Table 4 Surgeons’ approach to harm reduction and perspective on psychiatrist involvement in treatment of patient with OUD

Theme

Subtheme

Quote

Medication management (75%)

Limiting dose or duration (46%)

Give only a short prescriptions - 3 days for acute pain.

Give only a fixed amount – usually 7–10 days

I don’t know my specialty’s approach, but I will order a finite number of pills with no refills – firm.

Use Alternatives - multimodal pain management (23%)

I use alternatives included: acetaminophen, gabapentin, Robaxin®, and sometimes other alternative medications.

Use Narcan/naloxone (6%)

Co-prescribe naloxone, maximize non-opioids, minimize number of opioid pills, short-term follow up with outpatient pain / addiction specialist

Prescribe minimal amount of pills, prescribe naloxone and involve a family member if there is a trustworthy one

Patient Education 23%

Expectation setting (10%)

Limit prescribing: Max of 20 tablets, less commonly 30.

Expectation setting from initial visit to be off of any additional medications by the end of the prescription along with the expectation that there will not be refills after the immediate post-op period, usually just the single post-op prescription.

Specialist referral (13%)

Support patients with another specialist to educate and counsel on addiction management – pain specialist, addiction medicine, nursing, as appropriate.

Use Published Guidelines (2%)

We are monitoring postoperative opioid prescribing very closely and aiming to meet the Michigan OPEN guidelines by prescribing only a 3 days supply and only prescribe naloxone if prescribing > 50 MME/day.

Be available and engage throughout the process (64%)

Have a presence in the hospital and help in the perioperative setting.

We don’t have any psychiatrists available however their assessment and review of polypharmacy would be helpful.

Quick availability to assess and co-manage patients with OUD in the perioperative setting.

This list could go on for a long time. I think they should round on almost all trauma and complex EGS patients.

We do not have a psychiatrist in house or to consult, only through telemedicine, and there’s no follow up after discharge, and they don’t consult for pain management either.

Counselling and coordination by other specialists

Psychiatrists should be helping to provide patient counselling

Psychiatrist and addiction counselors are needed to support expectation setting, clarify roles and assist with care coordination for the post operative period.

Help treat conditions that exacerbate the pain experience, such as depression and anxiety and direct care away from medications to behavioral and distraction techniques

Be involved in the process

Institute automatic referrals to psychiatry when a patient has OUD. Provide psychiatric evaluation and consult to ensure patient is using appropriate coping mechanisms; help with treatment plan, ensure post-discharge follow up by psychiatry.

Professional Education (13%)

Protocols/guidelines/review polypharmacy

Psychiatrists are comfortable with medications such as buprenorphine but are often not comfortable with the administration of narcotics / acute pain management.

Staff Education and how to outreach for consultation

Education of staff, students, residents and colleagues, plus patients on OUD management in the perioperative setting.

Identify their role as consults – how can we utilize them to optimize patient recovery – patient expectation setting, treatment of co-morbidities, care coordination post-discharge, medication management.

Involve Pain Specialists (15%)

Pain and Addiction Specialists

Care coordination with addiction medicine as appropriate with referral to pain specialist.

I wonder if a pain specialist would be better than a psychiatrist to help treat/collaborate with patients chronic pain/addiction issues.

Uncertain of how psychiatry could help (8%)

Psychiatrists are not available in the hospital; I don’t know how they can help.