Teaching trainees how to write: Surgical resident opioid prescribing and perioperative pain management

Opioid use disorder is rampant across the U.S. and has become a leading cause of injury-related death in the nation. In 2017, approximately 19,000 individuals died from an opioid overdose, quadrupling the rate since 2002.^1,2 In parallel, opioid prescriptions have increased by a factor of four over the same time period.^3-7 At present, more than 5 million people in the U.S. abuse prescription opioids, and 10.3 million have abused prescription opioids at some point in their lifetime.^2,4 These numbers are so high because an estimated 70 percent of nonmedical users of opioids obtain narcotics from a friend or relative; only 17 percent of abusers actually have valid prescriptions.^4,8

Attempts to thwart this crisis have garnered national attention, and 26 states now have laws restricting outpatient opioid use.^9,10 Nonetheless, individuals continue to abuse prescription opioids, highlighting the fact that physicians have a moral obligation to consider how overprescribing may contribute to this crisis.

Surgery often is the first exposure patients have to opioids, with opioids being the most commonly prescribed medication following an operation,^11,12 but variations in practice are discernible.¹³ For example, patients undergoing identical operations by the same provider often receive different numbers of pills.¹⁴ Eid and colleagues found a range of 0 to 56 narcotic pills were prescribed following laparoscopic appendectomy, even within the same surgical service.¹⁵

The Centers for Disease Control and Prevention (CDC) has recommended that treatment of acute pain be less than seven days,¹⁶ and little scientific evidence is available to support or explain such excessive and dissimilar prescribing practices between health care providers. Indeed, many surgeons continue to provide opioid medications for much longer than a week following an operation.¹² Consequently, the growth of the opioid epidemic has led to an increase in the prevalence of opioid use disorder and the number of surgical patients on pharmacologic treatment for this disease. Lack of consensus on appropriate perioperative management in these patients poses an additional challenge for surgeons.¹⁷

Prescriber-focused initiatives have been implemented to address the epidemic and include opioid prescriber education, establishment of prescription drug monitor programs, and limits on the amount of opioid medications prescribed.¹⁸ These initiatives primarily are focused on addressing the prescribing habits of board-certified physicians, but most opioid prescriptions are written by surgeons in training.¹⁹ Residents are obliged to ensure a patient’s postoperative pain is addressed, but also have a societal imperative to avoid overprescribing.

The role of residents in the opioid crisis

Trainees are ideal vectors for reversing the opioid epidemic, as they comprise the cadre of almost 120,000 U.S. physicians who prescribe narcotics in the U.S.²⁰ Of particular value are surgical residents, who are at increased probability of opioid prescribing relative to residents in other specialties.²¹ From the first day of residency, surgical interns write most of the discharge prescriptions, yet instruction on opioid prescribing is largely peer-to-peer with minimal consideration given to opioid-sparing analgesics.^21,22 Despite their best intentions, surgical residents have been found to prescribe twice as many pills as originally anticipated.²¹

In reality, the reason for these poor prescribing habits is multifactorial and includes a lack of specific guidelines, as well as a dearth of formal education.²³ For example, surgical residents report prescribing more opioids to patients to avoid inconveniencing their senior faculty or negatively affecting patient satisfaction scores.^20,23 Unfortunately, only 33 percent of incoming surgical interns at one academic center reported receiving training on opioid prescribing during medical school, and most felt ill prepared at the start of residency.²² Moreover, a survey of surgical residency program directors found that a mere 20 percent offered mandatory trainee education on opioid prescribing, yet 95 percent still allowed trainees to prescribe outpatient opioids.²⁴ Even worse, some residency program directors do not understand the regulations regarding individual and hospital Drug Enforcement Administration registration or state licensure requirements.^20,25 Hence, the Accreditation Council for Graduate Medical Education recently mandated that program directors be responsible for understanding such policies so as to supervise and teach residents appropriate habits.²⁵

As a result of omitting these crucial components of education in medical training, young physicians lack an understanding of the significance or scope of opioid abuse. Data demonstrate a significant knowledge gap in trainee education on the opioid crisis and the role of physician prescribing practices. It is imperative that surgeons address this issue if we want to have an impact on the opioid crisis in the future.

Studies have demonstrated the positive effects of surgical resident education on opioid prescribing practices.^26-28 Two related pieces published in 2018 by Chiu and colleagues report the results of a survey in which residents explained their prescribing habits, knowledge about narcotics, and previous education on prescribing analgesics.^28,29 The survey revealed a range of morphine milligram equivalents (MME) that residents would hypothetically prescribe to patients after common general surgery procedures. Also notable was a significant difference between hypothetical MME amounts between senior and junior residents, with senior residents prescribing more. Reported factors influencing resident prescribing habits were attending preferences, presence of a standard prescription amount based on the operation, concern for opioid abuse, and concern for patient dissatisfaction. In addition, 12.1 percent of residents reported educating patients about opioid overdose and only 6.2 percent provided instructions to patients for proper disposal of excess narcotics.²⁸

In the follow-up study, these same authors implemented a formal curriculum on postoperative pain management for incoming interns,²⁹ which provided residents with a greater sense of confidence about prescribing both opioid and nonopioid analgesia to postoperative patients. Furthermore, participants prescribed significantly less MME per prescription over the same time span compared with interns the previous year. Another set of studies published by Hill and colleagues similarly found wide variability in the number of postoperative opioids prescribed for common surgical procedures.¹⁴ The authors implemented an educational intervention, providing recommendations for the quantity of opioids needed after common procedures, which resulted in a significant reduction in the number prescribed. Furthermore, only one of the 224 patients included in the analysis required a refill.²⁷ Although these opioid-reduction studies are from single centers, they provide a framework for how residency programs can provide education on postoperative pain management and optimal prescribing practices.

Targeted techniques for reducing overprescribing

Young surgical residents, who are most often charged with clerical duties like prescription writing, rarely witness the downstream effects of their opioid-prescribing habits because of minimal clinical exposure and the disjointed rotation schedule of residency.²³ Therefore, early structured education may mitigate provider ambivalence and empower residents to make smarter prescribing decisions. Specifically, education surrounding multimodal analgesia and prescription-writing practices should begin in medical school or, at the latest, during residency orientation.³⁰ Instruction centered on opioids should include prescribing appropriate, specified amounts of narcotics after many standard procedures; effective use of nonopioid analgesics as adjuncts to pain management; methods of educating patients on the risks of opioids; appropriate screening of patients at increased risk of opioid dependence; and methods of proper disposal of excess opioids.

These interventions should be directed toward academic, teaching hospitals. After all, approximately 60 percent of U.S. operations are performed at teaching hospitals, and high-risk prescribing is more common in teaching institutions than at community hospitals.²² Educational opportunities, such as presentations at grand rounds highlighting departmental opioid data, have yielded a significant reduction in discharge doses.³¹ Mandatory education, standardized patient instruction, and evidence-based prescribing guidelines have reduced opioid prescribing practices.³²

Other specific methods to combat overprescribing include implementation of electronic prescribing systems. Data show that both attendings and residents are more comfortable with prescribing smaller opioid volumes when using e-prescriptions.²³ Furthermore, mandating the use of state prescription drug monitoring programs can facilitate better prescription tracking.

Teaching residents about the risk factors for opioid abuse disorder or persistent opioid use (POU) also is critical. For example, a history of mental illness, such as anxiety, depression, or substance abuse, has been shown to independently increase risk for POU.^33-35 Harbaugh and colleagues found older age, female sex, prior substance abuse, chronic pain, and preoperative opioid prescriptions were independent risk factors for POU.³⁶ Further, preoperative opioid use has been associated with new persistent use following multiple types of surgery in pediatric and adult populations, particularly in thoracic surgery.^37,38 Various populations also are at heightened risk, such as individuals with cancer, where up to 10.4 percent of these patients report POU after curative intent surgery.^39-41 Keeping all of these factors in mind, surgeons and surgeons-in-training should thoroughly assess each patient at discharge, as well as provide alternative strategies for pain management in those at highest risk for POU.

Next, a collaborative approach should be used to implement protocols and best prescribing practices for common surgical procedures.22 The Michigan Opioid Prescribing Engagement Network (OPEN) provides an excellent example of such collaboration. Using patient-reported data, Michigan OPEN has developed recommendations on the quantity of opioids prescribed after a number of common procedures.⁴² Fulfillment of these recommendations and standardization of opioid prescribing requires buy-in from hospital administrators and surgical faculty.

Sceats and colleagues suggest that faculty incorporate the discussion of pain control on surgical rounds, similar to thromboembolism prophylaxis, which would normalize the discussion around opioids and reduce certain stigmas.²³ Moreover, most academic centers have a pain management service that specializes in multimodal approaches to analgesia. Perhaps surgical trainees should rotate through these services or attend clinic with these specialists to better understand longitudinal, multimodal options.22,23,43 Indeed, multimodal therapies, including use of nonsteroidal medication and gabapentinoids, have been shown to reduce opioid use in the perioperative period.44 Residents could learn about co-prescription of Naloxone to patients at risk for opioid overdose,^16,20 as well as learn to manage pain in patients with chronic buprenorphine use.

Acute pain management and chronic buprenorphine use

Prolonged opioid use can lead to opioid use disorder, which is defined as a “problematic pattern of opioid use leading to problems or distress” and at least two other symptoms related to patterns of use or physiologic characteristics related to use within a 12-month period.⁴⁵ With the increasing prevalence of opioid use disorder, the proportion of patients prescribed buprenorphine (partial opioid agonist used to treat opiate use disorder) also is increasing. For example, retail prescriptions for buprenorphine increased to 12.5 million people in 2016 from 8.2 million in 2015.⁴⁶ Typically dosed between 8–24 mg of buprenorphine daily, it has a high affinity for mu-receptors, displacing illicit mu-agonists such as heroin.⁴⁷ It is available in two formulations—Subutex (exclusively buprenorphine) and Suboxone (Naloxone and buprenorphine). The addition of naloxone prevents patients from abusing Suboxone through crushing and injecting intravenously. The ability of buprenorphine to displace mu-opioid agonists also creates a ceiling effect for pain relief, which requires thoughtful management in the postoperative period.⁴⁸

No societal or national guidelines are available for the perioperative management of buprenorphine. The clinical guidelines for the use of buprenorphine in the treatment of opioid addiction from the Center for Substance Abuse Treatment state, “While patients are taking opioid pain medications, the administration of buprenorphine generally should be discontinued.”⁴⁹ However, different institutions take varying approaches to buprenorphine management. The University of Michigan, Ann Arbor, guidelines recommend stopping buprenorphine one to three days before a major elective operation and transitioning from buprenorphine to patient-controlled analgesia for individuals undergoing major emergency operations.⁵⁰ The University of California San Francisco department of anesthesia and perioperative care recommends dose reduction or discontinuation only for patients on higher doses (> 8 mg/day Suboxone or Subutex).⁵¹

In general, published recommendations agree that buprenorphine should be continued at the usual dose in the postoperative period following minor operations for patients on doses less than 8 mg/day. A recent editorial by Lembke and colleagues proposed a controversial protocol in which all patients continue buprenorphine in the perioperative period. It recommends that patients taking more than 12 mg/day buprenorphine tapered to 12 mg daily two days before an operation.⁵² Postoperatively, these patients would continue to take 12 mg daily as a part of multimodal pain therapy, including short-acting opioids. The authors argued that discontinuing buprenorphine before surgery in patients with opioid use disorder introduced unnecessary risks of delaying an operation, created management complexity, and forced patients to undergo a period of active opioid withdrawal.⁵²

Whereas national consensus guidelines for the management of buprenorphine in the postoperative setting do not yet exist, experts agree that postoperative analgesia in patients with opiate use disorder requires institutional protocols for postoperative buprenorphine use, involvement of acute pain services and multimodal analgesia, and plans tailored to each patient’s history and needs.

Call to action

While most surgical interventions are designed to alleviate pain, often surgery is the first time that a patient is exposed to opioids, which can lead to narcotic dependence and opioid use disorder in some individuals. Unfortunately, surgical residents are ill-equipped to formally evaluate for risk factors for POU and opioid use disorder. A lack of trainee education combined with a surplus of narcotics in the possession of an individual with inherent risk factors for abuse fuels this epidemic. Therefore, universal implementation of formalized resident education on prescribing practices should be prioritized. Specifically, interventions aimed at opioid-prescribing reduction should start as early as possible in medical education, be directed at teaching hospitals, and emphasize establishment of consensus-based prescription guidelines.

As evidence-based approaches to pain management and opioid prescribing develop, it will be important to continue to incorporate these into resident education. However, such recommendations are evolving in parallel with the development of resident education on this topic, so a coordinated and thoughtful approach is essential. Nevertheless, while there are multiple laudable approaches aimed at solving the problem of opioid overprescribing, it is vital that health care professionals, particularly surgical trainees, be an integral part of the solution.

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