Short Messaging Service (SMS) Education for Post-operative Pain

1.0 BACKGROUND, RATIONALE Since the turn of the century, opioid prescriptions and opioid-related overdose deaths in the United States has been on the rise, and is seen as the main cause of the consecutive decrease in life expectancy seen in 2015-2016. This epidemic has been declared a Public Health Emergency by the Department of Health and Human Services (HHS), with approximately 115 people dying daily from opioid-related drug overdoses nationwide. Over 40% of these overdoses are associated with prescription opioid abuse.

While non-medical opioid use is seen most commonly in those aged 15-24, accidental opioid overdose rates are highest in the those aged 45-54, an age group in which the medical use of opioids is most common. For many adults, their first medical exposure to opioids is following a surgical procedure. New persistent opioid use has been identified following both minor and major surgical procedures in 5.9% to 6.5% of patients, and was associated with behavioral and pain disorders rather than surgical pain itself. Furthermore, prolonged opioid use beyond 5 days, and even more so when the prescription exceeds 10 days, has been associated with an increased probability of continued long term opioid use.

Better pain management strategies and better research are key strategies the HHS have identified to combat the growing opioid epidemic. Current prescription patterns in the US are highly variable, although initiatives have been put into place to develop evidence based guidelines. Prescription opioid use has previously been linked to improved patient satisfaction with care, and in a study of primary care providers, those physicians who were incentivized by patient satisfaction scores reported an increased impact of these scores on their opioid prescribing practices. However, multiple studies have revealed no correlation between patient satisfaction scores and the amount of postoperative opioids prescribed.

A systematic review of studies describing opioid oversupply after surgery reported that 67-92% of patients reported unused opioids with few storing or disposing of excessive pills in an appropriate manner. Multiple studies have looked at interventions on the provider side, in order to minimize opioid prescriptions and thus minimize the availability of excess opioids that may facilitate opioid dependence and diversion into the community. While there has been an almost universal reduction in opioids prescribed, fewer studies have demonstrated a reduction in actual opioids taken by the patient.

Hill et al identified in 642 patients undergoing 5 common outpatient procedures a wide variation in the number of opioid pills prescribed and identified an ideal number of opioid pills per procedure that would adequate treat postoperative pain in the majority of patients, a number that was typically less than 50% of what was historically prescribed. The same group then presented their findings at their institution and recommended prescribers to encourage patients to use nonopioid analgesics. They found that following this education, there was a significant reduction in number of opioid pills prescribed across all procedures and also a decrease in the mean number of pills taken by patients following inguinal hernia and partial mastectomy with sentinel lymph node biopsy (SLNB) patients.