Efforts to close existing policy gaps and misaligned payment practices in current opioid management practices can promote greater utilization of multimodal opioid-sparing pain management options.
Opioid prescriptions in the perioperative setting are a known risk factor for long-term opioid use and misuse. Recent initiatives in the United States to address the issue have focused on judicious prescribing patterns and quality measurement to minimize opioid dispensing. However, policy gaps have limited the effectiveness of current interventions. Expanded policy considerations are warranted, including patient-focused opioid risk screening and preferences for nonopioid pain management, with broader plan coverage for multimodal opioid-sparing pain management (OSPM). Additionally, formalized clinician education regarding specific nonopioid pain management alternatives may increase utilization, as will incorporation into perioperative OSPM clinical pathways. It is also important for patients to have access to the option for multimodal OSPM in the perioperative setting without financial disincentives, which may arise in surgery-specific bundled payment models. Finally, expansion of research activities regarding clinical and cost-efficacy outcomes may help to advance use of these options, laying the groundwork for development of a broader set of quality measures reflecting utilization and outcomes of multimodal OSPM in the perioperative setting.
Am J Manag Care. 2022;28(8):369-372. https://doi.org/10.37765/ajmc.2022.89196
Recent initiatives in the United States to address opioid misuse have focused on judicious prescribing and quality monitoring. However, policy gaps have limited their effectiveness. We propose recommendations for a more comprehensive approach, including as follows:
For the 12-month period ending in April 2021, sequelae from the COVID-19 pandemic resulted in more than 100,000 overdose deaths—a nearly 30% increase from the prior period, according to the CDC.1 Of these deaths, more than 75% involved an opioid. This was a nearly 35% increase from the prior period,1 reflecting a disproportionate rise in opioid-related deaths. For 2019, the last full year of available data, prescription opioids were involved in more than 28% of all opioid overdose deaths, although there was a nearly 7% reduction in prescription-related opioid deaths from the prior year.2 However, concerns remain regarding the use of prescription opioids as a trigger for subsequent illicit opioid use,2 with the level of opioid dispensing in morphine milligram equivalents remaining nearly 3 times greater than it was in 1999.3
Opioids prescribed at hospital discharge are a known contributor to chronic opioid use,4 as well as opioid misuse and addiction.5 Efforts to decrease prescription opioid use have resulted in a downward trend since 2012, especially for high-potency opioids such as oxycodone or hydromorphone, for which prescribing rates fell by nearly 60% through 2017.5 Much of the current effort to reduce prescription opioid use has targeted physicians, and particularly surgeons, to be more judicious in their prescribing patterns. However, opportunities exist for earlier intervention in the course of treatment to minimize or potentially eliminate opioid use, particularly in the perioperative setting.6 Despite the broad availability of multimodal opioid-sparing pain management (OSPM) offerings, as well as opioid misuse risk stratification resources, these interventions are infrequently included as opioid use reduction tactics in existing quality improvement frameworks.7 The goals of this commentary are to present a brief overview of evolving approaches to reducing perioperative opioid use and to provide recommendations for policy changes to systematically broaden the scope of efforts to mitigate opioid use into the perioperative setting.
Patient-Centered Opportunities to Reduce Perioperative Opioid Use
Opioid misuse risk assessment and stratification as part of clinical pathways. Validated risk assessment and stratification instruments have been developed to evaluate opioid misuse potential in the perioperative setting.8,9 These tools can be supplemented with other data sources to enhance risk stratification, including state prescription drug monitoring program websites. When utilized in the preoperative setting, such tools can complement more commonly used needs assessments as part of preoptimization enhanced recovery after surgery (ERAS) pathways to improve surgical outcomes.10,11 Preoperative use of an opioid abuse risk assessment provides a more consistent approach to informing perioperative pain management approaches. When such an assessment is incorporated into ERAS pathways along with multimodal OSPM offerings, effectiveness has been demonstrated in a variety of settings.10
Pain management alternatives for high-risk individuals. In an effort to reduce opioid use, the CDC Prescribing Guideline12 and the HHS Pain Management Inter-Agency Task Force Report13 encourage providers and patients to consider all available treatment options, including multimodal nonopioid and nonpharmacological therapies that can be used alone or together with opioids. Clinical experience with innovative, multimodal perioperative OSPM options is rapidly accumulating10,14 and may help to further mitigate the need for postoperative opioid use.
Recommended Policy Changes to Expand the Approach to Judicious Perioperative Opioid Use
CMS should consider new presurgical interventions to avoid unnecessary opioid use, including (1) a structured opioid abuse risk screening tool, (2) standard questions about patient preference regarding opioid use in preoperative screening, (3) provider decision support systems, and (4) promotion of the expanded use of anesthesia guidelines to identify patients likely to benefit from use of nonopioid alternatives.
Presurgical patient screening regarding opioid use and risk of subsequent misuse does not appear to be a broadly adopted component of perioperative management, despite recent recognition of value.13 CMS could take action through the Physician Fee Schedule and Outpatient Prospective Payment System regulations by adding a quality measure and/or by requiring that physicians and hospitals that receive the bundled surgical payment conduct an opioid risk screening and document patient pain management preference.
Ensure consistent health plan coverage of nonopioid treatment alternatives for pain management, in addition to identifying clinicians with expertise in their use, particularly in the perioperative setting.
As part of their clinical coverage policy documents, health plans should incorporate OSPM in the perioperative setting. Additionally, individuals seeking or warranting use of nonopioid options due to opioid misuse risk concerns or personal preference should be able to readily identify in-network clinicians who are experienced in their administration. Provider directories should include identification of clinicians with expertise in OSPM.
Expand access to clinician education regarding use of multimodal nonopioid treatment alternatives and their role in OSPM for perioperative pain management.
Recent research has highlighted the effectiveness of nonopioid options in perioperative pain management, achieving results that appear comparable with or superior to those of opioids.15,16 In this setting, reduced use of opioids has also been associated with fewer complications,17 decreasing the potential for a prolonged hospital stay and associated costs. Clinician education regarding these outcomes can likely facilitate greater use of nonopioid alternatives.
Many, but not all, state medical societies have implemented mandatory continuing medical education programs related to pain management and opioid use.18 If not already included, incorporation of structured educational content regarding solicitation of patient pain management preferences, the value of opioid misuse risk assessments, and the evolving array of OSPM options may accelerate clinician awareness and use of additional approaches to decrease opioid use. If this consideration is not viable at the state medical board level, implementation as part of annual clinician credentialing for health care facilities may be a reasonable alternative.
Payers should ensure access to OSPM in the perioperative setting.
Access to the broad array of new nonopioid medications and treatment alternatives for perioperative OSPM has been limited due to their positioning in bundled payment models for surgical care. Currently, most bundled pricing contracts for surgical care exclude nonopioid alternatives, thereby creating a financial disincentive for their use because they are comparatively more expensive than opioids. As a result, for the sake of expanded margins, these options may be withheld from patients who would otherwise derive benefit.
Instead, bundled payment models for surgical care should include an explicit carve-out of nonopioid alternatives to permit their appropriate use based on opioid abuse risk stratification as well as patient preference. Formalizing a carve-out for nonopioid alternatives will eliminate the financial disincentive for their use and enhance patient-centered care. This approach may also facilitate greater throughput as a result of shorter postoperative recovery times and lower costs of care in reduced treatment-intensity settings.19
Expand research efforts to evaluate the impact of OSPM on patient-reported outcomes, as well as on the efficiency of surgical services delivery.
When implemented as part of ERAS pathways, nonopioid alternatives may facilitate faster postoperative recovery, improved symptom control, shorter length of stay, reduced postoperative complications, and lower health care expenditures. As a consequence, lower opioid use at hospital discharge may reduce the risk of long-term opioid use. Expansion of research activities to quantify these outcomes is likely to provide additional insight into consequences related to greater facility throughput for surgical procedures, which may well result in greater revenue despite the incremental increase in case-related costs due to the inclusion of nonopioid offerings.19
Expand quality measures to incorporate patient opioid risk assessment, as well as preferences for and use of OSPM.
Two recent publications have created a formal context for quality measures related to opioid use. In its 2020 report, the National Quality Forum characterized current quality measures regarding opioid use and identified top priority gaps in quality measurement science.7 Additionally, the CDC Guideline for Prescribing Opioids for Chronic Pain12 provides a detailed guide for clinician practices and health systems to manage opioid prescribing to minimize the risk of opioid misuse using a quality improvement framework.
These reports provide thoughtful discussion and considerations for opioid quality measures, and they also illustrate the critical need for expansion of quality measures to include consideration of nonopioid alternatives as part of OSPM. Inclusion of these measures will help formalize the role of OSPM treatments, further reducing the need for opioids. The Table includes representative measures that can potentially supplement the existing perioperative quality measure set.
Opioid overdose fatalities continue to plague people living in the United States and are driven in part by prescription opioids. Without reform to the existing opioid paradigm, widespread misuse of opioids will continue. A growing knowledge base is progressively enhancing our understanding of the multiple sources of value of use of nonopioid alternatives as part of OSPM in the perioperative setting. By implementing policy changes to broaden availability of OSPM options in perioperative care, clinicians and health care organizations can expand their role in the deescalation of the opioid crisis.
Author Affiliations: Triad HealthCare Network (BWS), Greensboro, NC; Case Western Reserve University School of Medicine (BWS), Cleveland, OH; Goldfinch Health Inc (BN), Austin, TX.
Source of Funding: Partial funding from Pacira Pharmaceuticals.
Author Disclosures: Dr Sherman reports a consultancy supporting Pacira regarding employer health benefits purchasing and partial payment from Pacira as part of consultancy duties. Dr Newland is CEO and board member of Goldfinch Health.
Authorship Information: Concept and design (BWS, BN); drafting of the manuscript (BWS); critical revision of the manuscript for important intellectual content (BWS, BN); obtaining funding (BWS); and administrative, technical, or logistic support (BN).
Address Correspondence to: Bruce W. Sherman, MD, Triad HealthCare Network, 117 Kemp Rd E, Greensboro, NC 27410. Email: email@example.com.
1. Drug overdose deaths in the U.S. top 100,000 annually. News release. National Center for Health Statistics. November 17, 2021. Accessed December 16, 2021. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm
2. Prescription opioid overdose death maps. CDC. March 24, 2021. Accessed October 21, 2021. https://www.cdc.gov/drugoverdose/deaths/prescription/maps.html
3. Guy GP Jr, Zhang K, Bohm MK, et al. Vital signs: changes in opioid prescribing in the United States, 2006-2015. MMWR Morb Mortal Wkly Rep. 2017;66(26):697-704. doi:10.15585/mmwr.mm6626a4
4. Calcaterra SL, Yamashita TE, Min SJ, Keniston A, Frank JW, Binswanger IA. Opioid prescribing at hospital discharge contributes to chronic opioid use. J Gen Intern Med. 2016;31(5):478-485. doi:10.1007/s11606-015-3539-4
5. Prescribing practices. CDC. August 13, 2019. Accessed October 21, 2021. https://www.cdc.gov/drugoverdose/deaths/prescription/practices.html
6. Fawcett W, Ljungqvist O, Lobo D. Perioperative opioids—reclaiming lost ground. JAMA Surg. 2021;156(11):997-998. doi:10.1001/jamasurg.2021.2858
7. Opioids and opioid use disorder: quality measurement priorities. National Quality Forum. February 20, 2020. Accessed October 11, 2021. https://www.qualityforum.org/Publications/2020/02/Opioids_and_Opioid_Use_Disorder__Quality_Measurement_Priorities.aspx
8. Chaudhary MA, Bhulani N, de Jager EC, et al. Development and validation of a bedside risk assessment for sustained prescription opioid use after surgery. JAMA Netw Open. 2019;2(7):e196673. doi:10.1001/jamanetworkopen.2019.6673
9. Karhade AV, Ogink PT, Thio QCBS, et al. Machine learning for prediction of sustained opioid prescription after anterior cervical discectomy and fusion. Spine J. 2019;19(6):976-983. doi:10.1016/j.spinee.2019.01.009
10. Smith TW Jr, Wang X, Singer MA, Godellas CV, Vaince FT. Enhanced recovery after surgery: a clinical review of implementation across multiple surgical subspecialties. Am J Surg. 2019;219(3):530-534. doi:10.1016/j.amjsurg.2019.11.009
11. Joliat GR, Ljungqvist O, Wasylak T, Peters O, Demartines N. Beyond surgery: clinical and economic impact of Enhanced Recovery After Surgery programs. BMC Health Serv Res. 2018;18(1):1008. doi:10.1186/s12913-018-3824-0
12. Quality improvement and care coordination: implementing the CDC Guideline for Prescribing Opioids for Chronic Pain. CDC. August 20, 2021. Accessed October 7, 2021. https://www.cdc.gov/opioids/healthcare-admins/qi-cc.html
13. Pain management best practices inter-agency task force report: updates, gaps, inconsistencies, and recommendations. HHS. May 9, 2019. Accessed December 14, 2021. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf
14. Chin C, Sigman S. Experience-based opioid-sparing orthopedic surgical protocols. J Orthop Exp Innov. April 8, 2021. Accessed January 26, 2022. https://journaloei.scholasticahq.com/article/21694-experience-based-opioid-sparing-orthopedic-surgical-protocols
15. Hallway A, Vu J, Lee J, et al. Patient satisfaction and pain control using an opioid-sparing postoperative pathway. J Am Coll Surg. 2019;229(3):316-322. doi:10.1016/j.jamcollsurg.2019.04.020
16. Anderson M, Hallway A, Brummett C, Waljee J, Englesbe M, Howard R. Patient-reported outcomes after opioid-sparing surgery compared with standard of care. JAMA Surg. 2021;156(3):286-287. doi:10.1001/jamasurg.2020.5646
17. Chung BC, Bouz GJ, Mayfield CK, et al. Dose-dependent early postoperative opioid use is associated with periprosthetic joint infection and other complications in primary TJA. J Bone Joint Surg Am. 2021;103(16):1531-1542. doi:10.2106/JBJS.21.00045
18. Continuing medical education: board-by-board overview. Federation of State Medical Boards. December 7, 2021. Accessed January 7, 2022. https://www.fsmb.org/siteassets/advocacy/key-issues/continuing-medical-education-by-state.pdf
19. Johnston A, McCutcheon C, Renwick A, Moug S. PWE-414 a designated ERAS nurse consistently achieves ERAS goals with significant cost reductions for the NHS. Gut. 2015;64(suppl 1):A391-A392. doi:10.1136/gutjnl-2015-309861.860