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Hello everyone. My name is Dr. Warner ha. I'm the chair of the department of obstetrics and gynecology at the university of Alabama Birmingham. And I would like to welcome you to this episode of women's health with Dr. Ha and we have two guests with us today. Dr. J Michael Straughn Jr. Who is a professor of obstetrics and gynecology, within the department of OB GYN and also the associate chief medical officer, for UAB medicine, as well as the fellowship director for the division of gynecologic oncology, as well as Dr. Theresa Boitano, who is a fellow instructor within the division of gynecologic oncology. Also within the department of OB GYN, I've asked both of them to discuss an incredibly important topic. one in which I think is a. an important public health crisis that I think many of our listeners are aware of.

And that's the topic of, reducing opioid use and gynecologic surgery. I think you're going to really enjoy listening to them. I think they have a lot to contribute in both in terms of basic knowledge, as well as practical advice. And again, I'd like to welcome.

Dr. Straughn: Thank you.

Dr. Boitano: Thank you.

Dr. Huh: So, obviously, this is an immensely important topic. And I would argue that the two of you have been truly transformational in terms of how we contribute to reducing opioid use as it relates to surgery, specifically gynecologic surgery. So, Dr. Straughn, I thought maybe you could provide some background related to the prescription of opioids in gynecologic surgery. Is it common? And can you tell us this is a function of limited education, understanding and awareness?

Dr. Straughn: So I'd like to first start off by saying that OB-GYNs have a number of different opportunities in clinical scenarios to manage pain. Most common scenario is going to be in patients undergoing gynecologic surgery. For a number of years, OB-GYNs have been quite liberal in prescribing opioids after surgery, mainly to benefit the patient.

We've always wanted patients to be close to pain-free as possible. And so we have sent patients home once they've left the hospital with an adequate supply of opioids, so that once they were home, that they didn't have issues with increasing pain. We've also wanted them to have an adequate supply of opioids post-operative so that they didn't run out over the weekend or run out at night and so, again, that's probably increased the amount of opioids that patients have received at discharge. You know, I think finally there has been sort of a lack of understanding of some of the side effects and risks related to opioid use that clinicians probably didn't recognize through the years.

There's probably two important facts to consider. One is that persistent use of opioids is common in about 10% of patients. So 10% of patients who receive opioids for a minor surgery are at risk for developing an addiction or continued use of opioids. And then the second thing is that patients probably have not been adequately counseled on really the effectiveness of both Tylenol and Advil. Most of these medications are considered to be used for headaches or backaches or sprained ankle, but really both of these medications are quite effective in eliminating postoperative pain. So I think now we have a better for sense of the risks and benefits of opioids, and that's really helped us implement some of the things we're going to talk about today.

That's great. So what I'm hearing from you, Dr. Strong, is that the risk of opioid addiction? When being prescribed narcotics after surgery is actually quite high, I think 10% is actually remarkably high.

And so I think they're really two main messages for our listeners. One is that they should keep in mind that the risk to opioids, particularly after major surgery, when being prescribed narcotics is high. And I think that's important to, be aware of that. And then number two, I think it's incumbent upon physicians, surgeons, and providers.

To counsel and educate our patients about the risk of addiction. I think that the element of education is truly important here, but we also have patients who are definitely scared of being prescribed narcotics, because they've heard about this opioid epidemic and the risk of addiction. On the flip side, we also have some patients who clearly don't understand what that risk is.

So again, I think it's our responsibility to take some time and carefully educate, what that risk is and what we're trying to do to minimize that risk yet, you know, manage patient expectations and improve the patient experience.

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Dr. Huh: So Dr. Boitano, you and your group have been truly central to bringing in what's known as an enhanced recovery protocol to the Gynecology Service at UAB. First, can you just tell us a little about what this is and what have been your observations and outcomes thus far? And then secondly, is this a new standard of care? I mean, is this something that patients should be asking for when they come to have surgery?

Dr. Boitano: Yeah. Thanks for having us, Dr. Huh. I appreciate it. So in 2016, the Division of Gynecologic Oncology initiated an enhanced recovery protocol for patients undergoing surgery. Enhanced recovery protocols are collection of patient-centered, multidisciplinary best practices that are aimed at reducing the patient's surgical stress response, optimizing their physiologic function and improving recovery.

So this includes preoperative education, intra-operative methods to manage fluids and decrease opioid use, and then proactive post-operative care, including pain medications that target different pathways, early feeding and encouraging early ambulation. These interventions have been shown to decrease complications, shorten hospital stay and decrease hospital costs.

In response to the question about the standard of care, enhanced recovery protocols were largely adopted and developed by colorectal surgeons early on. But now most fields, including obstetrics and gynecology and gynecologic oncology have their own guidelines that have been tailored to the specialty.

We published two papers from UAB, where we saw our length of stay decreased by half, a large reduction in our complication rates and an overall improvement in patient satisfaction. We specifically showed that our enhanced recovery protocols decreased postoperative complications in obese patients and patients older than 65. Given these results are similar to most other studies that have been performed, we do think this is the new standard of care.

Dr. Huh: Oh, you know, this is really an important point because, you know, the length of stay of patients have has dramatically dropped particularly over the last decade plus. But I thought maybe you could comment on just the patient satisfaction related to the protocol. Do you think that's made a difference? Has that improved patient satisfaction with recovery after surgery?

Dr. Boitano: I think one of the biggest factors is that, by educating patients, we're giving them the ability to participate more in their care. So they come in with expectations of what they're going to encounter during their hospital stay, what it's going to be like postoperatively. And so they're better able to kind of deal with the stress surrounding their surgery. And I think that improves their overall satisfaction.

Dr. Huh: Both of you, that I think that the enhanced recovery protocol is perhaps one of the most transformative exercises initiatives that you guys introduced to gynecology. It's been amazing. And I would just tell it to our listeners that if you're having major surgery, regardless of where you are, you definitely need to ask your surgeon whether or not a protocol of that nature is available to you. I think it's that much of a game changer.

So the both of you have also been equally pivotal in what's known as a restrictive opioid prescribing algorithm. And I think our listeners would be very interested in learning what this is. So I thought, Dr. Straughn, maybe you could comment on that and what the rationale is behind that.

Dr. Straughn: Yeah, I'd be happy to. So when we developed our enhanced recovery protocol, we knew that patients would ultimately require less opioids during their hospital stay. Many of the things that we were doing related to interventions that our anesthesiology colleagues could provide, and the way that we created these multimodal pathways where patients were receiving different medications after surgery. There was good data and we showed it in our studies that the number of opioids during the hospital was significantly decreased.

What we did not originally do was really make any specific guidelines for patients once they were discharged from the hospital. And so, as we previously mentioned, we were still giving patients 20 to 30 tablets at the time of discharge, just in case if they had an increased level of pain once they got home.

So in 2018, there was a fair amount of emerging data that suggested that restrictive opioid-prescribing guidelines were really necessary in order to decrease the amount of opioids that patients were sent home from. And importantly, the original studies in gynecology patients showed that even when you limited the amount of opioids at discharge, this really had no impact on patient outcomes or patient satisfaction. And so we essentially just decreased the amount of opioids that patients were given at discharge and really focused on other ways that patients could control their pain, specifically Tylenol, Advil, movement, et cetera.

And so we developed these guidelines at UAB and our guidelines were based on the type of surgery that patients had. So if a patient had an outpatient procedure, then many of those patients were not prescribed opioids. If a patient had a minor surgical procedure and stayed overnight, then they were sent home with five opioid tablets which basically covered them for about 24 hours once they got home. And then patients who had major surgery were discharged with 15 tablets, which would cover them for approximately three to four days. We also developed guidelines for patients who were on chronic opioids prior to surgery to help make sure that those patients had adequate pain control at the time of discharge.

All of these changes that were made contributed to a significant reduction in the amount of opioids that we were prescribing to our patients undergoing gynecologic surgery.

Dr. Huh: I think our listeners want to know, so what has that impact been? I mean, I'm just very curious. I mean, can you comment on that, Dr. Boitano?

Dr. Boitano: So by following this restrictive opioid-prescribing algorithm at UAB, we've had a significant reduction in the numbers of opioids that we've prescribed. As Dr. Straughn mentioned through patient education and multimodal pain control, we've also had a reduction in the amount of opioids that patients even use once they get home.

So we performed a study at UAB looking at around 2,500 of our patients. And we found that our numbers decreased from 34,000 annually to 14,000 in just the first year. We also conducted a survey of our patients and it showed that 95% of our patients were satisfied with their pain regimen. This change in opioid prescribing also didn't increase the refills that patients were asking for or increase our ER visits for pain. And overall, the average number of pills prescribed for patient decreased from 31 to 11.

We found that a third of our patients still even had leftover pain pills despite this reduction that we made. So overall, that's 20,000 fewer pills that have been prescribed and that's 20,000 fewer pills that have the potential to be misused by either the patient or their family member and friends.

Dr. Huh: Twenty thousand? I just want to make sure I heard that correctly.

Dr. Boitano: Right. And that's just in one year in one division at the University of Alabama.

Dr. Huh: So I think it's safe to say that the widespread impact on all surgical services at UAB and beyond would be enormous if we actually had a policy like this.

Dr. Boitano: Exactly. I think as physicians, we have the opportunity to make a huge impact on the opioid crisis.

Dr. Huh: To me, that seems like the most straightforward way of tackling this. So, I mean, that's impressive that you guys have done that. Kudos to you all. So one of the things I'm sure the listeners are also learning, that you're learning more about is something what we call the UAB Opioid Stewardship program. I thought maybe you could give us an overview of that, dr. Straughn.

Dr. Straughn: Yeah, happy to. In 2019, UAB Medicine for the first time created what we call the Opioid Stewardship Program. And this is a group of administrators, nurses, physical therapists, pharmacists, and clinicians that were assembled to create an infrastructure that advocates for safe opioid-prescribing while maintaining effective patient-centered pain management. And this was to deal with really all aspects of opioid prescribing and consumption both as an inpatient and when patients were discharged from the hospital.

And there are really four major goals of the program. First is to develop acute pain guidelines for all patients admitted to UAB Hospital. So this is any medical patient or surgical patient who is admitted to the hospital, that there are specific pain guidelines for the patients for the clinicians, for the nurses. So that was the first goal of the program.

The second was to educate the staff and clinicians on all aspects of opioids, including safety, alternatives to opioids, different programs for pain management at UAB and then specifically, guidelines once patients were discharged, like we've previously discussed today.

The third was to educate patients and families on expectations related to their pain and how we were going to manage their pain. And so now patients, when they're admitted, they all have access to the same patient information. That's now also placed in the surgical education that patients get. And so the education across all disciplines are now the same regarding pain management.

And then the fourth major goal of the program is to track and maintain prescribing practices for our UAB clinicians. And so we have a website related to stewardship that's developed. We have scorecards that are developed. And obviously, we have pushed out e-prescribing across the entire UAB Medicine, which is a safer way to prescribe opioids.

These acute pain guidelines have been written over the last two years and are now currently being rolled out actually this month at UAB. And so there's a lot of education going on across campus for clinicians, nurses and patients.

Dr. Huh: That's great. Yeah. I mean, I think that many of our listeners want to learn more specific details. And for physicians and healthcare providers who are listening to this, we can certainly share elements of that with you.

So one question that we commonly get is if you are a patient and you do fill an opioid prescription or narcotic prescription, you have extra pills leftover, how does one dispose of them? What's the right way to do that, Dr. Boitano?

Dr. Boitano: Yeah. So we found that education was probably the thing that was lacking the most describing proper disposal of unused opioids. We encourage all of our patients to dispose of any unused opioids at three weeks after their surgery.

Per the FDA's guidelines, patients are counseled to take their opioids to a take-back center, which are frequently at pharmacies that are part of your local community. You can dispose of them properly in the trash. You can go to the FDA's website in order to figure out how to do that. Or you can flush them down the toilet if they're on the safe flush list.

We found that only about a third of our patients were disposing of their leftover opioids. About 71% of them flushed them down the toilet, but only 7% of them use a disposal center. So because of these findings, we obtained a grant to perform a pilot study using the Deterra Disposal Bag. This is an environmentally-friendly disposal system that patients are given at their preoperative visit.

Patients are then instructed to add water and the unused pills to the bag and dispose of them in the trash. The components in the bag then deactivate the opioid medication. This has increased our disposal to 65% with about three-fourths of our patients using the bag. But overall, we found that the key way to increase disposal of leftover pills is to educate our patients.

So Dr. Boitano again, that's the Tara, D E T E R R a disposal system. And I've just for the listeners that we have. We don't have a financial relationship. with this company, just a grant to understand how to best utilize this with patients who are prescribed opioids or narcotics after surgery.

But again, my understanding is that they get instructions. They understand how to use this. They place the unused narcotics or opioids in this disposal system. And then they're able to actually able, just to throw it away.

Dr. Boitano: Exactly. So the nice thing about it is that all they have to do is put their pills in the bag, add some water, and then they can throw it away. They don't have to worry about, you know, looking up any guidelines online or concerned about affecting the environment. So pretty easy disposal system.

Dr. Huh: That's great. Well, I want to thank you both. it would be an understatement to say that your contributions to medicine based on this topic had been immeasurable. Just personally, the reduction in opioid use and the commensurate increase in patient satisfaction has been really dramatic at least based on my experience. But I don't know if you guys have any closing thoughts or comments that you all want to make before we sign off.

Dr. Straughn: Yeah. I mean, I would say that the 20,000 number of decreased opioid tablets was remarkable when we looked at our first year of data using our restrictive opioid algorithm ,that was sort of mind blowing to me. And UAB Medicine is striving to do the same thing with their Opioid Stewardship Program.

I think in conclusion for me, I think as a surgeon, we should always strive to balance the risk and benefits of opioids in our surgical patients. And as long as we educate our patients about pain expectations, we implement these multimodal pain strategies that we're doing in our enhanced recovery protocol using restrictive prescribing protocols and then finally, you know, educating patients on safe disposal. These sort of quick things really can impact how our patients deal with pain and basically keep them out of trouble down the road.

Dr. Boitano: Yeah, I completely agree with all that. Just educating our patients and making sure that you have these aspects in your surgical practice, surgeons are able to, you know, improve their patient's surgical experience, but then also decrease any potential contribution that they have to the opioid crisis.

Dr. Huh: That was great guys. There's a lot in this podcast to digest. And so just in summary, I think for our listeners, couple of key elements I think that you should take away. One is that those are real risk of addiction in patients who are prescribed opioids. Two, that this enhanced recovery protocol has been transformative to our major surgical patients and something that, you know, the listeners and patients should ask about and a big part of that is really managing their pain. The third one is the important contribution of education and awareness, both between the patient and the provider, but also the family and the provider. I think that's actually equally important as well. And lastly, just thinking about how you're going to dispose some of these medications in an environmentally safe way to protect others.

I think perhaps the most important thing that I'll pass on to the listeners is, you know, whether you get your care at UAB or whether you get your care elsewhere, I think it's really important that you recognize that you also have a personal responsibility to bring these topics up with your physician, surgeon and providers.

Not only that, I think it's important -- not to editorialize -- that we make, you know, our elected officials aware that this is an important mechanism, actually relatively cost-effective one, to markedly reduce the risk of opioid addiction.

And so I think, to listeners, ask those questions of your surgeons. I think this is super important, and this is how we're actually going to make a difference.

But anyway, I want to thank both of you. Thank you, Dr. Straughn. Thank you, Dr. Boitano, for your time. This was a fantastic podcast.

So this concludes this episode of women's health with Dr. Ha again, like to thank the listeners Dr. Strong, Dr. Boitano for your time and your contributions, as always, we'd love for you to, rate and comment on this podcast.

And if you are seeking additional information on the podcast itself, or the services that we provide here at UAB, please go to UAB medicine.org. I hope you all have a good day and we look forward to the next podcast with you.