Quality of Patient Education Materials on Safe Opioid Management in the Acute Perioperative Period: What Do Patients Find Online?

Nurse-led support impact via a mobile app for breast cancer patients after surgery: a quasi-experimental study (step 2)

Breast cancer patients may experience some health issues following surgery. Training patients about self-care plays a vital role in managing these symptoms. Mobile applications are a contemporary and appropriate approach to support patients about the potential symptoms following breast cancer surgery. This quasi-experimental study aimed to assess the impact of nurse-led support mobile application (NL-Mapp) delivered on breast cancer patients after surgery. Ninety participants were recruited, with 45 assigned to the intervention group and 45 to the control group. Subjects in the intervention group received NL-Mapp in addition to routine care, while those in the control group received only routine care over four weeks. The intervention included educational content on the postoperative period of breast cancer. Outcomes were assessed at baseline (M0), before discharge (M1), and one month after surgery (M2). The intervention group patients had significantly improved pain, affected shoulder functions, and anxiety owing to the effects of group, time, and group-time interaction. Body image and sexual adjustment were enhanced based on time and group-time interaction effects. During the follow-up period, experimental group patients experienced an improvement in body image and sexual adjustment, while those in the control group showed a decrease. This suggests that NL-Mapp may play a significant role in training breast cancer patients to manage their symptoms after surgery.

Improving Perioperative Pain Education for Patients Prescribed Opioids: An Integrative Review

BACKGROUND

Postoperative pain is still inadequately managed for a significant number of patients despite the extensive use of opioids. Among several pain management strategies, patient education is a vital component of perioperative pain management. However, perioperative education practices remain inconsistent and incomplete in many hospital settings.

AIM

This integrative review aims to synthesize current evidence regarding pain education interventions across all phases of perioperative care in order to promote the safe use of opioids among patients prescribed opioids.

METHODS

The literature search identified 443 records published since 2016 through Cochrane Library, PubMed, the Cumulative Index of Nursing and Allied Health Literature Plus, and Embase. This review process was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. A total of 12 articles met the inclusion criteria.

RESULTS

The study settings varied from a general surgery center to multiple settings in the United States or Canada, with sample sizes ranging from 27 to 536. The main themes from the analysis include the key components of education, the optimal timing and frequency of education, education delivery methods, and a multidisciplinary team approach.

CONCLUSION

The findings from this review will help nursing professionals across surgical specialties identify effective educational approaches for patients prescribed opioids during the perioperative period. Developing education interventions based on these findings would enhance the quality and effectiveness of pain education, improve patient understanding and their preparedness to manage pain at home, and, ultimately, promote the safe use of opioids postoperatively.

Regional and Acute Pain Anesthesiology Post COVID-19 Assessment and Recommendations for Fellowship Web Based Platforms

In today’s applicant landscape, the SARS-COV-2 pandemic has drastically altered the traditional model of in-person interviews shifting it to an online format often conducted by web-based applications. Fellowship programs and naturally fellowship program directors face a new challenge of standardizing information to be distributed to prospective fellowship applicants through American Society of Regional Anesthesia and Pain Medicine (ASRA) common application. Here we describe a set of 11 criteria recommended by other similar studies selected for evaluation of online program training platforms, where only 13.3% of the acute and regional pain fellowship program online platforms met 75% of the criteria with limited presence in areas of research, rotation schedules, list of fellows, alumni, and life in the area. Additional considerations pertaining to the types of procedures performed, evaluation, mentorship, academic involvement, and teaching should be undertaken by the programs.

Prospective Randomized Study Examining Preoperative Opioid Counseling on Postoperative Opioid Consumption after Upper Extremity Surgery

Background: Rates of opioid addiction and overdose continue to climb in the United States, increasing pressure on prescribers to identify solutions to decrease postoperative opioid consumption. Hand and upper extremity surgeries are high-volume surgeries with a predilection for inadvertent overprescribing. Recent investigations have shown that preoperative opioid counseling may decrease postoperative opioid consumption. In order to test this hypothesis, a prospective randomized trial was undertaken to determine the effect of preoperative opioid counseling on postoperative opioid consumption. Methods: Eligible patients undergoing outpatient upper extremity surgery were randomized to either receive preoperative opioid counseling or to receive no counseling. Surgeons were blinded to their patient's counseling status. Preoperatively, patient demographics, surgical and prescription details were recorded. Postoperatively, patients' pain experience including opioid consumption, pain levels, and satisfaction was recorded. Results: There were 131 total patients enrolled, with 62 in the counseling group and 69 in the control group. Patients receiving counseling consumed 11.8 pills compared to 17.4 pills in the control group (P = .007), which translated to 93.7 Morphine Equivalent Units (MEU) in the counseling group compared to 143.2 MEU in the control group (P = .01). There was no difference in pain scores at any time point between groups. Among all study patients a total of 3767 opioid pills were prescribed with approximately 50% left unused. Conclusion: Patients receiving preoperative counseling consumed significantly fewer opioids postoperatively. Inadvertant overprescribing remains high. Routine use of preoperative counseling should be implemented along with prescribing fewer opioids overall to prevent overprescribing.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

Attending and Resident Surgeon Perspectives and Prescribing Practices of Pain Medication During the Opioid Epidemic

OBJECTIVE

Over 67,000 individuals died in the United States due to drug overdose in 2018; the majority of these deaths were secondary to opioid ingestion. Our aim was to determine surgeon perceptions on opioid abuse, the adequacy of perioperative and graduate medical education, and the role surgeons may play. We also aimed to investigate any differences in attending and resident surgeon attitudes.

DESIGN

Anonymous online survey assessing surgeons' opioid counseling practices, prescribing patterns, and perceptions on opioid abuse, adequacy of education about opioid abuse, and the role physicians play.

SETTING

Two Accreditation Council for Graduate Medical Education accredited general surgery programs at a university-based tertiary hospital and a community hospital in the Midwest.

PARTICIPANTS

Attending and resident physicians within the Departments of Surgery participated anonymously.

RESULTS

Attending surgeons were more likely than residents to discuss posoperative opioids with patients (62% vs. 33%; p < 0.05), discuss the potential of opioid abuse (31% vs. 6%; p < 0.05), and check state-specific prescription monitoring programs (15% vs. 0%; p < 0.05). Surgeons and trainees feel that surgeons have contributed to the opioid epidemic (76% attending vs. 88% resident). Overall, attending and resident surgeons disagree that there is adequate formal education (66% vs. 66%) but adequate informal education (48% vs. 61%) on opioid prescribing. However, when attending physicians were broken down into those who have practiced ≤5 years vs. those with >5 years experience, those with ≤5 years experience were more confident in recognizing opioid abuse (61% vs. 34%) and fewer young faculty disagreed that there is adequate formalized education on opioid prescribing (45% vs. 84%).

CONCLUSION AND RELEVANCE

Patient education should be improved upon in the preoperative setting and should be treated as an important component of preoperative discussions. Formalized opioid education should also be undertaken in graduate surgical education to help guide appropriate opioid use by resident and attending physicians.

Assessment of Opioid-Prescribing Practices in Breast Augmentation: Future Directions for Prescribing Guidelines

BACKGROUND

The United States (US) is in the mid of an opioid epidemic propagated, in part, by prescription opioids. With excess overprescribing documented in a variety of surgical procedures, several societies have recommended opioid-prescribing guidelines. Considering the scope and postoperative pain associated with aesthetic plastic surgery procedures, earnest evaluation into opioid-prescribing practices for breast augmentation was conducted.

METHODS

Members of the American Society for Aesthetic Plastic Surgery were electronically surveyed on their opioid-prescribing patterns. The survey was distributed to 1709 plastic surgeons. Descriptive statistics were collated into percentages, deviations, and morphine milligram equivalents (MMEs), when appropriate.

RESULTS

Two hundred twenty-nine American Society for Aesthetic Plastic Surgery members (13.4%) provided responses. A total of 91.2% of respondents prescribe opioids to patients undergoing breast augmentation. The most commonly prescribed agents included oxycodone/acetaminophen (Percocet, 47.0%) and hydrocodone/acetaminophen (Vicodin, 38.3%). On average, 165.3 ± 81.7 MMEs were dispensed (range, 25.0-600.0 MMEs; number tablets, 5-60). Prescribers felt that a lack of phone-in prescribing (52.4%) and the ease of preemptively prescribing opioids (52.4%) propagate opioid overprescribing. A total of 61.3% of respondents reported that they are or may be in favor of developing plastic surgery societal guidelines related to opioid prescribing. These respondents indicated support for guidelines on opioid-sparing pain management strategies (74.2%) and guidelines identifying the type (54.7%), duration of use (69.5%), and number of opioid tablets (61.7%) necessary for procedures.

CONCLUSIONS

Considerable variability exists among prescribing patterns after breast augmentation. Societal guidelines aimed at providers and patients may serve a future role in opioid prescribing.

Opioid-free anesthesia-caution for a one-size-fits-all approach

Post-operative pain management should ideally be optimized to ensure patient’s mobilization and ability to partake in effective pulmonary exercises for patient’s early recovery. Opioids have traditionally been the main mode for analgesia strategy in the perioperative period. However, the recent focus on opioid crisis in the USA has generated a robust discussion on rational use of opioids in the perioperative period and also raised the concept of “opioid-free anesthesia” in certain circles. Opioid-related adverse drug events (ORADE) and questionable role of opioids in cancer progression have further deterred some anesthesiologists from the routine perioperative use of opioids including their use for breakthrough pain. However, judicious use of opioid in conjunction with the use of non-opioid analgesics and regional anesthetic techniques may allow for optimal analgesia while reducing the risks associated with the use of opioids. Importantly, the opioid epidemic and opioid-related deaths seem more related to the prescription practices of physicians and post-discharge misuse of opioids. Focus on patient and clinician education, identification of high-risk patients, and instituting effective drug disposal and take-back policies may prove useful in reducing opioid misuse.

Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery

Background and objectives

At our institution, we developed an individualized discharge opioid prescribing and tapering protocol for joint replacement patients and implemented the same protocol for neurosurgical spine patients. We then tested the hypothesis that this protocol will decrease the oral morphine milligram equivalent (MME) dose of opioid prescribed postdischarge after elective primary spine surgery.

Methods

In this retrospective cohort study, we identified all consecutive elective primary spine surgery cases 1 year before and after introduction of the protocol. This protocol used the patient’s prior 24-hour inpatient opioid consumption to determine discharge opioid pill count and tapering schedule. The primary outcome was total opioid dose prescribed in oral MME from discharge through 6 weeks. Secondary outcomes included in-hospital opioid consumption in MME, hospital length of stay, MME prescribed at discharge, opioid refills, and rates of minor and major adverse events.

Results

Eighty-three cases comprised the final sample (45 preintervention and 38 postintervention). There were no differences in baseline characteristics. The total oral MME (median (IQR)) from discharge through 6 weeks postoperatively was 900 (420–1440) preintervention compared with 300 (112–806) postintervention (p<0.01, Mann-Whitney U test), and opioid refill rates were not different between groups. There were no differences in other outcomes.

Conclusions

This patient-specific prescribing and tapering protocol effectively decreases the total opioid dose prescribed for 6 weeks postdischarge after elective primary spine surgery. Our experience also demonstrates the potential generalizability of this protocol, which was originally designed for joint replacement patients, to other surgical populations.