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Opioid Conversations with Surgeons

Opioid Conversations with Surgeons

De: The HealthCare Improvement Foundation
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 Opioid Conversations with Surgeons explores current topics and innovative approaches to surgical opioid stewardship, focusing on both clinician and patient perspectives.2022 Ciencias Sociales Enfermedades Físicas Hygiene & Healthy Living Relaciones
Episodios
  • Episode 6: Opioid-Free Surgery: One Patient’s Story

    Episode 6: Opioid-Free Surgery: One Patient’s Story
    Oct 25 2022
    Wendy Nickel: Thank you both for being here today to share a little bit about your surgery story. My name is Wendy Nickel. I'm the president of the Healthcare Improvement Foundation and I have a deep background in shared decision making between patients and clinicians. I'm really excited to speak with both of you and better understand what led you to the idea of opioid-free surgery and that's what we're going to be talking about today. I would love it if you would introduce yourselves. Starting with Dr. Bar, if you could share a little bit about you and your background, and then we'll go to Donielle.   Dr. Allen Bar: I'm Allen Bar. I was a surgeon at Pennsylvania Hospital. Retired about a year ago. I've been in practice for 47 years doing general surgery, primarily breast, GI surgery, and hernias.             Starting in 2015—in answer to your question about how I got interested—three of us got involved with enhanced recovery. I was the surgeon. The other two were quality nurses who were involved in quality and data. And we realized that there were some issues at our hospital as far as data was concerned. I had heard a lecture on enhanced recovery and felt that this was something that we should do. And a big part of enhanced recovery is non-opioid analgesia and anesthesia. And that when I got really involved.             At a personal note, I've known for 20 or 25 years that I cannot come near an opioid, even something as little as low modal, without getting violently ill. And making it personal, I've tried to figure out if I needed any major surgery, what are the alternatives? Well, enhanced recovery gave us that and in my practice the last five, six years, even more than that I have pretty much eliminated opioids from my postoperative care.   Wendy Nickel: Great. Thank you, Dr. Bar. Donielle, would you provide an introduction please?   Donielle Calabrese: Hi, good afternoon. I'm Donielle Calabrese and I was a patient of Dr. Bar's in 2018. I had a hernia repair and I knew of Dr. Bar and sought him out to do my surgery—one of the reasons being he's an excellent surgeon, but also I knew that he did not prescribe narcotics and in the past I did not do well with opioids. I tend not to take them anyway. So sometimes I'm prescribed yet I don't even get them filled.             So my professional background is I am a registered nurse in the University of Pennsylvania health system. And I've been a nurse for 29 years. And right now in the last 10 years I've worked in the recovery room, so I recover patients from surgery. Prior to that, I worked in an ED for 10 years. Before that it was in surgical units. I have a lot of background with pain management.   Wendy Nickel: Great. Thank you, Donielle. So Dr. Bar, turning it back over to you, can you tell us a little bit about the procedure that Donielle required?   Dr. Allen Bar: Well, I do open hernia repairs. And as you may or may not know, in the past we used to give 40 Percocets for this. Realizing that this was not the way I wanted to go. As I say, it's an open hernia repair. It is "theoretically" very painful... I operate on Tuesdays and I will say to the patients, "You will not like me until Thursday afternoon."             And I hate to use the word pain. Pain implies something bad, and I much prefer to use discomfort. So I talk to the patients about surgery does hurt and they'll be uncomfortable. And we give them pre-op Tylenol. Intraoperative we give them Toradol. And I use Marcaine and ice on their wound, all of which have shown to decrease "pain" or discomfort. Then they go on every three hours Tylenol and ibuprofen alternating. I have had over a hundred patients in this and I think maybe two or three have called and asked for any kind of narcotics and I usually give about two or three pain pills. So it's been very successful. Most of my patients I do talk to beforehand, like Donielle, as soon as I say I don't use narcotics, they smile and say, "I don't want them."   Wendy Nickel: Thank you. Donielle, can you talk a little bit about how you did after surgery with the opioid free techniques. How did you feel in the days post surgery and throughout your recovery?   Donielle Calabrese: I did very well. I will tell you Dr. Bar did call me the next day. That evening of the surgery. I did take Motrin and Tylenol. The next day I remember talking to Dr. Bar and I said to him, "I haven't taken anything." And he's like, "Well, maybe you should take a little bit of Motrin at least or something so you don't have discomfort and that you can move around better." But I honestly felt like I didn't need anything. And I only took it because he told me to take it. I probably wouldn't have taken the Tylenol and Motrin either.   Dr. Allen Bar: If I may also, three years ago I had my hernia fixed. And again, I did not take any opioids and it was done on a Thursday and by Friday I wasn't taking anything and I had ...
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    19 m
  • Episode 5: The Role of the Surgical Nurse in Opioid Stewardship

    Episode 5: The Role of the Surgical Nurse in Opioid Stewardship
    Oct 25 2022
    Christine Schleider: Thank you, Judy, Kathy, and Lee, for being here today. I appreciate the opportunity to get together and talk about this very important topic of surgical opioid stewardship. The climate today around surgical prescribing is so different than it was when we all started as nurses. As surgical nurses, we were the ones who took care of patients before surgery and after surgery, and who prepared them for surgery. We were involved in all phases of patient care. And, we helped treat their pain. So, let’s think about opioid stewardship now, in 2022. I think we’ve all struggled with patient communication at times, during our careers. For this surgical opioid stewardship program, we’ve developed different brochures. There are videos we can show to patients. Can we talk a little about patient communication? Especially when we’re short on time, what’s the best way to get a message across to a patient?   Lee Holman: Having the surgeon tell them. If the surgeon sets the expectation, that's sort of the highest bar, the gold standard.   Judith DellaPorta: And I also think having a family member there when you discuss pain management. We've all been there where the patient's yelling in pain, the family member is yelling at you… So, if the family knows ahead of time that it's not going to be perfect post-op, but we're going to try and do everything we can to manage this, I think they can reinforce to the patient sometimes that you'll get through this.   Kathleen Shindle: That's so true. I think in that pre-op education with the family involved and also maybe setting some guidelines such as, "I'd like you to walk today every day before surgery for 30 minutes," or "I'd like you to do this." So that you have some kind of guideline, not just to say, "Okay. I want you to walk more or I want you to do what do you normally do." And asking a patient, "What can you do that you think that could increase your mobility?" and then say, "Well, do you think you could walk maybe 30 minutes today?" And go from there. And I also always like the statement, "And I also want you to bring your sneakers.” So that way that gives that patient the thought in their mind, "Oh yeah. I got to get up out of bed. As soon as I have my surgery… that's a good thing they're going to expect me to get up."  I think you have to really weigh how we say to a patient, "You're going to have pain." Try to make it more... Turn that into more of a positive, right? "You might have some pain. This is what you can do to...   Christine Schleider: A lot of patients and even people that I know and family members, when they need to have a hip replaced or a knee replaced, they put it off for so long because they're so afraid of the pain that they're going to have afterwards. And so many people always say afterwards, "I shouldn't have waited this long. I should have done it sooner."   Lee Holman: Yep.   Judith DellaPorta: And I think with the advent of minimally invasive surgery, that's just going to get better and better and better and better. So hopefully, pain won't be as difficult to control for these patients.   Christine Schleider: So, what we’re talking about here is communication and honesty.   Judith DellaPorta: I think it's important to have a conversation even preoperatively in the surgeon's office and be open and honest with them that, "You will have pain. We will try our best to relieve it to the best of our capabilities." And, you're working as a team, and you're going to help them get through this. I think that supports them and gives them some confidence going into the surgery.   Christine Schleider: Judy, I agree. Pre-op, I think, is very important to reach out to a patient or even at the time of getting ready for surgery in the surgical clinic… having a whole conversation and education session about the expectations of pain. You're going to have discomfort, but you're going to be able to do all the things that you need to do to help you recover."   Judith DellaPorta: I think the appendectomies, the choles, they really come down on our opioid discharge medication. But patients that have major abdominal surgery, major vascular surgery, they have acute pain and it needs to be relieved. So, I think we have to look at this individually—you have to look at every patient. They're all different. They’re not just a surgical patient. So we have to take a lot into consideration and make sure that they are getting what they deserve.   Kathleen Shindle: And knowing their history. I think we all need to know, "Does this patient have a history of opioid use or abuse and is pain service on board? Is this someone that maybe should have a pain consult prior to surgery?"   Judith DellaPorta: I know what we're doing here is anybody who's opioid tolerant is seeing anesthesia preoperatively, and they're making up a plan for the postop care. And I remember when I was a PACU nurse, we dreaded getting an opioid-tolerant ...
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    18 m
  • Episode 4: Top 5 Things Your Surgeon Wants You to Know

    Episode 4: Top 5 Things Your Surgeon Wants You to Know
    May 19 2022
    Today’s episode titled top 5 things your surgeon wants you to know features Dr. Scott Cowan, a cardiothoracic surgeon and associate professor at Thomas Jefferson University hospital and Dr. Matthew Philp a colorectal surgeon and associate professor of clinical surgery at Temple Health. Both Dr. Cowan and Dr. Philp also serve as clinical advisors for the PENNJ-SOS program. Today’s episode is also moderated by Pamela Braun, MSN, who currently serves as the Vice President for Clinical Improvement at the Health Care Improvement Foundation. Pamela Braun: Dr. Cowan and Dr. Philp, I want to begin by thanking you for joining me on today's podcast. As you know, you were each asked to come up with a list of the top things you want your patients to know about opioids and pain management when they need to have surgery. I have your lists, and I think you both provide some really great advice for patients. One of the things you both listed is the importance of having a conversation with your surgeon about pain management. Dr. Philp, we'll start with you - can you tell me why a conversation is so important? Dr. Matthew Philp:             Thanks, Pam. I'm really happy to be here and speak with you and Scott today. Having a conversation is huge, because it just sets all the expectations with you, and with your surgeon and the patient. There’s a wide range of operations that we do. We have the insight of what recovery will be like, what expectations are—because a lot of times we see that, where they say, “I've seen someone that's had that procedure”. And they have this set expectation of how things are going to be.             Especially if it's something that may have happened 15-20 years ago, when management was different. We had different options. We didn't do things the way we do today. We do things better, and recovery can often be faster. For example, using something like minimally invasive or laparoscopic surgery for major abdominal cases. The recovery is just so much different and better for patients, so they expect sometimes to have all this pain and it's not going to be like that.             Having that conversation is just so huge. Setting expectations from the get-go is really important. Answering the questions that patients have is really important. Pamela Braun:             Thank you. And perhaps also the question for you, Dr. Cowan, is that at what point should these conversations happen with the surgeon? Dr. Scott Cowan: Thank you for inviting us to participate in the podcast, Pam. It's great to be here today. I think it's always important to have those discussions about pain at the time that the patient's scheduling their surgery, really to help set those expectations that Dr Philp mentioned. And also to talk to and educate the patient's family members about what to expect in terms of potential side effects with the patient and any potential long term consequences of being on these medications.             One of the most important things a surgeon can do is to let their patients know that having some pain after surgery is completely normal and is to be expected. So, the goal isn't to completely eliminate their pain, but really to make it so that they can function and get through that acute phase, those usually two to three days after surgery, where the pain is the worst. And that's where opioids really play the largest role nowadays. Pamela Braun:  Really a great point. Thank you. Dr. Philp, you mentioned in your list that it's also really important to develop plan with your surgeon. I wonder if you can elaborate a little bit about that? Dr. Matthew Philp: Yeah. So I think having a good plan is important. We're talking about opioids here today, but opioids really should only be a part of a total pain management plan. I think one of the things we're doing—I mentioned things we do differently now than we did 10 or 15, even five years ago—is   incorporating other modalities of pain management. Nonsteroidal drugs, ice, elevation, even some cognitive therapies… there's a whole spectrum of things that you can do. And it's going to vary by surgeon, by procedure, by patient. The more information we know about the patients, their histories, their prior experiences, the better we can tailor a plan. It really shouldn't be a one size fits all approach to pain management. It's best when it's done with some thought and nuance to the particular patient. Pam: Great. That's really helpful, because postoperative pain is unique for every individual. So, I think that is nicely aligned with exactly what you were just saying: truly tailor that plan to the unique needs of the patients.             Dr. Cowan, for patients that have an opioid use disorder, or may have struggled with addiction in the past, should they bring that up with their surgeon before surgery? Dr. Scott Cowan: Great question. And absolutely. And it's important that the...
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    24 m
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