It is a common experience for patients – you visit the hospital for a surgery or procedure and are sent home with a prescription for a large number of opioid pain relief pills, such as Percocet or Tylenol 3. Nearly two million Ontarians fill prescriptions for opioids every year. Research shows that higher rates of opioid prescription leads to opioid misuse or misdirection, and are directly related to increases in opioid-related emergency visits, hospitalizations, and death.
At Grand River Hospital (GRH), a community hospital in Kitchener, Ontario, we worked with the National Surgical Quality Improvement Program (NSQIP) to identify that we could effectively reduce rates of opioid prescription for our general surgery patients, without compromising their pain management.
In order to do this, the GRH outpatient pharmacy helped the surgical team measure a baseline of opioid prescriptions written by general surgeons that were filled at the pharmacy. They found during a three-month period in 2019, general surgery patients were prescribed an average of 31 pills. That’s typically less than a seven day supply, but still can be further reduced to enhance care for patients and our community.
“One thing we kept in mind is that there wouldn’t be an opioid crisis if there wasn’t widespread opioid availability in the community,” said Lashen Naidoo, manager of retail pharmacy operations at GRH. “Prescriptions originating in hospital are only part of that story, but if we can control that aspect, we can be part of the solution.”
When the pharmacy team investigated prescribing trends amongst general surgeons at GRH, they found that many larger doses were prescribed because the surgeon did not want the patient to run out of medication while they still needed it, causing challenging prescription renewals impacting surgeons and patients alike. Prescribers were also concerned about patients visiting an emergency department for pain management follow up – avoidable with an appropriate prescription.
“Initially, I think many of the surgeons didn’t know that many of the pills they were prescribing were not being taken. Once we had that evidence, we immediately involved the surgeons.” said Dr. Monica Torres, Surgeon Champion for NSQIP at GRH. “It just gives patients a little more control and knowledge on how they can manage their pain with many methods, not just taking their opioids. Surgeons have the power to impact the opioid crisis by prescribing less and providing more pain management tools and education for their patients”.
To address this, GRH implemented an “Opioid Prescribing for Acute Pain” campaign, developed collaboratively with Health Quality Ontario (HQO) and NSQIP, to reduce opioid prescribing while providing optimal pain control. During this campaign in 2019 and 2020, Grand River Hospital was able to reduce opioid prescribing by 47.5% within the general surgery program – on average, a reduction of 15 pills per prescription.
The campaign embraced multiple strategies for reduction. GRH provided surgeons with education and resources on procedure-specific opioid prescriptions, establishing a standard number of pills to prescribed for certain procedures. To address surgeon concerns about prescription renewals or ‘running out’ of needed opioids, the team implemented interval prescribing with expiry dates. This prevents the patient from filling an entire prescription of a larger number of pills in a single pharmacy visit, and places expiry limits on how far after the procedure a prescription can be filled. “The significant majority of patients with opioid prescription for acute pain management don’t end up filling all the intervals prescribed to them”, says Lashen. “This greatly reduces the likelihood of pills sitting in a medicine cabinet, to be used for a non-indicated purpose or redirected to another person in the future.”
GRH also educated patients and staff on how to safely use opioids, including recognizing the signs of dependence or withdrawal, how to taper and discontinue use, and how to safely dispose of unused opioids. We also provided education on non-opioid treatment options, such as using over-the-counter pain relief as the primary pharmaceutical option, and non-pharmaceutical techniques like physical therapy and cognitive behavioural therapy. When the GRH outpatient pharmacy fills an opioid prescription, they also provide counselling on opioid use and disposal.
“I don’t typically prescribe opioids” shares Dr. Torres. “When I began practicing at GRH, this was unusual – nursing staff would regularly call to make sure I hadn’t forgotten to create a prescription. Today, that doesn’t happen often. As a department we’re prescribing opioids less frequently and in lower quantities, and we have a greater understanding that other pain management methods can provide relief for many patients.”