Into their second year of implementing key initiatives, the Hospital for Special Surgery (HSS) Controlled Substances Task Force has achieved substantial results in the fight against the opioid epidemic in three key areas: considerably reducing opioid prescribing, increasing clinician and patient education, and identifying and working with high-risk patients.¹

HSS is a national leader in the field of orthopedics, performing approximately 32,000 surgical cases in 2018. Orthopedic surgery is associated with significant perioperative pain, and has been identified as a risk for long-term opioid use and misuse.^2,3

To prevent and mediate potential problems with opioid medications, HSS has implemented a pain management program that spans the care continuum, and in late 2017, launched the interdisciplinary Controlled Substances Task Force.

“The Controlled Substances Task Force was created in order to centralize the hospital’s opioid policy, so we’re all prescribing opioids appropriately, in an evidence-based fashion, and in a consistent way,” said Seth Waldman, MD, anesthesiologist and director of Pain Management at HSS. “Before the Task Force was created, the existing processes were somewhat haphazard. Now, we’ve standardized what prescriptions are given according to procedure; doctors can still use their clinical judgment, but they can refer to the base prescriptions. We’ve also made documentation of prescriptions consistent (i.e., what was prescribed and why?) as well as standardizing checking toxicology screens, narcotic takeback, etc. We’ve made it consistent for everyone prescribing at every circumstance.”

“The task force also aimed to make the opioid prescribing process and analysis as seamless as possible. Electronic health records have helped with that; we are able to monitor our progress, see the flow of prescriptions and whether medications are being used appropriately or not, and see the amount of opioids doctors prescribe to identify doctors who need help with prescribing and documenting,” Dr. Waldman said.

“One of the main goals of the Task Force was to change the culture of prescribing in the hospital,” said Bobby Stack, MS, an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force. “We were able to accomplish that by educating clinicians and highlighting the risks of overprescribing opioid medications.”

HSS Controlled Substances Task Force Accomplishments To Date

• Opioids issued were reduced by 500,000 over approximately 18 months, and there have been continued reductions in the number of pills prescribed at discharge due to implemented prescribing guidelines
• Preliminary internal results suggest that preoperative complex patient screening may reduce length of stay by up to 26%
• Every week, up to 30 high-risk preoperative patients are identified and put on a plan to prevent opioid use complications after surgery
• Physicians who prescribed a higher than average amount of opioid medications received one-on-one education, reducing their average number of opioid prescriptions written per month by approximately 27% compared to their pre-intervention average
• At an HSS leadership forum in June 2018, a multidisciplinary panel of experts produced a consensus statement about appropriate pain management for total hip replacement and total knee replacement: “Consensus Statement: Toward Opioid-Free Arthroplasty,” published in a special edition of HSS Journal
• Patient/provider opioid agreements were designed and successfully implemented in all service areas across the hospital, with nearly 100% patient compliance with signing

“The reason the task force has been so effective is that we have a variety of different partnerships; the clinician and administrative partnership has been vitally important,” said Dr. Waldman. “I can’t accomplish my part without Bobby on the administrative side. This effort has also required the support of CEO Lou Shapiro and hospital administration, not just financially but also culturally. And it’s been the support of the Surgeon in Chief and the Physician in Chief that has allowed us to implement preoperative screening services.”

“Since implementing these changes, the doctors have seen not only a huge difference in the care of patients, but it’s also simplified their care of patients in pain by providing better guidelines about how, when, and why to prescribe opioid medications; it’s been a support to them both medically and legally,” he added.

The Task Force’s results were achieved through actions taken in three key areas:

1. Educating Patients and Clinicians

• Mandatory prescriber education modules were created and provided online and in-person
• A short-term surgical patient/provider opioid agreement was implemented to help surgeons set patient expectations for opioid therapy perioperatively
• Opioid-focused editions of the HSS digital newsletter and educational online articles were published (Opioids: Understanding Addiction Versus Dependence; A Patient’s Guide to Opioid Tapering; Multimodal Analgesia: Move Better, Quicker After Surgery with Fewer Side Effects)
• Fact sheets were developed for patients and prescribers
• Patient-facing videos were created to provide education about appropriate use, storage and disposal of opioids
• Webinars were provided on opioid prescribing, opioid stewardship, and multimodal analgesia to share best practices with clinicians
• Opioid-related courses were created and posted on HSS E-Academy

2. Inspiring a Culture of Conservative Prescribing

• Guidelines were developed to standardize prescribing and documentation for patients receiving opioids at discharge
• Prescribing patterns for all clinicians is under ongoing analysis, which can help surgeons set patient expectations for opioid therapy perioperatively
• One-on-one counseling and training was scheduled for clinicians who deviated from the average opioid prescribing patterns according to specialty and diagnosis
• An opioid disposal mechanism was provided via a DEA approved disposal receptacle located on the HSS main campus

3. Identifying and Managing At-Risk Patients

• Complex patients who are referred to the screening program receive a comprehensive evaluation with a pain management physician, and most also receive a toxicology screen
• For patients identified as high risk, the HSS Preoperative Controlled Substances Clinical Team:
  • Engages the patient’s outside prescriber
  • Implements taper schedules
  • Makes referrals to psychiatric/psychological resources or to detox, substance use disorder facilities, 12-step groups, or private psychiatric addiction clearance facilities when appropriate
  • Delays elective surgery if necessary until the patient is treated and can safely proceed
  • Carefully monitors inpatients and implements strategies to minimize opioid use and wean medications after recovery

“The philosophy behind the Task Force is not to avoid opioid use, but to use these medications in a medically and ethically responsible way,” said Dr. Waldman. “The term that’s being used to describe this is ‘opioid stewardship.’ These medications can do a lot of good, but also terrible harm; our goal is to use them in a way that they’re not causing any more harm than they have to.”

The Controlled Substances Task Force is expanding this work with further initiatives for 2019.

“Some of the work the Task Force is looking to do moving forward includes: providing mechanisms to help patients dispose of prescriptions after surgery, becoming a registered NY state opioid overdose prevention center, continuing to educate patient and surgeon populations, providing more holistic support and alternative therapies to opioids, and sending all patients home with an opioid tapering schedule,” Ms. Stack said.

Dr. Waldman added, “This includes making more progress in use of multimodal analgesia with anesthesiologists, nurses, and physician’s assistants, and in increasing complementary treatments such as aromatherapy, virtual reality, and massage therapy.”

“I think the most important next step is to take what we’ve learned in preoperative evaluation and managing opioid prescriptions and educate others so this becomes the standard of care elsewhere. Everyone taking opioids should be evaluated before surgery and tapered after surgery, and we believe it’s important that these principles of service line guidelines are applied outside of HSS,” Dr. Waldman concluded.

Dr. Seth Waldman is an anesthesiologist and director of Pain Management at HSS. He is a physician consultant to the U.S. Department of Justice and Drug Enforcement Administration, and a master’s candidate in bioethics at Columbia University.

Roberta (Bobby) Stack, MS, is an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force.

References

1. Waldman SA, Stack RJ, Goldstein L. Clinician-healthcare administrator partnerships: effective treatment for opioid epidemic. Healthcare Business Tech. http://www.healthcarebusinesstech.com/clinician-healthcare-administrator-partnerships-effective-treatment-for-opioid-epidemic/. Accessed April 19, 2019.

2. Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS Journal. 2019 Feb; 15(1):57-65. doi: 10.1007/s11420-018-9652-2

3. Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017 Nov;125(5):1704-1713. doi: 10.1213/ANE.0000000000002433