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Table 3 Surgeons’ challenges and barriers when working with patients with OUD

From: Surgeons’ knowledge regarding perioperative pain management in patients with opioid use disorder: a survey among 260 members of the American College of Surgeons

Questions:

What are the most common challenges faced by your specialty when working with surgical patients with OUD? (n = 228)

What are the barriers for using medication (such as buprenorphine, methadone, naltrexone) for OUD in the hospital? (n = 217)

Theme

Subtheme

Quote

Lack of Knowledge (65%)

Surgeons are not trained nor educated to prescribe MAT

Need training on additional pain medication to treat acute postoperative pain on top of chronic dose.

Poor understanding of how to prescribe (dosing) and/or manage these medications or their side effects combined with a lack of physicians to then follow those patients.

Lack of experience

I don’t have experience managing substance abuse for patients who need acute pain control.

The patient’s pain specialist is reluctant to prescribe medications acutely after surgery, despite doses in excess of my comfort level and training.

Fear of contributing further to patient’s addiction

It is difficult balancing the control of postoperative pain with pain seeking behavior (diversion).

Communication and patient expectation setting

Most patients have low postoperative pain scores but use opioids for sleep, feeling relaxed, and manage pain at other non-operative sites. Patients don’t see the harm in taking the medication provided to them, approaching it in a naïve way.

Lack of Resources (29%)

Lack of access to (pain/addiction) specialists/lack of care coordination

Sometimes it’s hard getting in touch with the methadone clinic to work out missed doses and formulate a plan of care.

Buprenorphine has largely been regulated to pain management and palliative care but pain management does not prescribe for outpatients.

Lack of infrastructure (EHR); restrictive regulations by state/insurance

(Institutional hurdles) Existing standard order sets include easily ordered high opioid dosing. Hard to decrease dosing or not order for those patients stating no opioids. If surgeon order high opioid doses, they could be subject to discipline. On the other hand, they could be cited for poor patient pain control.

Lack of transition of care following postoperative pain control to maintenance therapy and dosing

There is a lack of coordination of care with their pain management/addiction physician.

Insurance doesn’t cover the cost always of non-opioid alternatives. Unfortunately, it’s easier to prescribe an opioid.

  1. Table 3 synthesizes the challenges when working with patients with OUD. The barriers to include two main themes: a lack of knowledge (cited by 65%) and a lack of resources (cited by 29%). Surgeons cite a lack of guidelines, a lack of training in prescribing higher than usual amounts of opioids for postoperative pain control, and an overall lack of experience in managing pain in patients with OUD. Additionally, standard order sets make it easy for surgeons to over-prescribe opioids to patients who may not necessarily need all of them. Surgeons cited a lack of training when prescribing medication assisted treatment (MAT) and the need for guidance to balance postoperative pain control while not worsening a patient’s OUD. The need for specialists to work with surgeons to manage OUD and the need for patient education to teach how to use analgesics correctly for acute post-operative pain versus other issues are also needed
  2. Surgeons’ approach to harm reduction and perspectives on psychiatrist involvement in the treatment of patients with OUD
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Patient Safety in Surgery

ISSN: 1754-9493