Clinician perspectives on the feasibility of a pain management protocol in kidney transplant

BACKGROUND: Opioids are often prescribed to treat pain after kidney transplant (KT) but pose significant risks to patients as well as the risk of diversion of unused opioids into the community. While there is growing interest, only 18% of KT programs in the United States have a pain management protocol. We described the current pain management practices in KT at a large academic medical center and assessed the feasibility of implementing a pain management protocol. METHODS: We conducted semi-structured individual interviews and focus groups with clinicians from a large-volume KT program. The interviews and focus groups were audio-recorded, transcribed verbatim, and coded inductively. We used the constant comparative approach to identify and refine emerging themes. RESULTS: Twenty-three clinicians participated including 7 advanced practice providers, 7 nurses, 5 transplant fellows, 3 attending surgeons, and 1 pharmacist. We identified six overarching themes: (1) clinicians report prescribing opioids to most KT recipients (KTRs) as outlined in the standardized postoperative order set; (2) there is provider variation in opioid and non-opioid prescribing beyond the initial order set; (3) pain management requires a balance of setting realistic expectations about postoperative pain and controlling pain sufficiently for KTRs to complete activities of daily living; (4) clinicians believe that it is feasible to implement a protocol as long as it is flexible to individualize pain management based on patient-reported level and type of pain; (5) an acceptable protocol for KTRs includes preoperative blocks, scheduled acetaminophen, additional non-opioid strategies (e.g., ice, lidocaine patches, muscle relaxants, and gabapentin) and reserves oxycodone for breakthrough pain; (6) barriers to implementing a pain management protocol include concerns about inadequate pain control, delays in treatment, limited resources for preoperative blocks, and challenges changing clinician behaviors. CONCLUSIONS: Although there is variation in current pain management practices, clinicians were enthusiastic about the implementation of a standardized pain management protocol. Clinicians agreed that opioids should be used sparingly but are needed for some KTRs and emphasized the need for individualized pain management. Effective implementation will require coordination with anesthesiologists for preoperative blocks and coordination with nursing and prescribers to ensure timely follow up for breakthrough pain.