Prescribing a New Approach: Physicians Work to Change the Way They — and Patients — Think About Opioids

  • Laurie Curley, a registered nurse in the post-anesthesia care unit at the White River Junction VA Medical Center, explains an opioid buy-back program to Clarence Myer, of Alstead, N.H., after a surgery on Thursday, Dec. 7, 2017, at the medical center in White River Junction, Vt. Myer, who is the chairman of the Conneticut Valley Crime Stoppers, said that police departments in the area are plagued with the issue of drugs and that he thinks the buy back program is a great idea. "We have to do something," he said. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dr. Catherine Schneider, a surgeon at Mt. Ascutney Hospital, prepares to scrub up for surgery on Friday, Dec. 8, 2017, in the operating room at the hospital in Windsor, Vt. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dr. Jean Liu, a general surgeon at the White River Junction VA Medical Center, stands in the angiography unit on Thursday, Dec. 7, 2017, at the medical center in White River Junction, Vt. Liu established a buy-back program at the hospital in April where patients can turn in unused opioid prescriptions for up to $50 in credit. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dr. Richard Barth Jr., the section chief of general surgery at Dartmouth-Hitchcock Medical Center, looks over information about a patient he is about to see on Tuesday, Dec. 5, 2017, in his office at the medical center in Lebanon, N.H. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

  • Dr. Richard Barth Jr., the section chief of general surgery at Dartmouth-Hitchcock Medical Center, talks about a research paper he helped develop which created guidelines for opioid prescribing following abdominal surgery, during an interview on Tuesday, Dec. 5, 2017, at the medical center in Lebanon, N.H. (Valley News - Charles Hatcher) Copyright Valley News. May not be reprinted or used online without permission. Send requests to permission@vnews.com.

Valley News Staff Writer
Sunday, December 24, 2017

Lebanon — Ralph Thomas, a 68-year-old musician from Sunderland, Vt., who had surgery at Dartmouth-Hitchcock Medical Center in 2013, still has a bottle of oxycodone/acetaminophen at home.

Thomas, who said he has a high threshold for pain, didn’t find much use for the 30 pills following his outpatient surgery to prevent acid reflux and to repair a navel hernia. He might have taken one or two, he said in an email.

Still, he didn’t fault the doctor for prescribing the opioids.

“I might have gotten home and might have found that it was much different than I was expecting,” he said in a recent telephone interview.

Thomas has kept the pills on hand in case he needs them for any other reason — for his occasional back pain, for example.

It’s extra pills like Thomas’ and many others around the country that doctors at DHMC and beyond are seeking to reduce by improving health care providers’ and patients’ understanding of how many pills, if any, it takes to treat patients’ pain and by encouraging patients to dispose of unneeded pills properly.

Such efforts include new research by Dartmouth-Hitchcock surgeons that outlines simple, data-based guidelines for prescribing opioids to patients following surgery, a buyback program for outpatient surgical patients at the White River Junction VA Medical Center, and physicians’ work to comply with new opioid-prescribing rules in both New Hampshire and Vermont.

All of these approaches share the broad aim of shifting the way health care providers and patients think about opioids.

“Doctors are caring more about their patients’ pain by setting expectations with them,” said Dr. Richard Barth Jr., Dartmouth-Hitchcock Medical Center’s chief of general surgery, who co-authored three recent papers on opioid prescribing following surgery.

In his own practice, in addition to reducing the number of pills he sends home with patients, Barth also has begun employing a range of techniques to address patients’ pain without opioids, such as applying long-acting numbing medicine to incisions and giving patients medications such as Tylenol prior to surgery.

“Providers worry that their patients are going to have pain (and that) they’re going to get a bad provider satisfaction score,” Barth said.

But, in reality, he said, there are a “whole bunch of other safer ways to take care of patients’ pain other than just handing them a boatload of opioids.”

Motivated by media reports about the opioid epidemic and the role that the overprescription of opioids has had in fueling it, Barth and a group of surgeons and data analysts at Dartmouth-Hitchcock Medical Center aim to determine how many opioid pills are surgeons prescribing and how many are sufficient to treat most patients’ pain.

They hope to reduce the likelihood that their patients might develop an addiction and to reduce the number of unused pills that could be diverted for illicit use, Barth said.

Nationally, the researchers noted in a recent paper, opioid overdose is the leading cause of injury-related death, resulting in nearly 19,000 deaths annually — a number that has quadrupled in the past 15 years. The rate of opioid prescriptions also has quadrupled since 1999, the researchers wrote.

Perhaps surprisingly, before Barth’s team began this work two years ago, there was little published about how many opioids should be prescribed following surgery, so physicians had little research to use to inform their prescribing practices, Barth said.

The team’s first paper, published in the Annals of Surgery, examined opioid prescriptions following the six most common outpatient surgeries performed at DHMC. They found wide variation in the number of opioids prescribed and determined that patients took only 28 percent of the pills. Based on telephone interviews with patients, the team developed guidelines for how many pills ought to be prescribed to address the needs of 80 percent of the patients for each operation. The guidelines direct surgeons to prescribe five pills following a partial mastectomy, 10 pills following a partial mastectomy with sentinel lymph node biopsy, and 15 following two types of hernia repair, for example.

The team’s second study, also published in the Annals of Surgery, found that by providing the guidelines to surgeons, residents and nurses caring for outpatient surgical patients at DHMC, they were able to reduce prescriptions by 53 percent.

“Just through education alone there was a marked decrease,” Barth said.

Only one of the 224 patients included in the second study required an opioid refill, indicating that patients’ pain was adequately treated, Barth said.

In a new paper, published by the Journal of the American College of Surgeons, the team outlined opioid prescription guidelines for the six most common inpatient abdominal surgeries.

The guidelines are based on the number of pills 234 patients reported actually using after inpatient surgery at DHMC in the second half of 2016.

“What we looked for then were predictors of how many opioids are they going to take when they go home,” Barth said.

The researchers looked at a range of variables including the patients’ age, gender, the type of operation and how long they were in the hospital.

They found that “far and away the best predictor (was the) number they took on the day they were discharged,” Barth said.

So, if the patient takes no opioids the day before being discharged, no prescription would be needed, according to the paper. If the patient takes one to three pills, the guidelines recommend the surgeon prescribe 15 opioid pills at discharge. If the patient took four or more, the guidelines recommend a prescription of 30 opioid pills at discharge.

The study predicts that if surgeons follow these guidelines, they should be able to take care of 85 percent of patients’ home opioid needs and reduce the number of pills prescribed by 40 percent.

“The really nice thing about what we’re doing is it’s really patient specific,” Barth said.

Areas that need further investigation include determining whether his team’s guidelines work for more specialized surgery, such as thoracic, cardiovascular and orthopedic procedures, Barth said. He’d also like to incorporate the guidelines into the electronic medical record.

Dr. Catherine Schneider, a general surgeon who practices at Mt. Ascutney Hospital and Health Center in Windsor and New London Hospital, said research like Barth’s should prove helpful in reducing opioid prescriptions.

In speaking with patients, Schneider said, doctors can point to research like Barth’s and say studies show that, “what we’re prescribing is going to take care of your pain.”

Given all the press coverage of the opioid epidemic, Schneider said, some of her patients ask not to be prescribed opioids.

“Patients are definitely much more savvy,” said Schneider, who is vice president of the Vermont Medical Society.

New rules instituted in New Hampshire in January and in Vermont in July have produced the biggest change, she said: Physicians have had to retrain themselves to turn to ibuprofen or acetominophen before prescribing an opioid, she said.

“They won’t be pain free, but they won’t be suffering,” Schneider said.

Generally, the new laws require that providers query the prescription drug monitoring program or system to determine which prescriptions patients already have. The rules also ask providers to consider alternatives to opioids, discuss the risks of opioids with patients, have patients sign a consent form, prescribe the smallest dose possible for the shortest duration possible and encourage them to talk to each other about shared patients.

The new rules also require those prescribing opioids to screen patients for their risk of abusing the medication and, in the case of chronic pain management, to regularly re-evaluate patients’ need for opioids. Exemptions exist for certain patients, such as those in skilled nursing facilities.

Patients using opioids for chronic pain were left out of all three of Barth’s studies — about 5 percent of the patient populations in the studies — so these guidelines do not necessarily apply to that population. And, he said, more research is needed to better understand how best to treat those patients’ pain.

Schneider also pointed to this group of patients as one in need of attention.

“It’s a very difficult group,” she said, of patients suffering from chronic pain. “They’re not all the same.”

Surgeons have to work with the physician prescribing the opioids for chronic pain to determine, she said: “How are we going to manage that pain together?”

Doctors want to avoid driving patients with chronic pain who’ve seen their prescriptions reduced to seek relief through illicit drugs, said James Potter, executive vice president of the New Hampshire Medical Society.

Potter noted that deaths caused by prescription drug overdoses have declined in recent years, while deaths caused by illicit drugs such as heroin or fentanyl have increased.

Other areas of priority for the New Hampshire Medical Society include increasing access to long-term recovery treatment, reducing the stigma associated with addiction and increasing the number of providers qualified to prescribe medication-assisted treatment, Potter said.

The new state rules and research like Barth’s all aim to strike a balance between overprescription and underprescription, said Jessa Barnard, the executive director of the Vermont Medical Society.

“We’re still, I think, learning,” she said. “What’s the trade-off between access and wanting to avoid addiction?”

Buying Them Back

While DHMC surgeons aim to curb opioid prescribing through research and policymakers aim to curb prescribing through new state rules, a general surgeon at the White River Junction VA Medical Center seeks to reduce the number of pills on the street by another means.

Earlier this year, Dr. Jean Liu began an opioid buyback program, which is supported through a grant of about $50,000 from the VA Innovators Network. She came up with the idea after the father of a friend of hers suffered a stroke and, in cleaning out his medicine cabinet, the friend discovered a cache of unused medications. The only way the friend found to dispose of the medication was to take it to a distant police station dropbox, Liu said.

Liu thought that veterans ought to be able to return the medication to the place where they got it, she said.

To encourage veterans to dispose of unused opioids, Liu has begun to pay veterans who have recently had outpatient surgery at the VA Medical Center $5 per pill, up to $50, if they return their pills to a dropbox at the medical center’s pharmacy.

Since the program began about six months ago, Liu said, about one-third of veterans who’ve had outpatient surgery have returned their pills, for a total of more than 1,000 pills.

“I think it’s going really well,” Liu said.

Veterans are using the new pharmacy dropbox for more than just the pills the program is buying back. The new box needs to be emptied every six to eight weeks, which is much more often than the box on the inpatient side which is emptied only every six months, Liu said.

Another effect of the program, Liu said, is that some veterans opt out of an opioid prescription after hearing the description of the buyback program.

Some patients are saying, “I don’t even want to take it ... if it’s really that dangerous,” she said.

While a buyback program might not be feasible everywhere, Barth said, figuring out how to get patients to properly dispose of extra prescription opioids is important. In the study of the outpatient surgeries at DHMC, only 9 percent of patients brought pills to a dropbox or dissolved and mixed them with litter box filler or dirt before throwing them in the trash, two safe ways of discarding of opioids, Barth said. In the inpatient study 19 percent of patients properly disposed of their excess pills.

To make this change, “we have to change mindsets in patients a little bit,” Barth said. “You’re paying for a prescription that’s going to take care of the pain for that particular acute episode, OK. And then, really get rid of the rest of them.”

Valley News Staff Writer Nora Doyle-Burr can be reached at ndoyleburr@vnews.com or 603-727-3213.