Jeff Harrison, MD
At the Intermountain Orthopedics and Sports Medicine clinic at McKay-Dee Hospital they do thousands of procedures. The clinic team is good at what they do and yet they’re always looking for ways to improve. Lots of the progress they make is incremental as they refine procedures but last year they found a way to make dramatic improvements and most of what they have been doing doesn’t really affect their patients until they go home.
They’ve cut back the number of opioids they prescribe by 75 percent.
Craig Pulley is a physician assistant who’s been working with Jeff Harrison, MD, the clinic’s orthopedic surgeon, and others at the clinic to reduce the number of opioids prescribed.
Craig said for years there hasn’t been a lot of science behind the numbers of opioids physicians prescribe for patients to use as they recover from certain operations. Often physicians don’t know how many pills their patients actually take. One danger in prescribing more opioids than patients need is that the leftover pills can end up in a medicine cabinet or on a shelf. Addicts know how to watch for such surpluses and often repurpose them as fuel for addictions they’re unable to control. Having more opioids than are really needed also increases the odds a patient who uses them to aid in their recovery will develop a dependency on them, he says.
“We just started asking our patients how many pills they were taking and found out they weren’t taking nearly as many as we were prescribing,” he says.
Craig Pulley, physician assistant
Craig says they began prescribing far fewer opioids, sometimes as few as five for a given procedure, where they might have prescribed as many as 30 pills in the past. Doctors know prescribing a combination of Ibuprofen and Tylenol has proven an effective way to control pain but physicians have also prescribed opioids so they’ll be available if a patient needs them. Craig says they’ve found patients will often hold back and ration the opioids if they only have a few available.
“If someone has 30 pills available, they may be more likely to take an opioid for pain or just because they are worried about pain coming but if they’ve just five on hand, they are slower to use them,” Craig says. “Now we find patients are using opioids as a backup plan B if they can’t get the pain relief they need from ibuprofen and Tylenol, instead of using them immediately to prevent the pain from arriving.”
Craig says if a patient uses up all of his or her prescribed opioids, they know they can always call and get a refill.
“Our intention isn’t at all to have our patients just learn to endure more pain,” he says. “We’re ready to help them with the medication they need. We also want to do all we can to be sure opioids don’t become a long-term addiction for them.”
Craig says this work is personal to him because he has two people close to him who now have to fight against opioid addictions the rest of their lives and it all started with prescribed pain killers.
“This has been one of the most important things I’ve done in my career and it’s a huge deal to me,” he says of the work he and Dr. Harrison have done. “I know we can do better and that’s so important, especially if you’ve ever seen the damage misused opioids can do to someone’s life.”
He says they also get people started on recovery exercises right away and that can help decrease their pain levels over time and speed their healing.
“We try to empower patients to become active participants in the process,” Craig says. “They’re doing leg raises, ankle pumps, and an active range of motion exercises. They don’t see themselves as victims of a needed surgery; they see themselves as a partner in the healing process.”
In addition to prescribing fewer opioids, the team has found ways to refine its processes so that fewer opioids are needed.
Dr. Harrison, who’s also the head physician for the U.S. Olympic Ski Team, says surgeons can specialize, focus, and develop an expertise in doing certain kinds of procedures because they do so many of them. And that benefits patients because the sheer volume of work they do helps them refine their processes and make it so fewer opioids are needed.
“We can also focus on what happens in the operating room from the time they come in until the time they leave,” he says. “We do 95 percent of our procedures at one facility with the same team, the same anesthesiologists, and we’ve been doing that for 20 years.”
For example, the amount of tourniquet time or the time they block blood flow to the extremities is very low which means less pain for their patients, he says. Using more regional anesthesia can also reduce the number of opioids patients need to recover, he says.
He says being a good physician requires more than just doing a procedure efficiently.
“We need to be able to communicate with patients and hear their needs and really identify what they’re trying to achieve by coming to us,” he says. “We need to know what their goals and aspirations are when it comes to their recovery and how we can best help them restore physical losses they have. If we understand our patients, we are better prepared to work with them to reduce the number of opioids they need and that’s a critical step to helping them fully recover.”
Kim Compagni, the avp for Pain Management Services, says there a number of good ways to help patients coping with pain.
“By utilizing non-opioid strategies such as ice, scheduled doses of acetaminophen and ibuprofen, physical therapy, and mindfulness we can help to minimize pain with fewer side effects. Acute pain can convert to chronic pain due to hypersensitivity with prolonged opioid usage. We want to make sure our patients have adequate pain control without creating long-term problems.”