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Written by Dr. Becky Graham, board-certified OB/GYN and OBHG hospitalist
Unless you live under a rock, have been doing medical volunteering in a foreign country, or are just too busy to notice, we have an opioid crisis in the United States.
Throughout my career as an OB/GYN physician, my colleagues and I have used several strategies to notify one another that a patient is drug-seeking - such as adding flags to charts in the electronic medical record (EMR), drawing an eye on the patient’s paper chart by their name, etc. The bottom line is that none of these have worked. But why? As an educator who became a physician, I believe it is education from top to bottom - from physicians to nurses, and from pharmacists right down to the patients. Let me demonstrate what I mean.
As the physician, you are aware we have a national crisis on our hands. You are diligent about following the ACOG guidelines for opioid use in pregnancy as listed in the ACOG Committee Opinion Number 711 from August 2017:
- Early screening, intervention and referral for treatment for pregnant women with opioid abuse
- Screening for all substance abuse in the first prenatal visiting any of the validated screening tools given
- For chronic pain, practice goals include strategies to avoid or minimize opioid use, highlighting alternative pain therapies
- Using pain management physicians to safely help an opioid user withdraw from opioids
- - 9. You get the idea - there are lots of great suggestions in this committee opinion
Here’s our reality: you are in a very busy office, at a family activity, or sound asleep at night and you get the call. “Dr. X, your patient, Y, says her pain is not well controlled with either Motrin or Tylenol. Can I give her Norco or Tylenol #3?” You remember the patient well: Routine vaginal delivery, no laceration, so why does she need a narcotic/opioid?
Before you can answer the nurse, she reminds you of the low pain management scores on the Press Ganey surveys. She also reminds you that the nursing manager has asked the nurses to be more proactive with the doctors to help with pain management. Do you cave in just to please the nurse and get back to what you were doing? Do you just say NO? Or do you take the time to reinforce to the nurse why your patient doesn’t need a narcotic or opioid? Or have you received too many of those calls and you are tired of being interrupted so you just check the box of the routine orders so you don’t get the call?
You see our dilemma. So, what is the answer? Again, I believe it is education. Take an active role at your hospital to reduce opioid use. Here are some ways to do this:
- Set expectations for your nursing and pharmacy staff.
- Do a presentation about the opioid crisis during the OB/GYN section meeting.
- Ask the nursing coordinator/director of your OB/GYN unit to allow you time to give the same presentation to the nursing staff.
- Invite the community pharmacists to a sit-down meeting to do a presentation and get their feedback.
Your office or the OBED is the starting place. Make it clear at your first prenatal visit/OBED visit that opioids are harmful to the fetus. Leave copies of ACOG publications in your waiting room as conversation starters or references for your patients:
- Practice Advisory: FDA Boxed Warning on Immediate-Release Opioid Medications and All Prescription Opioids March 24, 2016
- Committee Opinion Number 633 June 2015
- Committee Opinion Number 473 January 2011
- Pregnancy: Methadone and Buprenorphine and Childbirth
- Breastfeeding and Infant Care
- Any patient handouts of your choice
- Set patients' expectations at the first prenatal visit or in the OBED, and communicate with your partners at checkout if you had a drug-seeking patient.
- Make sure your office/hospital nursing staff is on the same page with you.
- Give your nursing staff a list of conditions for which opioid prescriptions are appropriate.
- Make sure all order sets give you the ability to prescribe only NSAIDs and Tylenol when appropriate.
- Only prescribe opioids following ACOG recommendations.
- Have a unified approach that includes all OB/GYN physicians, nursing, pharmacy, and patients.
I believe education is the key to reducing the opioid crisis in the U.S.
This blog provides general information and discussion about healthcare-related subjects. The content and linked materials provided are not intended and should not be construed as medical advice. If the reader is an expectant mother with a medical concern, she should consult with an appropriately licensed physician or healthcare provider.
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