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Reversing the National Trend of Opioid-Related Overdoses What ASCs can do BY ROBERT KURTZ


he Centers for Disease Control and Prevention (CDC) reports that more people died from drug over- doses in 2014 than any other year on record ( epidemic/index.html). A majority of drug overdose deaths—more than 60 percent—involve an opioid. And nearly 80 Americans die daily from an opioid overdose.

ASCs can help reduce these fig- ures without compromising quality, says Mark Romanoff, MD, an anes- thesiologist in Charlotte, North Car- olina, who is part of the MEDNAX medical group and affiliated with several organizations, including the Carolina Center for Specialty Sur- gery in Charlotte. “Too many opioids have been put in outpatients’ hands,” he says. “This has contributed to the increase in deaths. Fortunately, ASC clinical staff can help decrease the number of opioids in cir- culation and decrease fatalities.”

Anesthesia Romanoff says anesthesia providers at the Carolina Center for Specialty Surgery take a number of approaches to reducing the amount of opioids patients receive.

“The use of multimodal analge-

sia is very helpful,” he says, pointing to medicines such as gabapentin and pregabalin. “They are


and can augment opioids. They work in the brain and spinal cord to help prevent long-term pain and decrease central sensitization.”

Another medication to consider

is ketamine, Romanoff says. “When administered along with the anes- thetic, ketamine can decrease analge- sic use postop.”

Other approaches he recommends include the use of nerve blocks, Tyle- nol and anti-inflammatories.

26 ASC FOCUS JANUARY 2017 He suggests prescribing just three

days’ worth of opioids, whenever pos- sible. “If patients still need medicine after those three days, they can request more. That is a better approach than giving patients a weeklong prescrip- tion. More than likely, after those three days, most people can move onto non-narcotics.” For patients likely to require sig-

Too many opioids have been put in outpatients’ hands. This has contributed to the increase in deaths.”

— Mark Romanoff, MD MEDNAX, Carolina Center for Specialty Surgery

Surgeons Surgeons can best play their part, Romanoff says, by focusing on two factors when prescribing medications: lowest dose and shortest duration. He references a March 2016 research letter in the Journal of the Ameri- can Medical Association (http://jama abstract/2503506) examining insur- ance claims from 2004–2012 for more than 155,000 adults undergoing four common outpatient surgeries. The research revealed increases in the num- ber of opioid prescriptions and amount of opioid medication dispensed fol- lowing these procedures. “More than likely, many of these patients received more opioids than necessary,” he says. “That gives us an opportunity to put less medicine out into the community.”

nificant pain relief following a pro- cedure, “do a quick risk evaluation to see whether a patient has tendencies or is known to have substance use or control issues,” Romanoff says. “If they do, give them less medication initially but offer refills if needed to limit their access, treat their pain and keep them safe.” There is another caveat he advises

physicians to heed. “Some surgeons will prescribe a long-acting narcotic like OxyContin or fentanyl for acute pain, but there have been associated overdose deaths. This should be a big red flag not to use long-acting pain medicines for an acute pain issue.”


ASC clinical staff can play a role in reducing opioid deaths as well, Romanoff says. “Counsel patients about the risks associated with taking opioids along with other medications and drugs as doing so could increase the risk of respiratory depression and death. “It is also important to establish

patient expectations concerning their pain,” he continues. “Patients should be advised that even though they are undergoing outpatient surgery and the ASC will do all it can to make sure they are comfortable, there will be pain following the procedure. Set- ting those expectations can be very important so patients are not sur- prised by the discomfort and take too many medications.”

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