, PharmD, senior director of clinical guidelines and quality improvement for the American Society of Health-System Pharmacists (ASHP), said that recognized risk factors for opioid misuse or opioid-use disorder (OUD) include a family or personal history of substance abuse, untreated psychiatric conditions, younger age, and social environments that encourage misuse.
“Thanks to our ability to track trends in opioid-use data, we have learned that early prescribing patterns of opioids, especially for those who are opioid naïve, [have] significant influence on the potential for long-term use,” Dopp said. “[The] risk of chronic opioid use...increases with each additional day of medication prescribed—
starting with the third day. This has led to numerous evidence-based policies that limit opioid prescribing to a certain amount of days, often required by institutional, state, or payer policies.”
According to Jim Lichauer, PharmD, BCPS, FASHP, performance improvement program director of pharmacy for Vizient, Inc, prescribed quantities and refills should be limited to 7 to 15 days, or up to 30 days with no refills. “[CDC data] show that the use of prescription refills after a patient’s initial opioid prescription is associated with an increased incidence of persistent opioid use at 1 year,” he said.
The Pharmacist’s Role
Hospital pharmacists can make a difference by conducting a prescription drug–monitoring program (PDMP) search prior to admission, and retail pharmacists can help by assessing current home supply and understanding patient habits by viewing their history of prescribers and early refills, as well as determining the stability of the current regimen.
“Pharmacists need to start setting short term and long-term goals for pain management, opioid use, and pain expectation,” Moose said. “It is also important to discuss what signs of addiction might look like. Pharmacists should also stress the importance of not leaving medications around the house.” Proper disposal prevents children, pets, and others from getting ahold of these medications.
If a patient is still in pain 5 days after their procedure with their current medication, a deeper dive should be conducted into why this might be, including the possibility that opioids might not be the best course of action. Pharmacists should engage with the interprofessional care team across the spectrum of pain management, including when opioids are indicated, in the screening for and prevention of opioid misuse, the management of opioid-exposed patients, and the management of patients with OUD.
Pharmacists can manage this collaboration by screening patients for risk factors, educating patients, monitoring PDMPs, building prescribing alerts into electronic health records, and developing policies and protocols to be on alert for potentially risky opioid-prescribing behaviors.
Taylor Fortson, PharmD, of Carolina Pharmacy, a Charlotte, North Carolina–based independent group with locations across the Carolinas, noted that pharmacists should provide both medication reconciliation and counseling to assess patient pain and help develop an action plan with physicians to explain to patients how to control postoperative pain safely and effectively.
“Although medication counseling should always be done upon either discharge from the hospital or after surgery, never assume,” she said. “Ask the patient if they have ever taken opioids and review their goals, [adverse] effects, and how to ensure safe use.”
Explain to the patient prescription opioids help relieve short-term pain, but carry a serious risk of addiction and overdose. Fortson typically recommends to patients that they take opioids only for severe pain and use ibuprofen for less severe pain. Fortson generally counsels patients to switch after a few days to alternating between acetaminophen and ibuprofen every 3 to 4 hours.
At Moose Pharmacy, patients are encouraged to read and sign a policy of procedure, which is a key step in opioid counseling. After going over the document and expectations, if a patient is not comfortable, then pharmacists provide counsel on other options and consider a secondary conversation with the prescriber. Pain management must also be patient centered, said Dopp.
“Including the patient in determining functional pain management goals, identifying therapy options, and setting realistic expectations for treatment will result in buy-in from the patient and their caregiver,” she said.
“Something we have been advocating for is to make pain management plans interoperable and accessible to everyone on the interprofessional care team. Doing so enables adherence to the plan throughout transitions of care from the postoperative setting to the patient’s home.” Simona Dorf, PharmD, BCMAS, clinical
pharmacist and editorial manager at First Databank, Inc, which publishes and maintains drug databases for health care professionals, said that some of the most difficult conversations she has had with patients have been on this topic.
“It was never on the first fill,” she said. “It typically occurred down the line with the third filll or later.” Dorf recalled a conversation she had with a patient taking 2 different opioids from different prescribers: 1 for leg pain and 1 for back pain.
Although the patient was adamant that each opioid worked on only that specific pain area, after counseling the patient, Dorf and the patient agreed to discuss the situation with each physician and let them consolidate the pain management regimen.
Making a Difference
Although a physician has to write the prescription, the pharmacist is the gatekeeper. They see their patients more frequently, which provides more opportunity to reinforce the correct medication habits and identify negative adverse effects.
“Pharmacists overall have a closer and more accessible relationship with their patients and the ability to spend time with them,” Moose said. “They also can look into details like where they last received [or] purchased medications to make an assessment on if it might be an escalating situation. ”
Robert Alesiani, PharmD, BCGP, chief pharmacotherapy officer at Tabula Rasa HealthCare, once had a patient who underwent a total hip replacement secondary to osteoarthritis and also experienced chronic, episodic lower back pain. The oxycodone prescribed after surgery also helped manage the patient’s back pain, so he continued using it long after the hip healed.
“While he originally self-medicated to improve his function, over time he found himself overmedicated and less functional,” Alesiani explained. “He always seemed to come in for a new fill a couple days early, but not so early that the prescription card didn’t pay.”
When the patient came in for a refill, Alesiani pulled him aside and in a nonconfrontational tone asked, “What are you expecting from these medications, and are they working for you?” The response was tearful and surprising: The patient just wanted to get back to normal—and no, the medications weren’t helping.
“After obtaining permission from the patient, I contacted his primary care physician and together, [we] came up with a plan that included an orthopedic consult,” followed by steroid injections and physical therapy. “After 6 weeks, the patient was taking much less of the opioid and utilizing a COX-2 [inhibitor]. He was more alert, cheerful, and positive. He was still experiencing some pain, but it was manageable.”