Strictly Clinical
  • Barriers and Facilitators to Intraoperative Alternatives to Opioids: Examining CRNA Perspectives and Practices

    Opioids are the mainstay of intraoperative pain control, but they have several deleterious effects. Alternative medications and strategies to opioids, while effective in producing intraoperative analgesia, are underutilized by anesthesia providers. The purpose of this study was to examine and describe Certified Registered Nurse Anesthetists’ perspectives and practices on administering opioids vs nonopioid or opioid-sparing strategies (“opioid alternatives”) to treat intraoperative pain. A qualitative study design using semistructured interviews was conducted (N = 12). Study participants described their perspectives and practices on treating intraoperative pain. Two key themes emerged: (1) barriers to intraoperative opioid-alternative administration and (2) facilitators to intraoperative opioid-alternative administration. Barriers expressed by study participants included opioid superiority, inconsistent analgesic effects of intraoperative opioid alternatives, limited experience with opioid alternatives, limited resources on opioid alternatives, negative experiences with intraoperative opioid-alternative administration, and patient comorbidities. Facilitators expressed by study participants included the adverse effects of opioids, institutional policy and procedures, positive experiences with opioid-alternative administration, and regional anesthesia superiority. This study highlights the importance of improving education, training, and institutional policies in support of opioid-alternative medications and strategies to treat intraoperative pain and better prevent opioid addiction and abuse.

    Keywords: CRNA, intraoperative, multimodal analgesia strategies, opioid alternatives.

    The United States has witnessed the development of a national opioid epidemic over the past 2 decades. Since 1999, the number of opioid prescriptions has quadrupled and the rate of opioid-related overdoses has increased 3 to 5 times over.1-3 The United States consumes approximately 80% of the world’s supply of opioids, and the Centers for Disease Control and Prevention estimates that approximately 115 people die every day of an opioid overdose.1,3 The perioperative period, surgery specifically, is particularly critical in the development of this epidemic because most surgical patients are exposed to opioids and thus put at risk of long-term opioid use. Studies have shown that any patient may be at risk of long-term use: both opioid-tolerant patients and opioid-naïve patients; patients undergoing low-pain procedures; and patients undergoing larger, more painful procedures.2 Several studies have demonstrated that previously opioid-naïve patients who underwent surgery continued taking opioids more than a year later.1,2,4 Echoing these findings, professional anesthesia organizations such as the American Association of Nurse Anesthetists urge healthcare professionals “to use opioid-sparing pain management techniques to better prevent opioid addiction and abuse.”5

    Opioids have been used in the medical field since the mid-19th century and have remained the mainstay for pain control. They are particularly valued in the administration of anesthesia because of their ability to reliably and rapidly suppress pain and sympathetic stimulation at multiple levels (brain, spinal cord, peripheral nervous system), as well their ability to decrease consciousness, reducing the minimum alveolar concentration of inhaled anesthetics.6 However, opioids are also associated with well-known, deleterious side effects such as excessive sedation, respiratory depression, ileus, and nausea and vomiting, all of which may increase postoperative complications, increase hospital length of stay, and raise healthcare costs.2,5,7 Such side effects have led some in the industry to decrease opioid use by implementing opioid-sparing (“opioid-alternative”) multimodal pain management strategies. An opioid-alternative pain management strategy is a key component of the multidisciplinary approach aimed at improving surgical patients’ outcomes known as Enhanced Recovery After Surgery (ERAS).1 Commonly used opioid-alternative medications include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs), ketamine, gabapentinoids, corticosteroids, a2-agonists, and local anesthetics and regional anesthesia.2,8 Opioid-alternative strategies include the use of multimodal analgesia, which is the practice of using 2 or more medications or interventions acting on different receptors to achieve pain relief.2

    Despite the number of opioid-alternative medications and strategies, many Certified Registered Nurse Anesthetists (CRNAs) demonstrate reluctance to use them clinically on a consistent basis. Much of the current literature focuses on side effects of opioid medications and the opioid crisis in the United States, and the number of qualitative studies that analyze healthcare providers’ approaches toward the administration of opioid alternatives for intraoperative pain control continues to be limited.9,10 Studies to date have focused on healthcare provider and patient perspectives on the use of opioid alternatives for control of chronic pain. These studies are aimed at identifying the issues that patients and providers face with the use of nonopioid medications for chronic pain.9,10 Common themes identified regarding the use of opioid-alternative medications include pervasive attitudes toward use of opioids, available access to nonopioid medications, and system support.9,10

    In a qualitative study by Lyon et al,11 the researchers evaluated barriers to implementing an ERAS protocol for colorectal surgical patients. After the identification of key stakeholders, the researchers used an in-person, semistructured interview to identify barriers and facilitators to the implementation of the protocol. Common themes identified included patient-related factors, provider-related factors, practice-related factors, and available resources.11

    To date, there are no known studies that have specifically assessed CRNAs’ perceptions on implementing opioid-alternative strategies for the treatment of intraoperative pain. It is important to identify and understand the barriers and facilitators to administering opioid-alternative strategies intraoperatively. The purpose of this study was to examine and describe CRNAs’ perspectives and practices on administering opioids vs opioid-alternative strategies to treat intraoperative pain.

    Methods

    This study used a qualitative, semistructured interview methodologic approach. Prospective study participants were recruited in the Chicago, Illinois, metropolitan area using a direct approach via purposive sampling with distribution of a recruitment flyer. Additionally, snowball sampling was used by asking study participants to voluntarily distribute the recruitment flyer to their colleagues. The primary investigator and research study team determined the study eligibility criteria for study participants based on the following inclusion and exclusion criteria: only CRNAs with at least 3 years of current working experience were included in the study. Student registered nurse anesthetists (SRNAs) ans well as CRNAs with less than 3 years of work experience were excluded from the study. To obtain a broader understanding of perspectives and practices on the topic, the researchers purposefully sampled CRNAs from 3 distinct practice settings: practice settings with minimal opioid-alternative resources and no implemented ERAS or other enhanced recovery policy, practice settings with opioid-alternative resources but no implemented ERAS policy, and practice settings with opioid-alternative resources and an active ERAS policy in place.

    The principal investigator was responsible for participant recruitment and interviewing. The research team met regularly to discuss study progress and interview findings. At completion of the interview with the ninth participant, the research team discussed initial findings of interviews 1 through 9 and reached group consensus that there were no new emerging themes to warrant continued exploration. Therefore, with use of Polit and Beck’s12 approach to determining sample size in qualitative research, it was “test[ed] whether data saturation had been achieved” by adding an additional 3 cases after “achieving informational redundancy” to ensure that no new themes emerged. The study was concluded after the 12th interview.

    Interview Guide

    The interview guide (Table 1) was developed based on empirical literature to date that identified knowledge gaps related to CRNA perspectives and practices surrounding intraoperative opioid-alternative administration. Additionally, the interview guide used the overarching structure of the semistructured interview guide published in the qualitative study by Lyon et al11 examining barriers to the implementation of ERAS. The research team responsible for developing and approving the interview guide included 1 PhD-prepared nurse scientist trained in qualitative methodology, 1 EdD-prepared CRNA, and 1 DNP-prepared CRNA, in addition to the principal investigator, a doctoral student. Collectively the research team represents more than 50 years of CRNA practice; as such, they served as content experts in the development of the interview guide. All research team members agreed to the final draft of the interview guide. The interview questions were used as a guide and focused on CRNAs’ work experience, background with enhanced recovery (eg, ERAS) protocols, and current use of opioid-alternative strategies intraoperatively.

    After obtaining institutional review board approval to conduct the study, the researchers recruited CRNAs via email, phone, and written letter to participate in the study. All interviews took place via phone. The principal investigator conducted every interview. Each interview lasted approximately 20 minutes. At the onset of each interview, the primary investigator explained the semistructured interview process and the purpose of the study, and acquired informed consent to begin the interview. Each interview included the following topics: the participant’s experience as a CRNA, experience administering opioid-alternative pain strategies, factors influencing the administration of opioid-alternative pain strategies, and experience working with an implemented ERAS policy. The principal investigator debriefed with research team members after each interview. Audio recordings of each interview were downloaded to a computer as MP4 files and were then submitted to Rev, an online company specializing in professional transcription of audio files. A Rev transcriptionist transcribed the audio of each interview verbatim and sent the research team the transcriptions as text files (Microsoft Word, Microsoft Corp). One of the authors (S.K.) reviewed each typed transcript with the accompanying audio for verification of accuracy.

    Quantitative study participant demographic characteristics were analyzed by 2 authors (D.V., S.D.S.) using statistical analysis software (SPSS 24, IBM Corp). The qualitative interview data were analyzed via thematic analysis using NVivo 11.4.2 software (QSR International Pty Ltd). The analysis was conducted by 3 research team members (D.V., S.K., S.D.S.), who each read the interview transcripts and identified preliminary codes. After identification of codes, the research team met to discuss coding and theme identification to ensure consistency. Codes were refined and clarified until consensus was reached. For this study, codes related to CRNA perspectives and practices surrounding intraoperative opioid-alternative administration were synthesized into distinct themes.

    Results

    A total of 12 participants completed the study protocol. Study participants’ characteristics are described in Table 2. Most study participants identified as male (75%) and 40 to 49 years of age (58%) and had an average of 8 years of CRNA work experience (range = 3-15 years). Participants described their perspectives and practices on treating intraoperative pain. Two key themes emerged, as shown in Table 3: (1) barriers to intraoperative opioid-alternative administration and (2) facilitators to intraoperative opioid-alternative administration.

    Theme 1: Barriers to Intraoperative Opioid-Alternative Administration

    The first key theme, barriers to intraoperative opioid-alternative administration, can be defined as factors that limit a CRNA from administering opioid alternatives intraoperatively. These barriers are composed of the individual provider’s knowledge and understanding surrounding opioid-alternative strategies, their personal experiences with opioid-alternative strategies, and their departmental and institution-level policies. Barriers described by study participants included perceptions of opioid superiority, inconsistent analgesic effects of intraoperative opioid alternatives, limited experience with opioid alternatives, limited resources on opioid alternatives, negative experiences with intraoperative opioid-alternative administration, and patient comorbidities.

    Opioid Superiority. “Opioid superiority” describes participants’ favorable preference for opioids over opioid alternatives because of their known efficacy in providing intraoperative analgesia. Of participants, 83% noted opioid superiority as a barrier to administering opioid alternatives, stating that “nothing beats the analgesia of an opioid.” Others described opioids’ effects as “fast and predictable.” One participant stated, “I think there are certain surgeries that you just simply need opioids … you can’t get away without [using] opioids.” Participants commonly discussed their perspectives that “small doses” of opioids were needed to administer a “quality anesthetic.”

    Inconsistent Analgesic Effects of Opioid Alternatives. “Inconsistent analgesic effects” describes participants’ experiences of poor predictability or variable analgesic effects of opioid alternatives. Most participants (83%) noted the inconsistent analgesic effects of intraoperative opioid alternatives as a barrier to opioid-alternative administration. Many participants commented on patients still “need[ing] opioids” even when the provider implemented an opioid-limiting pain management protocol. Others indicated that they prefer opioids to ensure pain is controlled. Participants widely shared their experiences with the inconsistency of the analgesic effects of intraoperative opioid alternatives and candidly expressed their perspectives in quotes such as, “I don’t care what the research shows; I anecdotally see a very poor outcome [with opioid alternatives].”

    Limited Experience With Opioid Alternatives. This barrier describes deficiencies in participants’ clinical experience and knowledge of using opioid alternatives for pain control. More than half (58%) of participants spoke of limited experience with opioid alternatives as a barrier to administering opioid alternatives. A few participants specified they “never use the alternatives” because “that’s how we [were] trained.” Some indicated to not “understand the pharmacokinetics” of opioid-alternative strategies as well as they understand opioids. In addition, participants shared that “[some] surgeons are not educated” on opioid alternatives and labeled surgeons as a limiting factor to administering opioid alternatives.

    Limited Opioid-Alternative Resources. “Limited resources” describes inadequate resources for routinely providing opioid-alternative strategies intraoperatively, resulting from departmental and institutional policies. Of participants, 42% identified limited opioid-alternative resources as a barrier to opioid-alternative administration. Some identified as being “limited” in using acetaminophen injection (Ofirmev) when attempting to administer it for pain control. Participants also described limitations to administering opioid alternatives as “what’s available to me,” indicating their institution’s lack of alternative resources.

    Negative Experiences With Intraoperative Opioid-Alternative Administration. “Negative experiences” describes participants’ experiences with inadequate analgesia and with adverse effects of opioid alternatives. Sixty-six percent of participants verbalized past negative experiences with intraoperative opioid-alternative administration as a barrier. Several participants described witnessing a patient “stimulated” and “breathing fast” as a negative clinical experience following the administration of opioid-alternative medications and strategies. Another participant explained an instance in which ketorolac “(Toradol) was given with an epidural” anesthetic, resulting in the development of an epidural hematoma. Participants’ negative experiences also included describing episodes in which patients were “screaming and crying” when opioid alternatives were unable to adequately manage pain.

    Patient Comorbidities. “Patient comorbidities” describes the patient-related factors that prevent or deter study participants from administering opioid alternatives. All participants discussed patient-specific health concerns and comorbidities as barriers to administering opioid alternatives. One participant specifically talked about patients who are “chronically addicted to narcotics” needing opioids for adequate pain control. Others discussed patient-related factors including poor liver and kidney function, advanced age, and patients with “chronic pain issues” as a barrier to administering opioid alternatives. The importance of “being patient-specific” in the administration of opioid-alternative strategies was consistently regarded as important by all interviewed CRNAs.

    Theme 2: Facilitators to Intraoperative Opioid-Alternative Administration

    Our second key theme, facilitators, can be defined as factors that support a CRNA in administering opioid alternatives intraoperatively. Similar to the barriers noted in theme 1, facilitators are influenced by provider knowledge, experience with opioid alternatives, availability of resources, and the presence of a supportive department and institution. Facilitators described by study participants included the adverse effects of opioids, institutional policy and procedures, positive experiences with opioid-alternative administration, and the belief that regional anesthesia is superior to other types of anesthesia.

    Adverse Effects of Opioids. “Adverse effects” describes the inclination of the participants to identify adverse effects of opioids and their tendency to avoid them in particular patient populations. Of participants, 92% described their desire to avoid the adverse effects of opioids as a supporting factor to administering opioid alternatives. Several participants aimed to avoid the adverse effects of opioids such as sleep apnea, respiratory depression, and hypotension in “morbidly obese” patients with “tons of respiratory problems.” Preventing nausea and the desire to “extubate faster” were also expressed as facilitating factors in favor of the use of intraoperative opioid-alternative medications and strategies.

    Institutional Policy and Procedures. This facilitator describes organizational factors that support the provider’s choice to use opioid-alternative strategies intraoperatively. Half of participants identified institutional policy and procedure as a factor facilitating the use of intraoperative opioid-alternative administration. A few participants recognized an ERAS policy or other enhanced recovery policy as an encouraging factor. Other participants included opioid-sparing techniques in addition to ERAS as a supporting factor. The willingness to implement regional blocks and peripheral nerve blocks was also identified.

    Positive Experiences With Opioid Alternatives. “Positive experiences” describes participants’ experiences with effective analgesia using opioid-alternative strategies, as well as the lessened adverse effects of opioids as a result of using opioid alternatives. Fully 100% of participants recognized previous positive experiences with opioid alternatives as a factor supporting opioid-alternative administration. One participant specifically described “attacking the pain receptors from every avenue” as a necessary intervention to adequately treat intraoperative pain. Numerous participants claimed that patients “have better wake-ups,” “breath[e] better,” and are “not nauseated” when administered alternatives to opioids. Several participants also acknowledged sending patients home “with a peripheral nerve block with limited to no opioids” as a “step in the right direction” in hastening their postoperative recovery.

    Regional Anesthesia Superiority. “Superiority” of regional anesthesia describes participants’ favorable preference for regional anesthesia for intraoperative analgesia because of its known efficacy. All participants contributed their perspectives and practice experiences noting regional superiority as a facilitator to opioid-alternative administration. Many participants described regional blocks such as peripheral nerve blocks to “get [patients] up and moving quicker,” instead of administering opioids. Several also recognized “a well-placed regional block” as a promoting factor in reducing or eliminating opioid administration intraoperatively. Various participants encountered experiences that have shown patients undergoing regional anesthesia to have “quicker recovery” and “better pain management” vs general anesthesia with narcotics. Others indicated “it’s better to go the [regional] route” than to give opioids intravenously.

    Discussion

    This qualitative study identified a range of barriers and facilitators to opioid-alternative administration as described by experienced CRNAs practicing in diverse institutions across a US metropolitan area. Barriers to opioid alternatives outnumbered the facilitators expressed by study participants. Six barriers and 4 facilitators to opioid-alternative administration emerged.

    Positive pervasive attitudes toward the use of opioids prevailed among interviewed CRNAs. Both opioid superiority and inconsistent analgesic effects of opioid alternatives were commonly noted barriers. With statements such as “I don’t think anything can beat … an opioid” and “I don’t care what the research shows…,” CRNAs demonstrate that they have embedded beliefs that may be difficult to change. Positive pervasive attitudes as a barrier is common in the literature; however, to date, this phenomenon has been primarily described in patient populations, not providers. The concept of pervasive attitudes toward opioids echoes the work of Penney et al9 and Simmonds et al,10 who noted that patients strongly believed in the benefit of opioids despite knowing the adverse effect of opioids and the stigma associated with dependence on opioid analgesics.

    Other major themes identified in this study also support the findings from earlier studies that described barriers and facilitators to opioid-alternative administration, including descriptions of limited experience in administering opioid alternatives13 and patient comorbidities14,15 as barriers to opioid alternatives. The desire to avoid the adverse effects of opioids was a strong factor for opioid-alternative use also supports the work of Hughes and colleagues.13

    Common barriers to implementation of opioid-alternative policies identified in the literature that are reinforced by our study findings include unfamiliarity with policy, lack of education, and limited resources.14 Limited experience was a challenging barrier to intraoperative use of opioid alternatives. This obstacle can be overcome with a well-developed and thorough education plan. Certified Registered Nurse Anesthetists must be educated on all aspects of the procedural changes, the available medications and opioid-alternative strategies, and organizational expectations. To change ingrained organizational behaviors, Gotlib Conn et al16 described a stepwise approach that included effective and engaged leaders to ensure a stronger buy-in and smoother implementation. In fact, half of study participants identified institutional policy as a promoting factor, which has been previously reported by the investigators of an enhanced recovery protocol.17

    Of note, some interviews in this study yielded related findings, with participants indicating frustration with poor organizational communication or a lack of leadership. A particularly interesting area of poor communication noted was in the availability and use of intravenous acetaminophen. Participants spoke of good pain-relieving outcomes with its use intraoperatively; however, the medication had been removed from some of the participants’ practice settings without explanation. Participants expressed disappointment and uncertainty with institution-level decisions being made in the absence of input from anesthesia providers.

    When implementing opioid-alternative pain protocols, healthcare providers must have the resources to achieve the desired results. The CRNAs participating in this study discussed medication shortages as a limiting factor, supporting a previous finding reported by Wu and colleagues.17 Without the necessary supplies, equipment, and medications immediately available to CRNAs, opioid-alternative strategies will be disregarded. Having an adequate amount of opioid alternatives for anesthesia providers to administer may promote a reduction in intraoperative opioid administration.

    The findings in this study corroborate previously reported barriers and facilitators to opioid-alternative use as described by CRNAs. When organizations place pressure on CRNAs to reduce or eliminate opioids from their pain management strategies, they must consider the CRNAs’ comfort and clinical expertise, including consideration of patient comorbidities and other factors for using opioids. Institutional leaders must also consider the availability of resources when implementing new policies to increase the use of opioid-alternative strategies. Regional anesthesia techniques, such as peripheral nerve blocks or epidural anesthetics, were supported by every CRNA as a superior opioid-alternative strategy. Institutional policies should support the use of regional anesthesia administration at every possible opportunity if opioid reduction is the ultimate organizational goal. Open communication among team members including surgeons, anesthetists, and nurses should be encouraged because some CRNAs have identified the surgical team’s own preferences for opioids as barriers to administering opioid-alternative strategies.

    This qualitative study has a number of strengths, especially its novelty because it was the first known attempt to examine and describe CRNAs’ perspectives and practice experiences with opioid-alternative medications and strategies. Additionally, we employed a rigorous process of review, with our research team consistently following consensus building and validation. We were successful in recruiting participants from various practice settings in our metropolitan area; however, our composition of a convenience sample and use of snowball recruitment techniques limit the generalizability of our study findings. Thus, limiting the generalizability of our study findings as the expressed perspectives and experiences of our study participants do not speak to the experiences of all CRNA professionals. However, this study is a major contribution toward our collective knowledge of the perspectives and practices of anesthesia providers, central to better understanding how to reduce the opioid epidemic moving forward.

    Future studies should include qualitative examination of the perspectives and practices of other groups, including SRNAs and CRNAs in rural areas. There is also a need to create a survey tool based on our qualitative findings to ascertain perspectives and practices surrounding opioid-alternative administration in larger, more diverse CRNA populations. Another need is to examine institutional and departmental barriers to developing and implementing enhanced recovery protocols. Major changes to the intraoperative pain management protocols require the support of the leadership team. In this instance, studying the attitudes and beliefs of chief CRNAs or other anesthesia leaders on intraoperative opioid use may be the first step toward policy changes that would lead to a successful reduction of opioid use among CRNAs.

    Conclusion

    This qualitative study examined and described CRNAs’ perspectives and practices on administering opioids vs opioid-sparing strategies to treat intraoperative pain. It identified key barriers and facilitators that affect CRNAs’ use of opioid-alternative strategies intraoperatively. This study adds confirmation to the importance of improving education, training, and institutional policies in support of opioid-alternative medications and strategies. These findings can be used to help practice leaders and organizational leadership guide future efforts promoting the administration of nonopioid medications to treat intraoperative pain and better prevent opioid addiction and abuse.

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    AUTHORS

    David Velasco, DNP, CRNA, is a graduate of Northshore School of Nurse Anesthesia and is currently in clinical practice at Franciscan St Anthony in Crown Point, Indiana.

    Shannon D. Simonovich, PhD, RN, is an assistant professor at DePaul University School of Nursing, Chicago, Illinois. Email: s.d.simonovich@depaul.edu.

    Susan Krawczyk, DNP, CRNA, APRN, is a faculty member at NorthShore University HealthSystem, School of Nurse Anesthesia, in Evanston, Illinois, and a clinical CRNA at Loyola University HealthSystem in Maywood, Illinois. Email: SKrawczyk@northshore.org.

    Bernadette Roche, EdD, CRNA, APN, is a faculty member at NorthShore University HealthSystem, School of Nurse Anesthesia, and adjunct associate professor of nursing at DePaul University School of Nursing. Email: Broche@northshore.org.

    DISCLOSURES

    The authors have declared no financial relationships with any commercial entity related to the content of this article. The authors did discuss off-label use within the article. Disclosure statements are available for viewing upon request.

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