October 10, 2019
3 min read

USC implements enhanced recovery after surgery program to reduce opioid prescriptions

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Michael Kim
Carol Peden

Keck Medicine of the University of Southern California is changing its standards of pain management after surgery as part of an enhanced recovery after surgery program for all service lines. By combining multimodal analgesia with patient involvement and education in their care, faculty and staff members at the institution have seen better outcomes and pain management, as well as shorter lengths of stay.

Jay R. Lieberman

“When we were putting together the [enhanced recovery after surgery program] ERP program for all the service lines, I just had a keen sense to know that patients recover better when they have less pain and more information and involvement with their care,” Michael Kim, DO, clinical assistant professor of anesthesiology at Keck School of Medicine and anesthesiologist at Keck Medicine of University of Southern California (USC), told Healio.com/Orthopedics.

Multimodal analgesia, patient education

Kim said they have developed a comprehensive multimodal analgesia protocol that has led to the success of the ERP. This involves use of opioid-sparing techniques and local anesthetic blocks intraoperatively, as well as use of acetaminophen, gabapentin and NSAIDs, eg, ibuprofen, before and after surgery.

“Not only have we dramatically reduced opioid use, but ... our patients are more comfortable. They have less pain with less opioids by adding in all these other analgesics,” Carol Peden, MD, MPH, professor of anesthesiology at Keck School of Medicine of USC and director of the Gehr Center for Health System Science and Innovation at USC, told Healio.com/Orthopedics.

Education of patients, their families, clinicians and everyone involved in the patient’s care has also helped reduce opioid use and improved outcomes, Kim said.

Patients using narcotics prior to surgery should also be sent to a pain management specialist to be weaned off the narcotics, according to Jay R. Lieberman, MD, chair and professor of orthopedic surgery at Keck School of Medicine of USC and chief of orthopedic surgery service at Keck Medicine of USC.

“[Our general philosophy is] to educate the patients about opioids before the surgical procedure about what kind of medications they are going to get and how long they are going to receive them,” Lieberman said. “Then, that is reinforced by the whole health care team when the patients are in the hospital.”

The protocols instituted at USC also ensure that patients are sent home with a limited number of opioids.

“[Patients] can get more pain killers if they need them, but they are not being given a large amount to take home and, in fact, I would say that the vast majority of our patients do not need them,” Peden said.


Keys to implement a protocol

Kim noted the best way to institute protocols to reduce opioid prescriptions is if it is physician led with administrative support. He added it is also important for everyone involved to have a “deep-dive conversation” about how to approach implementing the protocols, and to understand that change will not happen overnight.

“You have to persevere through it and stay persistent in some of these goals because at the end of the day, the patients end up doing better and ultimately that’s our goal,” Kim said.

According to Lieberman, someone on the surgical team needs to take time during the preoperative discussion to address pain management issues, which should be reinforced the day of the procedure and the day of discharge.

“All of the providers who are coming into contact with that patient need to provide a consistent message and that includes the nurses on the floor [and] the physical therapists so that the patient does not get confused,” Lieberman said. “This is a team effort. Other people need to reinforce that message. All the health care providers need to deliver a consistent message.”

Overall, the surgical teams at USC are continuing to monitor patients as they identify the best methods for providing the best in patient care.

“[Pain management] is an evolving field [and] I think that is the issue: What works best?” Lieberman said. “It may be something that is patient dependent. It may be operation dependent to a certain extent, so I think it is great that we are paying more attention to this issue so we can provide appropriate pain relief, but avoid the overuse of opioids.” – by Casey Tingle


Disclosures: Lieberman reports he is on the advisory board for Recro Pharmaceutical. Peden and Kim report no relevant financial disclosures.