This article will appear in the upcoming March print issue of Surgical Products.

Improving patient outcomes, decreasing hospital length-of-stay, and reducing costs are tasks best classified as perennially unfinished by hospitals. Any chance to make improvements must be considered, including evaluating the use of opioid use for perioperative pain management. Furthermore, recent research and anecdotal evidence point to several potential benefits of reducing the use of opioids in healthcare settings.

Phase 4 clinical trial results for bupivacaine liposome injectable suspension as the foundation of a multimodal analgesic regimen versus a standard opioid-based regimen for postsurgical pain control were published in the January issue of Current Therapeutic Research.

The study looked at 82 patients who underwent laparoscopic colectomy, a minimally-invasive procedure to remove all or part of the colon using several small incisions in the abdomen. The results found that compared to patients in the standard opioid-based treatment arm – who received IV opioids via patient-controlled analgesia devices – patients who underwent the same procedure and received a bupivacaine liposome injectable suspension experienced the following:

  • A 64 mg reduction in mean opioid consumption
  • A 1-day reduction in median length of hospital stay
  • Significantly fewer opioid-related adverse events (8 percent for those in the bupivacaine liposome injectable suspension group and 41 percent for those in the IV opioid-based PCA group)
  • A $1,784 reduction in mean hospitalization costs

According to John Marshall, PharmD, BCPS, Clinical Pharmacy Coordinator, Critical Care at Boston’s Beth Israel Deaconess Medical Center, his facility has decided to dramatically increase the use of both IV and oral acetaminophen as an analgesic. Prior to that, the prevailing attitude about acetaminophen, he states, was that it was meant for very mild pain.

That’s no longer the case, and the use of IV acetaminophen and oral acetaminophen has increased year-over-year for the past three years at Beth Israel Deaconess Medical Center.

“I think the initial reason for adding IV acetaminophen was we wanted to have it available for patients who were unable to tolerate oral or rectal administration and who needed acetaminophen,” says Marshall. “We also understood, in adding it, we did have a speculation that it would reinvigorate the use of all acetaminophen products across the board. It was kind of a dual-pronged approach.”

Anecdotal feedback from colleagues has been positive, he says. Many of the responses come from nurses in the post-anesthesia care unit and from medical surgical nurses in both the intensive care unit and on the floor.

“Their experience with it has been really favorable, and I think that’s been the major driving force,” says Marshall.  “Clinicians at the bedside have seen demonstrable benefit from it, and I think that’s why it not only continues to be used but that use continues to go up.”

However, favorable reactions alone aren’t enough to justify a reduction in opioid use for perioperative pain management. There are other factors to consider. Chief among those is cost.

According to Marshall, there is a large incremental cost associated with IV acetaminophen, especially for smaller institutions. Additional cost could lead to hesitance on the part of hospitals to make an investment.

“It could be the pharmacy departments or the people in control of the budget have been hesitant to add an agent that they feel doesn’t have benefits,” says Marshall. “More importantly, they feel like it may be abused, that the patient who could take oral medications is now going to be getting IV acetaminophen. So I think cost pressures on hospitals have been the driving issue as to why this hasn’t been implemented.”

Marshall also wonders whether the use of acetaminophen results in a clinically-significant reduction of opioids, or merely just a numerical reduction.

“I think that question is still being answered,” he says.  “There’s been a meta-analysis that’s been published recently that has started to get to some of that, but the financial people at hospitals have been hesitant to add that. Whether that’s been a pharmacy issue or other decision-makers, that’s hard to say.”

However, Beth Israel Deaconess Medical Center now uses acetaminophen more extensively than ever before. The hospital employs it in the PACU setting, uses it more with at-risk patients, and gives out oral acetaminophen before procedures.

“This means potentially giving patients scheduled acetaminophen one or two days before a procedure that may allow them to realize more of the benefits that we’re seeing with the IV formulation,” says Marshall. “Those are the things we’ve started to evolve into. Whether or not those work still remains to be seen.”

Marshall suggests a thorough approach to the evaluation of opioid use for perioperative pain management before any adjustments are made.

“I think that they would need to have a discussion with the stakeholders who were asking for it, to really talk to them about what their approach to pain management was going to be,” he says.

He also maintains the importance of setting clear guidelines to ensure pharmacy, anesthesia, and surgery personnel agree on how it should be used. That way, the facility can achieve the best possible results.

“I think, obviously, the financial impact of this drug can’t be discounted,” says Marshall. “I think every pharmacy budget is going to go up because of it, but I also think there is enough data externally that’s being generated now that can justify some of that in terms of the clinical benefit.”

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