In this interview, urologist Francis J. McGovern, MD, discusses the scope of the problem of opioid abuse, outlines opioid-sparing strategies, and explains what the future holds in this area.
The opioid crisis in the United States is widespread and affects many patients-including those undergoing major urologic procedures. In this interview, urologist Francis J. McGovern, MD, discusses the scope of the problem, outlines opioid-sparing strategies, and explains what the future holds in this area. Dr. McGovern is assistant clinical professor of surgery at Harvard Medical School, Massachusetts General Hospital, Boston. Dr. McGovern was interviewed by Urology Times Editorial Consultant Stephen Y. Nakada, MD, the Uehling Professor and founding chairman of urology at the University of Wisconsin, Madison.
What is the scope of the problem of opioid abuse?
The scope of the problem in the United States is very, very serious and it’s widespread. The first statement I’d like to make is that pain is not a vital sign. In 1996, the American Pain Society trademarked the slogan “Pain: The Fifth Vital Sign.” Soon to follow, health regulatory agencies agreed with this declaration and it contributed to a significant rise in the use of narcotics. The United States alone uses more narcotics than all other countries on the planet combined. In 2016, there were over 50,000 deaths in the United States from drug overdose, and 30,000 of those deaths are directly attributed to opioids. In the 1960s, heroin was the most common gateway to opioid addiction. That has been surpassed by prescription opioids.
U.S. studies have shown that 20% of the opioid prescription deaths can be traced back to a patient’s specific prescribing physician. In that same study, 54% of the opioids were obtained from a relative or friend. But when they traced back one step further, 80% of that 54% were, again, traced back to the prescribing pattern of a doctor.
At Massachusetts General Hospital, we are now seeing collaboration with other departments within the department of surgery to address opioid use. We’re all trying to get a better sense for prescribing patterns, establishing norms, and looking at ways to prevent or reduce the need for opioids.
How did you get involved in this area?
It’s been a surgical evolution. At Mass General Hospital, I have a very active urologic/oncologic surgery practice. I’m often operating 4 days a week. As operating surgeons, we all know that complications significantly affect patient outcomes. Every surgeon wants their patients to do well.
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Back in 2000, I chaired a committee at our hospital on the development of clinical pathways for major urologic surgery. During the development of these pathways, we dissected every aspect of care: pre-op, intra-op, and post-op. Efforts were made to standardize the pathways for all major urologic procedures.
We’re currently using these pathways and when we first executed them, we learned that this gave us a window into clearly seeing the issues that were contributing to post-op complications and increased length of stay. We learned that there are basically two main categories of surgical complications. One is directly attributed to surgical operative events. I would put bleeding, anastomotic leaks, anastomotic disruption, and infections in this category.
But then there’s a second, broader category of complications that can be traced to side effects from medications, particularly opioids. Medical literature is now categorizing this as ORADES (Opioid-Related Adverse Drug Events). These are opioid-related side effects including confusion, respiratory issues, ileus, and retention. These are just a few of the very common complications we see. By reducing opioid need, we would also significantly improve patient care, reduce complications, and reduce length of stay.
I credit our outstanding residents for pointing out that most of what they do in their shifts when they’re not in the operating room involves taking care of the side effects of opioids in post-op patients. This therefore became low-hanging fruit for improvement. It’s all been done in an effort to improve care, get more optimal results, and reduce length of stay.
Next: Key strategies to avoiding opioids
Please discuss the key strategies to avoiding opioids.
First, we should all be implementing an Enhanced Recovery After Surgery (ERAS) pathway or an ERAS-type pathway. Five of the twenty steps in ERAS involve opioid reduction. Second, we should collaborate with our anesthesia colleagues, instead of working in two separate silos of surgery and anesthesia. We get our best outcomes when we have a discussion about each patient. Third, develop an individualized pain control plan for each patient’s needs.
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Dr. Nakada, you may operate on a patient for a large kidney mass who has chronic obstructive pulmonary disease. This factor is critical in the development of an individualized pain plan. That patient may benefit greatly from a multi-modality pain control strategy, such as the use of general anesthesia, epidural and local blocks, and non-narcotic medications such as gabapentin and Tylenol. We know a patient who already has some compromised respiratory function will have further suppression with narcotics, so we want to minimize the opioids.
In a course that I gave with my anesthesia colleague, Tony Anderson, MD (currently at Stanford Medical Center), at the AUA annual meeting in Boston, we coined the pneumonic “ALARM.” “A” is for general anesthesia, “L” and “A” are for local anesthesia, “R” is for regional anesthesia, and “M” is for multi-modality. Oftentimes, the strategy for optimal pain management doesn’t come from just one segment but from a multi-modality approach.
I would also point out that if you’re going to make an incision, to think about using a block. Blocks are very easy, are tolerated extremely well, and can reduce the need for opioids in the post-anesthesia care unit. The next strategy is to educate the patient, the family members, nurses-particularly recovery room nurses-as well as the floor nurses and the resident team on the benefits of minimizing the use of opioids. Also important is for the team to include this teaching with any Visiting Nurse Association referral that is arranged at discharge.
What are some of the barriers to success?
This is a significant paradigm shift. The challenge is to change patterns of long-standing behavior. For example, everyone who comes into contact with the patient needs to be on board with the pain management process. You may have an anesthesiologist who always likes to use a high dose of narcotics or a recovery room nurse who always likes to give several doses of narcotics.
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We try to address this professionally by utilizing communication and education. When my residents deliver a patient to the recovery room now and greet the nurse or the anesthesiologist, they will say, “We specifically gave this patient a block and the patient should not require much in the way of narcotics.” We have seen a significant decrease in the use of opioids in the post-op course since we started to implement this process at Massachusetts General Hospital.
Next: "Every practicing urologist... can speak with their anesthesia team and their pain experts"
What should a practicing urologist, who may be a novice to this, do at this point?
Every practicing urologist, whether they’re at a major institution or at a small hospital, can speak with their anesthesia team and their pain experts. For most of my career, I would look at my surgical plan and delegate the decision on the pain management to my anesthesia colleagues. We get a better outcome when we collaborate with our anesthesia and nursing colleagues and work together. I strongly recommend for all of us to develop the surgical plan in parallel with the pain management plan.
Are there any caveats to this approach?
We’ve seen significant reductions in length of stay and increased patient satisfaction with this process, but there’s always room for improvement. Hopefully, new technologies and new innovations will get us to the point where we have medications that can replace or help minimize our need to use any opioids. But until we’re there, we need to do further research and development.
Could you expand a little on the future opportunities in research and development in this area?
This area is in its early stages. I asked my colleagues in other surgical departments at Mass General if they knew how much narcotic an average patient needs for a surgical procedure after they go home. I discovered that nobody had an answer. I asked my resident team how much narcotic the average patient having a radical prostatectomy would utilize and, again, there was a wide variability in the answers.
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At Mass General, we currently have submitted an IRB that is awaiting approval. This will basically allow us to send patients home with a calendar to record how much narcotic they took on post-op day 1 2, 3, 4, 5. The data will be reported at their post-op visit. We will use this information to help us quantitate the use of these medications so that we can establish a set of standards. The point is not to have all patients live by the same number but to understand the norm. This will help us identify patients that are outliers in using an excessive amount of pain medication, which may indicate a post-op clinical problem. Our hope is this data will help us to write for an appropriate number of pills without giving patient an excess amount.
We also need to find ways of research and development into education for patients and families that should begin before surgery-even intra-op or immediately post-op-so that we have everyone on board for the patient’s well-being and safe recovery. There will be great opportunities for research in this area because it’s often the anchor of what’s holding patients back from a speedy, safe recovery.
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