Perioperative Pain Management: Challenges in the Era of the Opioid Crisis

1. Perioperative Pain Management:  Challenges in the Era of the Opioid Crisis Roy Soto, MD Professor, Oakland University William Beaumont School of Medicine Residency Program Director, Department of Anesthesiology

2. Case 1 • 52yo s/p posterior cervical fusion • BMI 34 • OR pain meds: 0.5mg hydromorphone • PACU pain meds: 2.5mg hydromorphone • Hospital course: dead within 4hr of arrival on ward

3. Case 2 12yo boy fell from bike, suffering skull fracture and concussion Intermittently combative, confused, and unconscious in ER and PICU with breath holding spells and desaturation to 80s Morphine infusion hung for sedation… 3/24/17

4. Case 3

5. Case 4 Presentation Title Footer 3/30/18

6. Overview The opioid crisis: scope of the problem How the surgical setting contributes to the opioid crisis Opioid reduction/opioid safety/opioid free Multimodal analgesia The value of education What’s happening nationally, regionally, and locally

7. What we are NOT discussing today Management of the chronic pain patient Management of addiction/withdrawal

11. US vs EU • 99% undergoing surgery in US are treated with opioids vs ~60% in Europe • Hip/ankle fracture patients in the US and Holland: 85% of American and 58% of Dutch patients prescribed opioids in hospital • 77% of American and 0% of Dutch patients prescribed opioids after discharge • American patients use more opioids yet report more pain than European patients

12. State of Michigan • 1999 to 2016: opioid related deaths increased 17x in MI • In 2015: MI reported 11.4M prescriptions for opioids • Approximately 115 prescriptions per 100 people • 2016: 2335 MI citizens died from drug OD • UM research: one in 10 people who weren’t on opioid drugs before surgery become dependent on them after

15. Pressures for Opioid Use Patients expect zero pain after surgery If they have pain, they expect opioids Surgeons (at times) “sell” an operation as quick, simple, pain free, and minimally interfering with activities of daily living Opioids are simple to prescribe, inexpensive, and pervasive HCAHPS

16. Pressures for Opioid Avoidance Opioids delay recovery, prolong length of stay, add costs to a health system, and contribute to abuse Opioids increase morbidity and mortality associated with surgical care Opioid abuse has a tremendous public health cost

17. That was then…

18. N Engl J Med 1980;302:123-123

19. 608 vs 11

20. This is now

21. Anesthesia Pain Challenges • Determine quantity of pain • Determine quality of pain • Determine ability to tolerate side effects • Pain control versus side effects • “If you give a patient with no pain an opiate, the patient will have nothing but side effects.”

22. Surgery Pain Challenges • Determine if local anesthetics will help • Predict pain as activity/recovery change • Decipher pain complaints • Transition from IV to oral pain medications

23. Nursing Pain Challenges Decipher pain complaints Comply with satisfaction initiatives Placate demanding patients/families Sift through a zillion order sets Communicate with non-communicative physicians

25. Potential Patient Groups • Elderly • Frail • Obese • Young • At risk for opioid-related ADE and/or addiction • OSA/snoring • Concomitant use of other sedating drugs • History of depression/anxiety • Pulmonary or cardiac disease • Opioid naïve AND opioid tolerant

26. Potential Surgical Groups Oral Surgery ENT Minor gyn Minor urology Minor plastics Minor ortho Any procedure where a PNB is appropriate

27. Multimodal Analgesia • ASA Practice Guideline on Acute Pain Management (2004) • Facilitate safe and effective pain management • Maintain patient functional status • Unless contraindicated, all patients should receive around-the-clock regimen of NSAIDs, COX-2 inhibitors, or acetaminophen

29. Opioid Monotherapy • 2012 Premier database • 8,023,591 surgical and non-surgical inpatients and outpatients received IV opioids • 4,081,079 (51%) received opioid monotherapy Soto. PGA Poster Presentation. 2015

30. Naloxone? Presentation Title Footer

31. Naloxone Presentation Title Footer Anesthesiology. 2013

32. Hypofentanylemia

34. Moiniche. Anesthesiology. 2002

35. Opioid Induced Hyperalgesia?

36. Remifentanil

37. Fentanyl Findings: 10mcg/kg group (vs 1mcg/kg) experienced increased cold, pain, and heat sensitivity for 4.5-6.5hr Mauermann. Anesthesiology. 2016

38. Fentanyl Li. BJA. 2018

39. Laparoscopic ovarian cystectomy/staging, BMI 56

40. Alternatives to Hypofentanylemia? Deepening volatile anesthetic Esmolol Lidocaine Labetalol

42. Patient Education & Pain Management Apfelbaum. Anesth & Analg. 2003

43. Expectation Management Patients Reporting Selected Profile (%) “Moderate” V + “good” pain relief “Mild” C + “good” pain relief “Severe” I + “excellent” pain relief “Mild” I + “good” pain relief “Mild” D + “good” pain relief “Moderate” N + “good” pain relief “No” N + “fair” pain relief “Severe” D + “excellent” pain relief No side effects + “fair” pain relief “Severe” C + “excellent” pain relief Gan. Br J Anaesth. 2004

44. NY Times, 1/27/18

48. Provider Education • Webinars? • Surgeon • Anesthesia • Nursing • Dental • Primary care • Midlevel providers • Live presentations? • +/- CME/CE offerings? • +/- CME/CE requirements? • Print vs. digital vs. social media?