In 2017, New York City-based Hospital for Special Surgery implemented a Controlled Substances Task Force to limit the risk of opioid misuse among the roughly 32,000 patients who undergo orthopedic surgeries at the hospital annually.
Here, Seth Waldman, MD, director of the pain management division at HSS, shares how the task force has helped to lower opioid prescribing rates, increase provider education and identify high-risk patients, among other benefits.
Editor's note: Responses have been lightly edited for style and clarity.
Question: What makes the Hospital for Special Surgery Controlled Substances Task Force unique? How is it different from other hospitals' efforts to reduce opioid prescriptions?
Dr. Seth Waldman: I believe that our preoperative pain assessment and treatment program is unique, and a significant advancement in patient safety. When I speak with anesthesiologists and pain specialists from other hospitals, one of the most significant issues they face regarding opioid prescribing is how best to care for patients who are at increased risk for using opioids perioperatively (such as those with an addiction history, sleep apnea, who have had problems with post-op pain control in the past, or are already on high-dose opioids), or who may already be on a regimen that is not medically appropriate for other reasons. The usual response is that they just do the best they can postoperatively, which we feel is not in the patient's best interest.
Taking a step back prior to elective surgery to thoroughly assess the patient's pain; change or taper medications when appropriate; understand what he or she may be taking and why; identify and treat addiction issues; and set realistic goals for treatment goes a long way toward improving surgical outcomes, reducing prescribing risk, increasing patient and surgeon satisfaction, and reducing length of stay.
Q: What was the greatest challenge to implementing the task force's opioid initiatives and how did you solve it?
SW: We had a number of challenges, including educating the medical staff (and our patients) about opioids and opioid prescribing, monitoring prescribing behavior and documentation, and coordinating the medical and surgical service lines with respect to procedure and diagnosis-appropriate opioid prescribing. Developing appropriate prescribing structures in our EHR (monitoring the total morphine milligram equivalents of opioid medications we prescribe), encouraging and reminding providers to establish an opioid contract with their patients and demonstrating the importance of presurgical pain optimization were also challenges. There is no way that any of these programs could have been instituted without the support of our hospital administration, particularly our president, surgeon-in-chief and physician-in-chief. This is more about a culture change than about any one policy.
Q: A major focus of the task force was standardizing what opioid prescriptions are given for each procedure, along with how these prescriptions are documented. How did you gain physician buy-in for this effort?
SW: Initially, buy-in from the physicians, particularly the surgeons, was the result of the support by the surgeon and physician-in-chief. Once the programs were underway, and the culture began to change, the best way to maintain physician engagement has been to demonstrate that these programs are not just the right way to care for our patients, or mandated by law, but that they actually improve patient satisfaction and surgical outcomes.
Q: HSS has already seen major improvements since implementing the task force, including 500,000 fewer opioid pills prescribed over 18 months. What do you think has been the key to this success?
SW: We have worked hard to change the culture at HSS around responsible opioid prescribing. As a surgical hospital, it is unlikely that we will ever be completely opioid-free — these are extremely effective medications, which, for now, are a necessary component of how we alleviate suffering and perform modern surgery. Opioids can also be extremely dangerous not just for the individual, but for the public health, and it is our responsibility to use them as effectively and safely as possible.
Q: If you could solve one patient safety issue overnight, what would it be?
SW: First, a significant recurring theme in the U.S. opioid epidemic is the lack of adequate availability and coverage of addiction treatment services. Healthcare coverage must be expanded to cover not only addiction treatment, but the necessary behavioral and rehabilitation services that will reduce the need for opioid pain medication.
Second, much of this epidemic was produced by direct marketing to physicians, pro-opioid research, conference funding and lobbying efforts by the pharmaceutical manufacturers. There must be legislation to prevent corporate interests from influencing the prescribing behavior of clinicians. Selling opioids is not like selling shoes, and pharmaceutical advertising should be subject to clear regulation to prevent similar problems from occurring again.