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Dr. Tim Jackson and Lee Fairclough

Counting on surgical teams

When it comes to taking opioids for the first time, it is not surprising that this frequently occurs after having surgery.

Opioids have become the go-to class of medications for controlling pain and after surgery, many patients require drugs to help deal with pain as they recover from a procedure. This has been documented in a major report by Health Quality Ontario released in 2017 – showing that surgeries are second only to dentists’ offices for the percentage of opioids prescribed to patients who had never used opioids before.

Now, 47 hospitals in Ontario who are part of the Ontario Surgical Quality Improvement Network have launched a campaign to reduce the quantity of opioids that surgical teams prescribe after surgery. These hospitals are responsible for almost 80% of the surgical operations that take place in the province annually.

“Cut the Count” urges surgeons and the teams they work with to reduce the number of opioid pills they prescribe while at the same time continuing to help patients manage their pain using other medications and non-pharmaceutical options. The campaign will run for one year, participating hospitals will track their progress together through the network and hospitals who are not part of the network are also encouraged to participate. More information about the campaign and the steps to take can be found here.

Campaigns such as Cut the Count are vital as part of a comprehensive effort to reduce the number of opioid prescriptions. While data from 2017 indicates number of these prescriptions is decreasing in Ontario, Canada still has one of the highest opioid prescribing rates in the world. It is worth noting that surgeons have already been acting to reduce the dependence of patients on opioids to manage pain following surgery. Between 2013 and 2016, the quantity of opioids prescribed by surgeons to patients starting opioids for the first time dropped by 5%. However, surgeons believe much more can be done, and this is the first campaign to focus on this area.

Data show that when surgeons prescribe opioids for the first time, in 10% of cases they prescribe a supply of more than seven days. According to experts, three days of opioids or less is often sufficient and people who take opioids for more than seven days are more likely to become physically dependent on the drugs.

As patients often do not take all the pills they are prescribed, usually because their pain is controlled before the prescription expires, the campaign also aims to reduce the number of opioid pills in circulation that could be diverted and potentially be misused by others.

Patients should not have to rely on opioids when recovering from even complex and painful surgery. To quote Sheldon, a medical oncologist in Mississauga who had to deal with the effects of opioids after major lung surgery: “What you do not want to do is rely on medication only. It doesn’t work. It has long-term potential serious side effects and you don’t need it.”

Health Quality Ontario offers a number of resources to help surgical teams:

  • Multimodal pain management ideas found in Health Quality Ontario’s quality standard on opioid prescribing for acute pain
  • A patient guide to help patients ask informed questions about opioid prescribing and additional techniques they could use to help them manage their pain post-surgery.
  • A practice report for orthopedic surgeons who perform hip and knee replacements that provides them with personalized and confidential data on their prescribing patterns as well as suggestions to improve care. This initiative is also intended to help surgeons reduce the rate of opioids they prescribe.

While the campaign is focused on surgical teams, family physicians also play an important role in making sure patients do not rely on opioids as they continue their recovery process.

The campaign is an opportunity for many in the medical community to take positive steps to address the crisis currently facing our society while at the same time providing improved patient care.

Dr. Tim Jackson is Health Quality Ontario’s surgical quality lead and a general surgeon at the University Health Network, Toronto. Lee Fairclough is VP, Quality Improvement for Health Quality Ontario.

Why do some surgical teams send patients home with more opioid pills than they require? What else can they do to help their patients effectively manage their pain? Are there good systems in place to monitor how patients are managing their post surgical-pain? How can family physicians handle requests from patients for opioids post-surgery? Listen as we discuss these and other questions in our podcast with Dr. Jackson and Dr Tiffany Florindo, a family physician in North York, Ontario.



Read the transcript.



2 comments on article "Counting on surgical teams"

Gwen Piller

A great campaign and well overdue. Opioids are not effective for many types of pain management but other pain management can be of benefit which needs statistical data to show which therapies are most beneficial for different types of pain. My personal experience has shown Osteopathy best for me but Osteopaths are not recognized by the medical community or Government in Canada. I spent 12 years seeing an Osteopath for back and neck pain. He peeled away they layers of physical damage to find the source, and spent time decompacting my spine. In my late 20’s we realized I had grown a 1/2 inch. I went from a 15 degree bend at the waist to touching my toes and 25 years later although I still have issues with back pain and sciatica I can still touch my toes. I now manage pain with nerve blocks weekly, but without the miracle of my Osteopath I probably wouldn’t be walking.

Wanita Umer

I am troubled after listening to the podcast. None of it discusses Informed Consent and it is all from the perspective of prescribing clinicians. Particularly troubling is Dr Tiffany Florindo's commentary about only prescribing opioids after everything else has been tried including Epidural Spinal Injections. Leaving one in pain leads to other chronic illnesses and DOES NOT keep people safe. The complication rate of NSAIDS, Tylenol, biologicals, surgery, steroids, injections etc is completely ignored along with the Patient's right to autonomy over their own body. Guidelines re pain care were the knee jerk reaction to over prescribing.The guidelines were based on poor quality evidence as was that of the CDC. Every time I think balance will be achieved something happens that shows that concern from patients' perspectives is too often disregarded. I begin to trust that we are being heard then something such as this one sided podcast is promoted. Informed consent is not being used properly and in accordance with our health care consent laws if clinicians are forcing patients to exhaust all modalities they would choose for themselves before offering opioids. The Supreme Court Of Canada ruled that the Charter of Rights and Freedoms is violated when people are denied the right to autonomy and forced to go to the street to get treatment that the medical system should have provided. We all know tolerance to opioids previously led to increasingly higher doses being prescribed but since this is no longer the case why is HQO still working as though is. What about respecting the fact that we are adults capable of understanding benefit/ risk ratio and capable of making informed decisions? If patients decide that opioids are a better choice for them why not help them to keep the medication working without increasingly high doses? Most all people I know who are successfully being treated with long term opioid therapy have taken measures to make sure their medications continue to work. Why not learn from them and use the knowledge to help others rather than unilaterally deciding treatment?

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