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Opioid prescribing: ‘We’ve been able to change the culture’

OHSU Thyroid and Parathyroid Center sharply reduces opioid prescribing following surgeries
man sitting in chair, laughing with his doctor
David Knierim (left) of Wilsonville, OR, meets with his surgeon, Maisie Shindo, M.D., for an exam following his thyroid surgery. Shindo led an initiative to reduce the use of opioids for patients undergoing thyroid and parathyroid surgery. (OHSU/Kristyna Wentz-Graff)

Alarmed by the opioid crisis gripping the country, OHSU physician Maisie Shindo, M.D., decided to take action.

In the fall of 2016, Shindo, surgical director of the OHSU Thyroid and Parathyroid Center, led an initiative to sharply reduce the use of powerful opioids among patients undergoing thyroid and parathyroid surgery (the high-volume center conducts 300 to 400 endocrine-related procedures annually). The initiative has paid off. With the support of the hospital’s nursing staff, more than half of all patients who have had their thyroid or parathyroid glands removed go home with no opioids at all.

And patients seem to prefer it.

“The more you prescribe, the more patients think they need it,” said Shindo, a professor of otolaryngology/head and neck surgery in the OHSU School of Medicine. “Now we tell patients that some form of discomfort and pain is normal and there are ways to manage it without opioids.”

David Knierim, a 62-year-old engineer from Wilsonville, recently underwent two procedures to remove his thyroid gland due to cancer. He came out of each procedure with very little pain and relieved that he needed only over-the-counter acetaminophen. A key advantage for Knierim: Because he was able to think clearly without opioids, he was able to work from home starting the day after surgery.

Shindo had prepared him ahead of time, so he wasn’t surprised.

“I was expecting it to be tolerable,” he said. “Finding out that I wasn’t going to be on opioids was definitely a side benefit.”

doctor talks with a patient in an exam room
Maisie Shindo, M.D., (left) talks with David Knierim during a follow-up exam, November 2018. (OHSU/Kristyna Wentz-Graff)

Shindo recalls prescribing Tylenol with codeine when she started her career in the 1970s. Then, beginning in the 1990s, the medical profession stepped up its focus on helping patients reduce pain associated with surgery. Pharmaceutical companies began marketing opioids heavily, and opioid prescriptions rose accordingly. Widespread use of prescription opioids led to misuse, addiction and overdoses. In 2017 alone, more than 72,000 people died from overdoses in the United States.

Reversing this trend took a change in culture, Shindo said.

Shindo said the reduction in opioid prescribing in OHSU’s Thyroid and Parathyroid Program required the buy-in of the recovery room nurses, who directly tend to patients in the hospital following surgery. Amy Stone, R.N., recalled speaking with Shindo about the right amount of powerful pain medications following surgery – and questioning whether they were necessary at all after certain surgeries.

“I experienced that same kind of ‘ah-ha’ moment,” Stone said. “I used to do follow-up phone calls with patients and remember one patient saying to me that she was upset or concerned that she went home with 120 pain pills and only used one of them. I recall thinking, we’re overdoing it here.”

Through an OHSU nursing fellowship program, Stone and a colleague subsequently developed a presentation to share evidence-based research about post-operative pain management and opioids with nursing staff.

Shindo recently co-authored a retrospective review published in the journal JAMA Otolaryngology-Head & Neck Surgery that documented a sharp reduction in opioid prescribing among thyroid and parathyroid patients at OHSU. The study showed a sharp decrease in opioid prescribing through the end of 2017. Since then, the downward trend has continued.

“We’ve been able to change the culture,” Shindo said.

In her endocrine cases, Shindo rarely prescribes any opioids in patients who have not previously taken them. She has been active in encouraging other clinicians to minimize opioids for patients undergoing endocrine surgery.

Percentage of patients discharged without opioids

Procedure 2016-17 2017-18
Parathyroidectomy 39.5 percent 78.1 percent
Hemi-thyroidectomy 19.6 percent 64.9 percent
Total thyroidectomy 17.5 percent 54.9 percent
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