How hospitals help stem the tide in the opioid crisis

Summer 2019

The headlines point to a grim prognosis. In London, five deaths attributed to opioid overdose in one week. Canada wide, more than 10,000 people have lost their lives to opioids in the past three years. This has become public health crisis. How did we get here?

The incidence of opioid abuse and fatalities has grown over the past 20 years. Recent historical perspective is giving us insight into why this might be the case, and research is providing a way forward.

Why has there been such an increasing trend in opioid addiction in the past 20 or so years?

Traditionally narcotics were only provided to cancer patients, but then came a pharmaceutical push for chronic, non-cancer pain relief in the 1990s and early 2000s, explains Dr. Luke Hartford, general surgery resident at LHSC.

“It was propagated that pain was under-medicated - it was seen as the fifth vital sign - and more prescriptions were provided to patients for opioids. The aim became for no pain after surgery, but the addiction potential was underestimated.”

To help address the opioid crisis in Ontario and particularly Southwestern Ontario, London Health Sciences Centre and St. Joseph’s Health Care London along with the hospitals in the region, set up an Opioid Stewardship Council in an effort to reduce the use and abuse of opioids.

The Council is comprised of emergency physicians, surgeons, anaesthesiologists, residents, registered nurses and advanced practice nurses, pharmacists, patient and family advisors and other members of the care team.

“Acute pain is a complex process and narcotics, in particular opioids, do a good job in taking the pain away,” says Dr. Brian Rotenberg, Chair of the Opioid Stewardship Council.  “However, we now have more modern techniques in surgery and care provision, such that there is often less pain resulting from procedures, but prescribing practices have not caught up to that. This is one of the things we set out to change.”

To change prescribing practices and reduce the number of opioids in the community, the Opioid Stewardship Council looked to research and best practices to come up with its recommendations.

As a result, the following STOP Narcotics clinical protocols were put in place in February 2019:

  1. Once a patient is discharged after their surgery/procedure the default quantity for any new opioid prescription start is now three days. This is based on evidence guidelines that three days is sufficient for most types of acute pain. The prescriber can change the prescription as necessary for their patient.
  2. Tamper-resistant prescription scripts are now used for all opioid prescriptions making it difficult to copy or alter the script.
  3. The Institute for Safe Medication Practices Canada has developed an information sheet about opioids and pain management that will now print automatically with any new opioid prescription. Health-care providers review it with patients.

 

The Opioid Stewardship Council is measuring the success of these changes to see how well they are adopted and how effective they are.

Recognizing the role of opioid over-prescription in the national opioid crisis, a study demonstrating the efficacy of a new clinical protocol called STOP Narcotic was undertaken by the Division of General Surgery, Schulich School of Medicine and Dentistry, and Lawson Health Research Institute, the research institute of LHSC and St. Joseph’s Health Care London.

“The objective of the study was to provide adequate pain control, while reducing narcotic use through educating physicians to utilize non-opioid medications along with opioid-reduced prescriptions. We also educated patients what to expect in terms of pain, and how to use non-opioid medications (e.g. Tylenol) and dispose of excess opioids,” says Dr. Hartford, who was first author on the study.

“The goal is to limit the reliance on narcotics prescribed, providing the patient with good pain management, while providing the understanding and expectation that there can be some pain.”

The STOP Narcotics study enrolled 416 patients who underwent hernia repair. After their surgery they were prescribed meloxicam, a non-steroidal anti-inflammatory drug and instructed to take Tylenol regularly.

The participant further received a prescription of 10 opioid pills with the expectation that they would not fill the prescription unless the other medications were not effective in managing their pain. The prescription also had an expiry date of seven days, after which they could no longer fill it.

Those who did fill their prescriptions where asked to return to the pharmacy any pills they did not use.

Researchers then compared the results of their study group to a control group of patients not in the study.

 

Study Group

Control Group (patients not in the study)

45 per cent of patients filled their opioid prescription

95 per cent of patients filled their opioid prescription

23 per cent disposed of their excess opioids properly

Seven per cent disposed of their excess opioid properly

Pain level 2.1

on a scale of 1-10 where 10 is the highest

Pain level 2.3

on a scale of 1-10 where 10 is the highest

There was a 50 per cent reduction in the number of opioids being prescribed.

 “It is important to note that the reported levels of pain between the two groups were essentially the same. The intervention group reported a pain level of 2.1 and the control group a level of 2.3 on a scale of 1 – 10, where 10 is the highest level of pain,” says Dr. Hartford.

So looking at the results from this study, researchers found that the patient’s pain control was just as effective without a significant prescription of opioids.

“We recognized that before STOP Narcotics, every surgeon had a different approach to pain control,” says Dr. Ken Leslie, Lawson scientist and Chief of General Surgery at LHSC, who led the implementation of the new protocol.

While this new protocol has been rolled out in General Surgery, Dr. Leslie sees this as something that will be implemented across the services at LHSC.

“This is primary prevention. Patients don’t say to the surgeon, ‘I’m getting too much medication,’” says Dr. Leslie. “We can keep patients really comfortable without narcotics.”

 

 

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