Improving Perioperative Care for Patients with Opioid Tolerance

In the United States, nearly 1 in 6 adults filled an opioid prescription in the past year and 10 million adults are opioid tolerant. Compared with opioid naïve patients, individuals with opioid tolerance experience greater challenges in managing acute pain especially after having surgery and poorer outcomes following surgical

care. For example, opioid exposure before surgery has been shown to lead to greater rates of opioid consumption after surgery. Further, patients with opioid tolerance frequently encounter high-risk prescribing practices and delays in returning to their usual prescriber after surgery, as well as greater rates of morbidity

and mortality after surgery. Evidence-based care pathways have been developed to improve opioid prescribing before and after surgery for opioid-naïve patients, but little is known about the postoperative needs of patients with opioid tolerance. Specifically, important knowledge gaps exist regarding the appropriate amount of opioids

to prescribe after surgery, best practices in coordinating opioid therapy during the perioperative period, and the effectiveness of care coordination pathways to prevent high-risk prescribing practices and optimize clinical outcomes in this vulnerable population. To address these gaps, we will prospectively capture patient-reported

opioid use and pain outcomes among individuals with opioid tolerance undergoing common surgical procedures and develop a clinical care pathway to optimize outcomes across a large network of hospitals in the state of Michigan that are diverse with respect to geography and case mix. In 2016, we established the

Opioid Prescribing Engagement Network (OPEN), a federal and state funded quality improvement program focused on developing and disseminating best practices in surgical opioid prescribing and pain management for opioid-naïve patients. In this proposal, we will extend this work to examine patient-reported pain outcomes

and opioid prescribing practices after surgery among opioid tolerant patients in order to calibrate current prescribing guidelines for common general surgery procedures (Aim 1). We will then conduct qualitative interviews with surgical patients who have opioid tolerance; their providers; and healthcare leaders. This data

will inform the development of a clinical care pathway for perioperative pain management for patients with opioid tolerance (Aim 2). Finally, we will conduct a prospective randomized trial to determine the effectiveness of the care pathway on coordinating care and reducing high-risk prescribing practices after surgery, length of

stay, and readmissions, as well as optimizing patient-reported pain (Aim 3). We hypothesize that implementation of the care pathway will increase alignment with guideline-concordant prescribing without adversely impacting patient-centered outcomes. Given the high prevalence of individuals with opioid tolerance

undergoing surgery each year in the United States, interventions to reduce high-risk prescribing practices, adverse postoperative events, and optimize postoperative pain management will lead to safer perioperative care.