Guidelines at Mayo Clinic decrease number of opioids prescribed

With its guidelines that restrict opioid prescriptions, Mayo Clinic has drastically reduced the number of opioids prescribed to patients who undergo surgery.

“With the guidelines, we have seen dramatic drops in the number of opioids prescribed to our surgical patients but no observed increase, in general, across most of our procedures for patients needing opioid refills,” Elizabeth B. Habermann, PhD, professor of health services research at Mayo Clinic, told Healio.com/Orthopedics. “[That] was a concern. We don’t want patients to not be able to access care that they need but, in general, we haven’t seen any increases in refills which is a signal to us that even with the decrease in the number of opioids prescribed, patients are having enough opioids to manage their pain.”

Guidelines for every specialty

Habermann said beginning in 2017, each specialty at Mayo Clinic had a multidisciplinary team come up with specific guidelines for their specialty. After 9 months, presentations were made to help implement the guidelines, which were also electronically available with hard copies.

She noted almost all the procedures have adhered to the guidelines at an 80% rate or higher. For a few procedures, the teams have looked to see if the guidelines need to be altered to be more appropriate or more successful for a specific specialty.

“There has been a new patient-education brochure that has developed to prompt discussion,” Habermann said. “There are also new guidelines developed by my colleagues at Mayo Clinic on how patients should taper off opioids, but that’s going to vary by procedure.”

Place to dispose of opioids

Habermann said Mayo Clinic has worked with its community to give patients and community members a place where they can appropriately dispose of leftover opioids.

“We have developed ‘drug take-back days’ to have additional places for patients and community members to return leftover opioids here in Rochester,” Habermann said. “... We have disseminated our guidelines to all hospitals that participate in the Mayo Clinic Care Health Network, which includes hospitals across the country and also internationally. Our guidelines are not just meant to be applied to our own patients, but shared with others.”

Mayo Clinic seen as role model

The orthopedic department at Mayo Clinic created the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategy project in 2016, which looks at the entire patient care process from initial consultation to follow-up. Orthopedic surgeons and anesthesiologists review everything that may contribute to a patient’s pain.

“Many others in the state and nationally are looking at what the Mayo Clinic’s Department of Orthopedic Surgery has published on this topic,” Matthew J. Abdel, MD, professor of orthopedic surgery and consultant at Mayo Clinic, told Healio.com/Orthopedics. “At this point, many institutions are now following several protocols that have been developed and/or popularized in Rochester. Moreover, we have determined what the oral morphine equivalents are that are appropriate for certain procedures and now us those thresholds when discharging patients.”

The Department of Orthopedic Surgery guidelines, which have been published in a study co-authored by Cody C. Wyles, MD, include the maximum opioid-morphine equivalents that should be prescribed to opioid-naïve patients after surgery. For instance, if a patient undergoes surgery for an acute fracture, radiculopathy or carpel tunnel, the patient should be prescribed a maximum of 100 opioid-morphine equivalents. If a patient undergoes total hip arthroplasty, total shoulder arthroplasty, total knee arthroplasty or major spine surgery, the patient should be prescribed a maximum of 400 opioid-morphine equivalents.

Abdel said prior to the implementation of their opioid guidelines, the mean opioid prescription was 750 opioid-morphine equivalents, which went down to 388 opioid-morphine equivalents. He said a big factor that played into this decrease was staff education during which everyone was taught the maximum number of opioids a patient should be prescribed.

“We have pushed ahead and executed high-level, randomized, controlled clinical trials looking at the use of motor-sparing blockades, periarticular injections, short-acting spinals and tranexamic acid that have revolutionized the number of opioids that patients need to receive,” Abdel said.

Abdel said game changers in Mayo Clinic’s multimodal approach include ketorolac, celecoxib, tranexamic acid, short-acting spinals with efficient surgical procedures and periarticular injections. Apart from these approaches, Mayo Clinic has used music in the OR, physical therapy, massage therapy and ice therapy to also control pain.

Abdel said Mayo Clinic needs to further reduce the opioid refill rate, which is currently about5 35%.

“We need to move toward opioid-free for a subset of patients. Right now, we are doing opioid-sparing. That’s minimizing opioids,” Abdel said. “It is not zero. It’s just using them at a lose dose in combination with other medications.” – by Monica Jaramillo

 

Reference:

Wyles CC, et al. Clin Orthop Relat Res. 2019;doi:10.1007/s11999.0000000000000292.

 

Disclosures: Abdel reports he is a paid consultant for Stryker. Habermann reports no relevant financial disclosures.

 

 

With its guidelines that restrict opioid prescriptions, Mayo Clinic has drastically reduced the number of opioids prescribed to patients who undergo surgery.

“With the guidelines, we have seen dramatic drops in the number of opioids prescribed to our surgical patients but no observed increase, in general, across most of our procedures for patients needing opioid refills,” Elizabeth B. Habermann, PhD, professor of health services research at Mayo Clinic, told Healio.com/Orthopedics. “[That] was a concern. We don’t want patients to not be able to access care that they need but, in general, we haven’t seen any increases in refills which is a signal to us that even with the decrease in the number of opioids prescribed, patients are having enough opioids to manage their pain.”

Guidelines for every specialty

Habermann said beginning in 2017, each specialty at Mayo Clinic had a multidisciplinary team come up with specific guidelines for their specialty. After 9 months, presentations were made to help implement the guidelines, which were also electronically available with hard copies.

She noted almost all the procedures have adhered to the guidelines at an 80% rate or higher. For a few procedures, the teams have looked to see if the guidelines need to be altered to be more appropriate or more successful for a specific specialty.

“There has been a new patient-education brochure that has developed to prompt discussion,” Habermann said. “There are also new guidelines developed by my colleagues at Mayo Clinic on how patients should taper off opioids, but that’s going to vary by procedure.”

Place to dispose of opioids

Habermann said Mayo Clinic has worked with its community to give patients and community members a place where they can appropriately dispose of leftover opioids.

“We have developed ‘drug take-back days’ to have additional places for patients and community members to return leftover opioids here in Rochester,” Habermann said. “... We have disseminated our guidelines to all hospitals that participate in the Mayo Clinic Care Health Network, which includes hospitals across the country and also internationally. Our guidelines are not just meant to be applied to our own patients, but shared with others.”

Mayo Clinic seen as role model

The orthopedic department at Mayo Clinic created the Orthopedic Surgery and Anesthesiology Surgical Improvement Strategy project in 2016, which looks at the entire patient care process from initial consultation to follow-up. Orthopedic surgeons and anesthesiologists review everything that may contribute to a patient’s pain.

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“Many others in the state and nationally are looking at what the Mayo Clinic’s Department of Orthopedic Surgery has published on this topic,” Matthew J. Abdel, MD, professor of orthopedic surgery and consultant at Mayo Clinic, told Healio.com/Orthopedics. “At this point, many institutions are now following several protocols that have been developed and/or popularized in Rochester. Moreover, we have determined what the oral morphine equivalents are that are appropriate for certain procedures and now us those thresholds when discharging patients.”

The Department of Orthopedic Surgery guidelines, which have been published in a study co-authored by Cody C. Wyles, MD, include the maximum opioid-morphine equivalents that should be prescribed to opioid-naïve patients after surgery. For instance, if a patient undergoes surgery for an acute fracture, radiculopathy or carpel tunnel, the patient should be prescribed a maximum of 100 opioid-morphine equivalents. If a patient undergoes total hip arthroplasty, total shoulder arthroplasty, total knee arthroplasty or major spine surgery, the patient should be prescribed a maximum of 400 opioid-morphine equivalents.

Abdel said prior to the implementation of their opioid guidelines, the mean opioid prescription was 750 opioid-morphine equivalents, which went down to 388 opioid-morphine equivalents. He said a big factor that played into this decrease was staff education during which everyone was taught the maximum number of opioids a patient should be prescribed.

“We have pushed ahead and executed high-level, randomized, controlled clinical trials looking at the use of motor-sparing blockades, periarticular injections, short-acting spinals and tranexamic acid that have revolutionized the number of opioids that patients need to receive,” Abdel said.

Abdel said game changers in Mayo Clinic’s multimodal approach include ketorolac, celecoxib, tranexamic acid, short-acting spinals with efficient surgical procedures and periarticular injections. Apart from these approaches, Mayo Clinic has used music in the OR, physical therapy, massage therapy and ice therapy to also control pain.

Abdel said Mayo Clinic needs to further reduce the opioid refill rate, which is currently about5 35%.

“We need to move toward opioid-free for a subset of patients. Right now, we are doing opioid-sparing. That’s minimizing opioids,” Abdel said. “It is not zero. It’s just using them at a lose dose in combination with other medications.” – by Monica Jaramillo

 

Reference:

Wyles CC, et al. Clin Orthop Relat Res. 2019;doi:10.1007/s11999.0000000000000292.

 

Disclosures: Abdel reports he is a paid consultant for Stryker. Habermann reports no relevant financial disclosures.

 

 

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