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OPEN overcomes barriers to identifying, caring for surgical patients at risk of substance use in Michigan Hospitals

Aug 16, 2023

Introduction

Most Americans will have at least one surgery in their life and potentially be prescribed opioids for postsurgical pain management,1 and 6-10% of surgical patients will continue to use opioids months after a surgery.2 On average, 9.7 million Americans a year misuse opioids, and 19.7 million will be diagnosed with Substance Use Disorder (SUD).3 

The Opioid Prescribing Engagement Network (OPEN) has taken part in multiple studies to overcome barriers to identifying the level of risk for using substances for patients having surgery and providing them with the best care before, during and after they have surgery. Among the several barriers that exist, patients do not always perceive how disclosure of risky use may impact and improve their perioperative care and pain management.4

“Patients may be surprised to learn how their use of alcohol, marijuana, or other substances has the potential to impact their care in the operating room and their later recovery. But challenges stand in the way for patients to have a plan to lower those risks with their teams of surgeons, anesthesiologists, and nurses when they have surgery,” says Dr. Mark Bicket, co-director of OPEN.

Screening for risky substance use is recommended in the primary care setting, where completing a simple questionnaire can efficiently screen for opioid, drug, and alcohol use; however, translating that work to the perioperative setting has had several speedbumps.5,6 “Surgery provides a unique opportunity for change. Patients may be more motivated to make lifestyle changes when they understand it could improve their surgical health and outcomes,” said Anne Fernandez, Ph.D., an Associate Professor of Psychiatry at the University of Michigan. Research shows that implementing these screening measures to take place before surgery is important for identifying patients who may be at high risk of substance use.7

The Studies

In recent years, OPEN has taken part in several studies that investigated the impact of implementing screening tests pre-operation. In one study, they examined patient acceptability of implementing a presurgical screening that would assess at-risk opioid use factors with patients 18 and older who scheduled an appointment with their surgical team between December 2020 and April 2021.8 

In this study, a process to screen for risky opioid use and a pathway to help care for those patients was developed. Research assistants were trained to call patients using a standardized script and administer the screening tool two weeks before their appointments. After surgery, a nurse navigator called patients and asked them questions regarding their pain management.8 

Of all eligible patients who responded (470), nearly all respondents found the questions easy to understand; less than 2% were uncomfortable with the screening. Moreover, 98% found the care pathway acceptable. By implementing this screening tool for the length of this study, they found 13 patients at risk for opioid misuse.8

In another study, three weeks prior to meeting with their surgical team to talk about surgery, patients received an email request to complete the Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS) screening tool.7 The assessment was recorded and patients at a high risk for unhealthy substance use based on their assessment were identified.9 While traditional methods in assessing for tobacco, alcohol and other substance use such as opioids have been part of the normal workflow, they have had a greater tendency to miss at-risk patients compared to standardized self-assessments.10,11

In this study, 58% of patients completed the TAPS screening tool. Overall, the surgical staff widely endorsed the acceptability and usefulness of the substance use screening workflow. Most (79%) agreed that the tool was acceptable and feasible to implement. 71% believed patient screening results provided helpful guidance for surgical and recovery planning. Approval also included willingness for patients to be screened (83%) and a desire to receive risky substance use screening notifications (71%).12

In general, surgeons accepted the screening process, deeming it more desirable and useful when it was paired with risk information and guidance on actions that can lead to better behavioral lifestyle changes and surgical outcomes.12 

A third study included monitoring the care two different groups of patients received. This pretest-posttest study used a two-block nonrandomized design in which referred patients in the first block were initially assigned to one screening protocol, after which the referred patients were assigned to the other screening protocol. Patients in the surgery-relevant screening group received positive, gain-focused message framing that linked the screening request and responses to their upcoming surgery. The same Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) Tool was used for all patients given its brevity, standardization.13

Among 611 patients referred to the preoperative evaluation center, 539 (88%) were eligible and sent electronic requests to complete screening. More patients completed screening in the surgery-relevant screening group compared to usual care (61.2% vs 44.3%). Among respondents, the proportion of patients disclosing risky substance use did not differ between surgery-relevant screening and usual care (14.3% vs 14.9%).14

Jennifer Walijee, a co-director of OPEN, added “These studies highlight the importance of integrating a systematic, patient centered approach to screening to ensure that we provide the best care possible throughout the surgical journey and during recovery. Understanding the unique experiences, risks, and needs of our patients in this context is critical to accomplish these goals.”

Discussion

Variations in screening practices and differences in detection rates likely influence clinical outcomes and leave providers at increased risk of bias regarding who is screened. Thus, standardized tools may improve health outcomes and lessen furthering stigma linked with screening only those who would appear high risk.12

Interestingly, as the screening process included risk information and guidelines for intervention strategies, the acceptance of a standardized screening process highlights the improvement made upon previously identified barriers to ideal transitions of care for opioid management, specifically the knowledge constructed within the actionable domains deemed by Klueh et al. At the same time, the constructive feedback that was received is a reminder that screening for opioid and other substance use may still seem like tasks outside the scope of practice for some perioperative providers.15

“There is a lot that can be done for patients who screen positive for at-risk substance use before surgery.  For example, short-term abstinence from drugs and alcohol can greatly reduce risk of surgical complications relative to those who continue to use substances at risky levels.  However, if patients don’t know this information, they can’t act on it.  In my research we are addressing that knowledge gap. We recruit patients to take part in pre-surgical ‘health coaching’ for at-risk alcohol use, that includes short-term counseling and mobile health tools. Our health coaches educate patients about their alcohol-related surgical risks and help them abstain from alcohol use in the month before and after surgery,” said Fernandez.

References:

  1. Thiels, C. A., Anderson, S., Ubl, D. S., Hanson, K. T., Bergquist, W. J., Gray, R., Gazelka, H. M., Cima, R. R., & Habermann, E. B. (2017). Wide Variation and Overprescription of Opioids After Elective Surgery. Annals of Surgery, 266(4), 564–573. https://doi.org/10.1097/sla.0000000000002365
  2. Klueh, M. P., Hu, H. M., Howard, R., Vu, J. V., Harbaugh, C. M., Lagisetty, P., Brummett, C. M., Englesbe, M. J., Waljee, J. F., & Lee, J. H. (2018). Transitions of Care for Postoperative Opioid Prescribing in Previously Opioid-Naïve Patients in the USA: a Retrospective Review. Journal of General Internal Medicine, 33(10), 1685–1691. https://doi.org/10.1007/s11606-018-4463-1
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  7. Siglin, J., Sorkin, J. D., & Namiranian, K. (2020). Incidence of Postoperative Opioid Overdose and New Diagnosis of Opioid Use Disorder Among US Veterans. American Journal on Addictions, 29(4), 295–304. https://doi.org/10.1111/ajad.13022
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  9. Jones, C. M., Clayton, H., Deputy, N., Roehler, D. R., Ko, J. Y., Esser, M. B., Brookmeyer, K. A., & Hertz, M. F. (2020). Prescription Opioid Misuse and Use of Alcohol and Other Substances Among High School Students — Youth Risk Behavior Survey, United States, 2019. MMWR Supplements, 69(1), 38–46. https://doi.org/10.15585/mmwr.su6901a5
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  11. Kip, M., Neumann, T., Jugel, C., Kleinwaechter, R., Weiss-Gerlach, E., Mac Guill, M., & Spies, C. (2008). New Strategies to Detect Alcohol Use Disorders in the Preoperative Assessment Clinic of a German University Hospital. Anesthesiology, 109(2), 171–179. https://doi.org/10.1097/aln.0b013e31817f5be3
  12. Lin, V. J. T., Rieck, H., Gunaseelan, V., Wixson, M., Waljee, J. F., Brummett, C. M., Englesbe, M. J., & Bicket, M. C. (2023). The Acceptability and Utility of Opioid and Other High-risk Substance Use Screening as Implemented within the Perioperative Workflow. Pain Medicine. https://doi.org/10.1093/pm/pnad046
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