Viewpoint

Using Alternatives to Opioids In an Acute Care Setting


Brian Faley, PharmD

The problem of opioid overuse and abuse on society and public health is rightly gaining increased attention from lawmakers, regulators, medical professionals, and the press. But one aspect of the opioid epidemic that has been largely absent from the national dialogue is the use of opioids in acute care settings. Despite being associated with unwanted and potential life-threatening side effects, which range from nausea, vomiting, and constipation to respiration depression and addiction, opioids continue to be the standard of care in most postsurgical pain management regimens.

Opioid-related adverse events (ORAEs) not only diminish patient recovery and quality of life but also affect direct hospital costs and cost driving measures, as two recently published, large-scale studies show. The first, a national analysis of 320,000 in-patient surgeries found that patients who experienced ORAEs were hospitalized 3.3 days longer, cost the hospital an additional $4,707 and had higher 30-day all-cause readmission rates. The second, a regional study of 37,000 patients, found that ORAEs increased length of stay by 3.4 days, increased costs by 47% and increased readmission rates by 36%.

A shift toward less reliance on opioids seems inevitable, says the author.

Positive outcomes

In the last five years, government agencies and medical societies have issued public statements and guidelines urging hospitals and physicians to use nonopioid therapies and reserve opioids for extreme cases. While most providers theoretically agree with the merits and value of opioid minimization, implementation is difficult. New modalities cost more than the standard care that includes opioids, although if ORAEs are factored in, the difference might not be as large as it appears. In addition, the successful adoption of these new approaches requires the coordinated commitment of many clinicians, including anesthesiologists, surgeons, and nurses.

But by taking a proactive, collaborative approach with physicians, hospital pharmacists can help bring out change. At my institution, when a handful of spine surgeons started seeing positive outcomes associated with local infiltration of liposomal bupivacaine to manage pain following laminectomies, the pharmacy worked with the surgeons to design a small study (n=20) to measure the impact of using this new approach. The study found a statistically significant reduction in opioid use through postoperative Day 3 and a 50% reduction in patient-controlled analgesia (PCA) use.

These preliminary findings led us to conduct larger studies of other kinds of surgery. When 60 laparotomy patients received a local infiltration of liposomal bupivacaine as an adjunct to a multimodal analgesic regimen, we found a meaningful decrease in opioid use and time to flatus compared with the previous standard of care. Similarly, in a study of 200 patients undergoing total knee arthroplasty, use of liposomal bupivacaine resulted in a reduction in the use of opioids after surgery, PCA, and epidural use, and also a modest decrease in length of stay. The savings associated with these reductions was large enough to offset the cost (which was about $300) of adding liposomal bupivacaine to the analgesic regimen. As a result of quantifying the benefit of liposomal bupivacaine, most of our orthopedic surgeries now use this opioid-sparing multimodal approach, and our colorectal service has expressed interest in following suit.

The medical community has a long way to go before opioid minimization becomes standard. But with public health officials pushing for more limited use of opioids and payers incentivizing hospitals to optimize postsurgical recovery by reducing complications and readmissions, a shift toward less reliance on opioids seems inevitable. That change will be good news for hospitals and pharmacists striving to keep costs low and the quality of care high. But it’s even better news for our patients who will be spared the dangerous side effects of opioids.

References

  • Burnett AS, Faley B, McCain DA, et al. Liposomal Bupivicaine Reduces Narcotic Use and Time to Flatus in Patients Undergoing Laparotomy. J Am Coll Surg. 2015; 221: S73.
  • Implicito D. Novel Extended Release Infiltration Analgesic May Improve Recovery Outcomes Following Laminectomy. http://www.beckersspine.com/spine/item/18566-dr-dante-implicito-novel-extended-release-infiltration-analgesic-may-improve-recovery-outcomes-following-laminectomy.html. Accessed Oct. 12, 2015.
  • Kaplan J, Faley B, Thomas Z, et al. Evaluation of liposomal bupivacaine for pain for after total knee arthoroplasty, Crit Care Med. 2014;42:A1511.
  • Kessler ER, Shah M, Gruschkus SK, Raju A. Cost and quality implications of opioid-based postsurgical pain control using administrative claims data from a large health system: Opioid-related adverse events and their impact on clinical and economic outcomes. Pharmacotherapy. 2013;33:383–391.
  • Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of opioid-related adverse events on outcomes in selected surgical patients. J Pain Palliat Care Pharmacother. 2013;27(1):62–70.

Brian Faley is the clinical pharmacist for the Emergency Trauma Department of Hackensack University Medical Center in Hackensack, N.J., and a clinical assistant professor in the Department of Pharmacy Practice and Administration of Rutgers University.

Disclosure statement: Faley has received research grants as well as consulting fees from Pacira Pharmaceuticals, which makes Exparel, a bupivacaine liposome injectable suspension.

UP NEXT

Managed Care
By Frank Diamond
Managed Care
By Peter Wehrwein