Implementation of a Post-Surgical, Multimodal Analgesia Pain Management Order Set in Opioid-Naive Patients



 

Authors

Faith Brown PharmD1; Maggie Guinta PharmD, BCPS, BCCCP2; Jenna Swindler PharmD, BCPS-AQID3; Denise Allison MSNEd, RN3; Craig Selander MD4; Brenda Raynor BSN, RN3

Perm J 2020;25:20.048 [Full Citation]

https://doi.org/10.7812/TPP/20.048
E-pub: 12/23/2020

ABSTRACT

Background: Perioperative pain management guidelines recommend using multimodal analgesia to improve pain control while reducing opioids administered. The primary objective of this study was to assess whether implementing multimodal analgesia on general surgery postoperative pain management order sets would reduce opioid quantities postoperatively.

Methods: Opioid-naive patients undergoing nonemergent general surgery procedures were evaluated before and after order set revision. The primary outcome was the total quantity of inpatient opioids administered. The secondary outcomes were inpatient naloxone administration, patient-reported pain scores, and opioid quantities prescribed at discharge.

Results: The average daily opioid consumption was less each postoperative day (POD) after implementing the revised postsurgical multimodal analgesia pain management order set. On POD 1 and POD 2, average opioid consumption was 53.6 and 47.9 oral morphine equivalents (OME) before the multimodal analgesia order set, respectively, compared with 21.2 and 21.4 OME after, respectively (p < 0.01 and p < 0.01, respectively). Average daily opioid consumption through POD 3 was 60.6 OME before and 21.14 OME after the revision. Average daily pain scores were similar on POD 0, 1, and 2 before and after (3.2, 2.8, and 2.4 compared with 2.8, 3.1, and 2.7, respectively; p = 0.09, 0.33, and 0.12, respectively). On POD 3, pain scores were higher in the postorder set group (2.8 compared with 1.9; p < 0.01), but this was considered clinically insignificant. Average daily pain score through POD 3 was 2.6 before implementation compared with 2.8 after implementation. Neither group required naloxone administration.

Conclusion: Using perioperative multimodal analgesia reduces opioid consumption without increasing pain scores.

BACKGROUND

America is facing an opioid crisis. Opioid overdose was the leading cause of death in the US in 2016, surpassing the number of deaths from motor vehicle accidents.1 The quantity of opioid overdose deaths was 5 times higher in 2016 compared with 1999.2 The Centers for Disease Control and Prevention report the number of opioid-related deaths has consistently increased since 1999, with the initial wave of deaths involving prescription opioid overdoses, the second wave initiating in 2010 involving heroin overdoses, and the third wave of deaths involving synthetic opioids beginning in 2013.3

A retrospective analysis using an electronic sample of administrative health claims reviewed the incidence of opioid-naive patients prior to surgery becoming chronic opioid users 1 year following surgery. Over 600,000 claims were reviewed for 11 prespecified surgical procedures. The analysis found a statistically significant increase in chronic opioid use in the first year following surgery for 7 of the 11 surgical procedures vs that of nonsurgical patients, suggesting an increased risk for developing chronic opioid use in opioid-naive patients undergoing these surgical procedures.4

Current practice guidelines published by the American Pain Society and the American Society of Anesthesiologists recommend using multimodal analgesia perioperatively to achieve superior pain management postoperatively and to reduce the quantity of opioids required.5,6 Specific multimodal analgesia methods recommended in these guidelines include nonpharmacological modalities, such as nerve stimulation and early ambulation in addition to scheduled, around-the-clock use of nonopioid analgesics.5,6

Pain management order sets used by the general surgery physician group at McLeod Regional Medical Center include opioid and nonopioid medications, administered based on patient-reported pain scores on a 10-point numeric scale. The medications are listed as “as-needed” orders to reduce the number of scheduled opioids received postsurgery. Conceding the evidence published suggesting an increase in opioid use following surgery in opioid-naive patients, we assessed whether the implementation of a postsurgical pain management order set that implements multimodal analgesia would reduce the quantity of opioids required postoperatively. The overarching goal was to decrease opioid use in the general surgery patient population while limiting exposure of opioids to opioid-naive patients requiring surgery.

METHODS

Study Design and Inclusion Criteria

This was a single-center, retrospective, and prospective cohort study design that qualified as quality improvement by the Institutional Review Board. The study was conducted at McLeod Regional Medical Center, a 461-bed community hospital. Patients were identified for enrollment in the retrospective arm of the study by running a report on general surgeries performed between November 2017 and January 2018 from the electronic medical record. Patients were screened for inclusion and exclusion criteria. Patients were identified for enrollment in the prospective arm of the study by running a report on order set use between March 12, 2019 and June 11, 2019 from the electronic medical record and screened for inclusion and exclusion criteria. Patients were eligible if they were classified as opioid-naive adults ≥ 16 years old, had undergone a nonemergent or scheduled general surgery procedure, and had a hospital length of stay ≥ 24 hours. “Opioid naive” was defined as patients who filled ≤ 3 prescriptions and/or < 30 days’ supply of opioids in the 12 months prior to surgery. Patients were excluded if they were admitted to an intensive care unit postsurgery; were allowed nothing by mouth (including medications; ie, strict NPO) postsurgery; participated in the Early Recovery after Surgery protocol; or were pregnant, a prisoner, or on hospice. T test and Welch test were used for continuous variables of normal distribution and unequal variances, respectively, as determined by the F-test for equal variances. The Fisher exact test was used for nominal data, and the Mann-Whitney test was used for ordinal data; p values < 0.05 were considered statistically significant. Statistical analysis was conducted using Medcalc Statistical Software version 19.3.1 (MedCalc Software Ltd, Ostend, Belgium).

Intervention

Revisions to the postoperative pain management order set for general surgery patients were implemented on March 12, 2019. The previous order set provided all nonopioid and opioid medications on an as-needed basis and did not provide a scheduled pain medication regimen. Many of the opioids available on the order set were provided as range orders, for which doses administered were provided at the nurses’ discretion. Additionally, it offered multiple sources for acetaminophen ingestion as well as multiple sources for nonsteroidal antiinflammatory drug administration. The revised order set implements scheduled one-time doses of preoperative medications and nonopioid analgesic options postoperatively (Table 1). Additionally, the order set eliminated the opioid/acetaminophen combinations to prevent accidental acetaminophen toxicity. General surgery postoperative order sets affected include General Surgery Floor, Mastectomy/Partial Mastectomy, Thyroid/Parathyroid, Amputation (Extremity), Lap/Conventional Appendectomy, and Lap Hiatal Hernia Repair.

Table 1. Order set revisions

Previous Order Set

Postoperative drugs
Acetaminophen (Tylenol) 650 mg PO Q4HP mild pain/temp > 38.3°C
Ibuprofen (Motrin) 800 mg PO Q8HP for mild pain
Ketorolac (Toradol) 15-30 mg IV Q6HP for moderate pain ×72 h
Hydrocodone /APAP (Norco) 5/325 mg 1-2 tab PO Q4HP for moderate pain
Oxycodone/APAP (Percocet) 5/325 mg 1-2 tab PO Q4HP for moderate pain
Oxycodone/APAP (Percocet) 10/325 mg PO Q3HP w/food for severe pain
Oxycodone (Roxicodone) 5-10 mg PO Q3HP for severe pain
Morphine 2-4 mg IV Q2HP for severe pain
If allergic to morphine
 Hydromorphone (Dilaudid) 0.2-0.5 mg IV Q2HP for severe pain
Post-op pain medications short set
Revised order set
Pre-op pain medications short set
 Acetaminophen (Tylenol) 1000 mg PO × 1 ON CALL TO OR
 Celecoxib (Celebrex)
Gabapentin
 Gabapentin (Neurontin) ON CALL – 1200 mg PO (CrCl ≥ 60)
 Gabapentin (Neurontin) ON CALL – 600 mg PO (CrCl < 60)
 Gabapentin (Neurontin) not ordered due to ESRD
Must administer nonopioid pain medications before administering opioids
 Acetaminophen (Tylenol) 1000 mg PO Q8H × 48 h for mild pain, then Q8HP
 Acetaminophen 650 mg REC Q8H × 48 h, then Q8HP
 Ketorolac (Toradol) 15 mg IV Q6H × 48 h for moderate pain, then Q6HP
 Celecoxib (Celebrex) 200 mg PO BID × 48 h
Gabapentin
 Gabapentin 600 mg PO TID × 48 h (CrCl ≥ 60), hold for sedation ≥ 3 h
 Gabapentin 300 mg PO TID × 48 h (CrCl < 60), hold for sedation ≥ 3 h
Moderate pain
 Oxycodone 5 mg PO Q4HP moderate pain (can give with Toradol)
 Morphine 2 mg IV Q4HP for moderate pain
 Ketorolac (Toradol) 15 mg IV Q6HP for moderate pain
 Cyclobenzaprine (Flexeril) 10 mg PO TIDP for muscle spasms
Severe pain
 Morphine 4 mg IV Q2HP for severe pain
If allergic to morphine
 Hydromorphone (Dilaudid) 0.5 mg IV Q2HP for severe pain
 Fentanyl 25 µg IV Q2HP for severe pain

Table 2. Baseline characteristics

  Preorder set revisions retrospective general surgery patients, n = 76 Postorder set revisionsprospective general surgery patients, n = 89 p value
Average age, y 58.96 59.39 0.87
Male, n (%) 36 (47.4) 52 (58.4) 0.16
Race, n (%)
 African American 41 (53.9) 48 (53.9) 1.00
 White 34 (47.4) 36 (40.4) 0.64
 Other 1 (1.3) 5 (5.6) 0.22
Comorbidities, no. of patients (%)
 Hypertension 53 (69.7) 53 (59.6) 0.20
 Diabetes 23 (30.3) 36 (40.5) 0.20
 Heart failure 11 (14.5) 8 (9.0) 0.33
 Chronic kidney disease 7 (9.2) 15 (16.9) 0.17
 Substance abuse (present or history of) 2 (2.6) 5 (5.6) 0.45
 Alcohol abuse (present or history of) 5 (6.6) 5 (5.6) 1.00
Surgical procedure, n (%)
 GI procedure 33 (43.4) 37 (41.6) 0.88
 GU procedure 7 (9.2) 1 (1.1) 0.03
 Debridement 10 (13.2) 29 (32.6) 0.00
 Line placement or excision 10 (13.2) 3 (3.4) 0.04
 Amputation 8 (10.5) 13 (14.6) 0.49
 Other 8 (10.5) 6 (6.7) 0.41
Self-reported use of as-needed opioids 41 (53.9) 23 (25.8) < 0.001
Self-reported use of OTC oral analgesics 23 (30.3) 16 (18.0) 0.07
Self-reported use of gabapentin 11 (14.5) 14 (15.7) 1.00
Self-reported use of benzodiazepine 10 (13.2) 4 (4.5) 0.05
Average hospital stay, d 8.44 6.11 0.07

GI = gastrointestinal; GU = genitourinary; OTC = over the counter.

Education

Prior to implementing the revised order set, extensive education was provided to surgeons, surgical floor nurses and staff, postanesthesia care unit nurses, operating room nurses, and certified registered nurse anesthetists affected by the order set revisions. The nursing staff was educated on the changes to the postoperative order sets and encouraged to provide available nonopioid analgesic medications to patients prior to opioid medications. Surgeons received education regarding available literature to support providing a smaller quantity of opioid prescriptions at discharge, stratified by type of surgical procedure. Additionally, nursing staff and the Clinical Effectiveness staff prepared education materials to provide to patients, which reviews post-operative pain expectations, plans to control pain post-operatively (scheduled nonopioid analgesics), and how patients will be asked to communicate their pain (10-point pain scale). Pamphlets discussing risks surrounding opioids, naloxone reversal, and opioid disposal were also provided to patients. The educational materials are provided to patients preoperatively in the surgeon offices and are enforced postsurgery by nurses caring for them on the floor.

Outcomes

The primary clinical outcome was the quantity of inpatient opioids administered to opioid-naive patients postoperatively. These data were collected as an average daily opioid quantity consumed, in oral morphine equivalents (OME), through postoperative day (POD) 3. Secondary outcomes included average daily pain scores and naloxone requirement (yes/no) through POD 3 and the quantity of opioids, in OME, prescribed at discharge.

RESULTS

Enrollment and Baseline Characteristics

From November 2017 through January 2018, a total of 130 patients who underwent a nonemergent or scheduled general surgery procedure were screened for enrollment in the retrospective arm of the study. Fifty-four patients were excluded from the study (length of stay < 24 hours, nonopioid naive, intensive care unit postsurgery, age < 16 years, Early Recovery after Surgery protocol), leaving 76 patients who were included in the retrospective (or pre order set revision) cohort of the study. A total of 261 patients were screened for enrollment in the prospective (or postorder set revision) arm of the study between March 12, 2019 and June 11, 2019. One hundred seventy-two patients were excluded from the study, with 89 patients remaining for inclusion in the prospective cohort.

Baseline characteristics were similar between groups with respect to general demographics and comorbidities (Table 2). Postimplementation, male patients reported lower pain scores on average than female patients (2.52 vs 3.25). Oral morphine equivalents were also lower in male patients vs female patients by POD 3 (18.34 vs 20.12 OME). Whites reported an average pain score of 2.73 and OME of 15 by POD 3, whereas African Americans reported 2.81 and 26.9, respectively. Other populations had average pain scores of 2.5 and 15 OME by POD 3. The number of patients with as-needed opioids, over-the-counter analgesic medications, or benzodiazepines on their home medication list was lower in the prospective group compared with the retrospective group, in which they were reduced by approximately 50%, but reported use of gabapentin was similar between groups. Average hospital length of stay was shorter postimplementation, with a reduction of hospital stay greater than 2 days. Use of intraoperative multimodal analgesia increased following implementation of order set revisions. Liposomal bupivacaine use decreased in the prospective arm of the study, but intraoperative use of ketamine, lidocaine, ketorolac, and magnesium increased in the prospective arm of the study (Table 3).

Table 3. Intra-operative multimodal analgesia

  Preorder set revisions retrospective general surgery patients, n = 76 Postorder set revisions prospective general surgery patients, n = 89 p value
Bupivacaine, liposome, no. of patients (%) 23 (30.3) 8 (9.0) < 0.001
Ketamine, no. of patients (%) 20 (26.3) 33 (37.1) 0.18
Lidocaine, no. of patients (%) 58 (76.3) 77 (86.5) 0.11
Ketorolac, no. of patients (%) 2 (2.6) 7 (7.9) 0.18
Magnesium sulfate, no. of patients (%) 10 (13.2) 10 (11.2) 0.81

Table 4. Primary and secondary outcomes

  Preorder set revisions retrospective general surgery patients, n = 76 Postorder set revisions prospective general surgery patients, n = 89 p value
Average opioid consumption, oral morphine equivalents
 POD 0 28.9 19.77 0.07
 POD 1 53.64 21.19 < 0.001
 POD 2 47.88 21.38 0.01
 POD 3 45 22.22 0.09
Average daily pain score (0-10)
 POD 0 3.21 2.86 0.09
 POD 1 2.76 3.05 0.33
 POD 2 2.43 2.68 0.12
 POD 3 1.93 2.76 < 0.001
Naloxone administration, no. of patients 0 0 N/A
Opioid prescriptions prescribed at discharge, n (% patients) 29 (38.2) 54 (60.7) 0.01
Tablets prescribed at discharge, mean (SD) 12.2a (21.9) 15.8b (21.4) 0.3136

a. Seventy evaluable patients.

b. Eighty evaluable patients.

POD = postoperative day.

Primary Outcome

On POD 1 and 2, average opioid consumption was 53.6 and 47.9 oral OME before the multimodal analgesia order set, respectively, compared with 21.2 and 21.4 OME after, respectively (p < 0.01 and p < 0.01, respectively). Average daily opioid consumption through POD 3 was 60.6 OME before and 21.14 OME after the revision (Table 4). Surgical procedures performed between the retrospective and prospective group were similar between groups and included gastrointestinal procedures, genitourinary procedures, incision and debridement, line placements or excisions, amputations, and other (Table 5).

Table 5. Surgical procedures

Surgical procedure Preorder set revisionsretrospective general surgery patients, n = 76 Postorder set revisionsprospective general surgery patients, n = 89
GI procedures 33 37
 Laparoscopic/open cholecystectomy 10 12
 Hernia repair 5 8
 Hemi/colectomy 6 4
 Exploratory laparotomy 10 3
 Small bowel/GI resection 0 4
 Appendectomy 0 2
 Other GI procedure 2 4
Genitourinary procedures 7 1
 Urinary stent placement 4 1
 Hysterectomy 3  
Incision and debridement 10 29
Line placement or excision (graft, fistula, tunneled catheters) 10 3
Amputations 8 13
 Above knee 3 3
 Below knee 2 1
 Metatarsal 3 9
Other 8 6

GI = gastrointestinal.

Secondary Outcomes

Average daily pain score was collected based on a 10-point pain scale through POD 3. Average daily pain scores were similar on POD 0, 1, and 2 before and after (3.2, 2.8, and 2.4 compared with 2.8, 3.1, and 2.7, respectively; p = 0.09, 0.33, and 0.12, respectively). On POD 3, the pain scores were higher in the postorder set group (2.8 compared with 1.9; p < 0.01), but this was considered clinically insignificant. Average daily pain score through POD 3 was 2.6 before the order set compared with 2.8 after. Neither group required naloxone administration. Opioid prescriptions provided at discharge preimplementation totaled approximately 38.2% of patients, whereas 60.7% patients postimplementation received an opioid prescription at discharge.

DISCUSSION

Scheduled multimodal analgesia has demonstrated the ability to reduce perioperative opioid requirements. Average daily opioid consumption decreased approximately 60% after implementation of scheduled acetaminophen and scheduled gabapentin during the perioperative period. Increased use of intraoperative agents may have contributed to the reduced opioid requirements and pain scores seen on POD 0 (day of surgery) in the prospective group. Education surrounding order set changes and nursing administration of opioid medications may have also contributed to these requirements and scores.

At POD 1, 2, and 3, the postimplementation group reported with higher pain scores compared with those of the preimplementation group, although averages remained at or below a score of 3, which is recognized as an acceptable pain score for adequate pain control. The differences in pain scores between groups were minimal, suggesting normal variation between groups. A greater difference in pain score was noted between groups for POD 3. The authors correlate the increased pain score on POD 3 to the reduced number of patients remaining in the hospital at POD 3. Prior to implementation, 70 of the 76 patients included remained in the hospital with the ability to capture pain scores; postimplementation, 70 of the 89 patients included remained in the hospital with the ability to capture pain scores. The reduced number of patients, relative to the total included, is statistically significant but not clinically significant.

Discharge prescriptions provided to patients in the postimplementation group increased from 38.2% to 60.7%. The authors attribute this increase to the education provided to providers regarding discharge prescriptions. Before implementation, prescriptions provided at discharge were not appropriately scanned into the electronic medical record, resulting in an inability to appropriately capture the true quantity of opioids being prescribed at discharge. Extensive education was provided to providers and nursing staff on surgical floors to ensure discharge prescriptions are being scanned into the electronic medical record appropriately. Additionally, education regarding evidence-based recommendations for quantity of opioids prescribed to patients at discharge was provided to surgeons in the practice.

Limitations

There are many limitations of this study. This study included a small subset of inpatient general surgery patients with a length of stay > 24 hours. Therefore, opioid requirements in patients who underwent outpatient procedures were not included in the study data.

The method for classifying patients as opioid naive was changed during the study. Initially, the study team planned to use the Prescription Drug Monitoring Program to identify the quantity of opioids/opioid prescriptions patients had received in the previous 12 months. Research and data collection are excluded from the appropriate indications for use of the Prescription Drug Monitoring Program database. Therefore, the determination of patients’ opioid-naive status was based on their self-reported home medication lists. Patients with no opioid prescriptions on their home medication lists were classified as opioid naive, and those with scheduled long- or short-acting opioid prescriptions were classified as nonopioid naive. Patients with as needed opioid prescriptions required further investigation into their chart to identify if they were taking these medications on more of a chronic versus truly as-needed basis. If it was determined that patients used the opioid prescriptions on an as-needed basis, they were included in the study. Patients who used as-needed opioids on a routine basis were not included.

Intraoperative multimodal use data are still recorded via paper documentation instead of the electronic medical record. This limitation influenced the researchers’ ability to accurately collect intraoperative multimodal use data on all patients included in the study because the accuracy relies on the hand-written chart.

The ability to capture discharge prescriptions varied between groups. At first glance, it appears the quantity of prescriptions prescribed postimplementation was much higher than in the preimplementation data. While collecting retrospective data, it was identified that many of the prescriptions prescribed at discharge were not being appropriately scanned into the electronic medical record, which falsely underestimated the quantity of opioids being prescribed. As part of the education provided prior to implementing the revised order set, surgeons and discharge personnel were encouraged to document discharge prescriptions appropriately, which may be a contributing factor to the increased quantity of opioid prescriptions captured at discharge.

Pain scores were assessed using mean data instead of median data. Because pain scores are classified as ordinal data, the data should have been collected as median instead of mean.

CONCLUSIONS

The goal of reducing the quantity of opioids patients require perioperatively is to decrease opioid-related adverse events, provide superior pain control via the use of multimodal analgesia, and reduce patient risk for becoming a chronic opioid user. Results from this study suggest the use of perioperative multimodal analgesia reduces opioid consumption without increasing pain scores. Future studies might include general surgery outpatient populations and additional surgery divisions, such as orthopedics and neurosurgery.

Disclosure Statement

This manuscript has not been published and is not under consideration for publication elsewhere. We have no conflicts of interest to disclose. It is an Institutional Review Board-approved, single-center, retrospective and prospective cohort study.

Author Affiliations

1Medical University of South CarolinaFlorence Medical Center, Florence, SC

2Wellstar Kennestone Hospital, Marietta, GA

3McLeod Regional Medical Center, Florence, SC

4McLeod Loris Seacoast Surgery, Little River, SC

Corresponding Author

Denise Allison, MSNEd, RN ()

Author Contributions

Faith Brown, PharmD; Maggie Guinta, PharmD, BCPS, BCCP; and Jenna Swindler, PharmD, BCPS-AQID, participated in the study design, acquisition and analysis of data, critical review, and drafting and review of the final manuscript. Craig Selander, MD, participated in the study design, analysis of data, critical review, and review and submission of the final manuscript. Brenda Raynor, BSN, RN, participated in acquisition and analysis of data, critical review, and review of the final manuscript. All authors have given final approval to the manuscript.

How to Cite this Article

Brown F, Guinta M, Swindler J, Allison D, Selander C, Raynor B. Implementation of a post-surgical, multimodal analgesia pain management order set in opioid-naive patients. Perm J 2020;25:20.048. DOI: 10.7812/TPP/20.048

References

1. Confronting the opioid crisis in the United States. Accessed August 19, 2018. https://www.opioids.gov/.

2. Centers for Disease Control and Prevention. Opioid overdose. 2017. Accessed July 25, 2018. www.cdc.gov.

3. National Institute on Drug Abuse. Prescription opioids. Accessed August 19, 2018. https://www.drugabuse.gov/publications/drugfacts/prescription-opioids.

4. Sun EC, Darnall BD, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med.2016 Sep;176(9):1286-93. DOI: https://doi.org/10.1001/jamainternmed.2016.3298, PMID:27400458

5. Chou R, Gordon DB, de Leon-Casasola OA, et al Guidelines on the management of postoperative pain. Management of postoperative pain: A clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain 2016 Feb;17(2):131-57. DOI: https://doi.org/10.1016/j.jpain.2015.12.008

6. American Society of Anesthesiologists Task Force on Acute Pain Management. Practice guidelines for acute pain management in the perioperative setting: An updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012 Feb;116(2):248-73. DOI: https://doi.org/10.1097/ALN.0b013e31823c1030, PMID:22227789

Keywords: Analgesia, Multimodal, Pain, Opioid, Opioid-Naive

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