Over half of the patients using opioids chronically started with acute pain. [postoperative (27%) and injury-related pain (27%)]

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2 The Journal of Pain Volume 18, Issue 4, April 2017, Pages Over half of the patients using opioids chronically started with acute pain [postoperative (27%) and injury-related pain (27%)]

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10 Cochrane Database of Systematic Reviews 28 SEP 2015 DOI: / CD pub3 D fig-0001

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14 Anesthesiology 2016; 124:483-8

15 Anesthesiology 2016; 124:483-8

16 PO Acetaminophen Celecoxib po or ketorolac 60 mg im Local anesthetic IV Opioid for breakthrough pain Taper IV opioid to PO opioid Taper PO opioid off

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19 Vitamin C-? Acetaminophen- endogenous cannabinoid NSAID- anti-inflammatory Gabapentin- calcium channel Duloxetine- norepinehrine Ketamine- NMDA Lidocaine-sodium channel Reducing opioid prescribing- limit dose and duration

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21 FIGURE 3 Preventive Acetaminophen Reduces Postoperative Opioid Consumption, Vomiting, and Pain Scores After Surgery: Systematic Review and Meta-Analysis. Doleman, Brett; Read, David; Lund, Jonathan; Williams, John Regional Anesthesia & Pain Medicine. 40(6): , November/December DOI: /AAP FIGURE 3. Forest plot for 24-hour opioid consumption. Copyright 2015 by American Society of Regional Anesthesia and Pain Medicine. Published by Lippincott Williams & Wilkins, Inc. 2

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23 Evaluation of Celecoxib Addition to Pain Protocol After Total Hip and Knee Arthroplasty Stratified by Opioid Tolerance Rashid Kazerooni, PharmD, Clin J Pain 2015;31: BCPS*w and Michael H. Tran, PharmD*w Total morphine Eq and pain scores 200 mg twice daily for up to 5 days CELECOX 2.5 celecoxi 200 IB 2 b 150 PLACEBO 1.5 placebo OP NO 0 OP NO

24 Figure 6 Perioperative Single Dose Ketorolac to Prevent Postoperative Pain: A Meta-Analysis of Randomized Trials. De Oliveira, Gildasio; MD, MSCI; Agarwal, Deepti; Benzon, Honorio Anesthesia & Analgesia. 114(2): , February DOI: /ANE.0b013e d68 Figure 6. Pooled data evaluating the effect of ketorolac dose on opioid consumption (IV morphine equivalents) compared with placebo. Data evaluated using a randomeffects model. Weighted mean difference for individual study represented by square on Forest plot with 95% confidence interval of the difference shown as solid line. Larger sized square and thicker 95% confidence interval line denote larger sample size. The diamond represents the pooled estimate and uncertainty for the effects of the 30- and 60-mg doses of ketorolac, respectively International Anesthesia Research Society. Published by International Anesthesia Research Society. 2

25 Is analysis of pregabalin outcomes by surgical pain model evidence based?. Doleman B; Lund JN; Williams JP Pain. 157(2):504-5, 2016 Feb. DOI: /j.pain Table 1 Results from a meta-analysis on gabapentin for postoperative pain by surgical subgroup for the outcome of 24-hour morphine consumption International Association for the Study of Pain. 2

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28 Cochrane Database of Systematic Reviews 16 JUL 2015 DOI: / CD pub

29 Regional block Gabapentin ketamine

30 Anesth Analg Jan;94(1):11-5, table of contents. The effects of three different analgesia techniques on long-term postthoracotomy pain. Sentürk M1, Ozcan PE, Talu GK, Kiyan E, Camci E, Ozyalçin S, Dilege S, Pembeci K. Six months later, the patients were asked about their pain. The incidence and the intensity of pain were most frequent in Group IV-PCA (78%) and were the least in Group Pre-TEA (45%) (Group Pre-TEA versus Group IV-PCA, P = ; Group Pre-TEA versus Group IV-PCA, P = 0.014). Patients having pain on the second postoperative day had 83% chronic pain. 6 months months ALL PRE TEA POST TEA IV PCA 62% 45% 63% 78% NRS

31 Fig. 2. Intensity of chronic pain. Intensity of chronic pain was defined as no, mild, moderate, or severe. There were more patients reporting moderate to servere pain in group C, with significance noted on the sixth month postoperatively (p = 0.013). Hui Ju, Yi Feng, Ba-xian Yang, Jun Wang Comparison of epidural analgesia and intercostal nerve cryoanalgesia for post-thoracotomy pain control European Journal of Pain, Volume 12, Issue 3, 2008,

32 Table 2. Preincisional Paravertebral Block Reduces the Prevalence of Chronic Pain After Breast Surgery. Kairaluoma, Pekka; Bachmann, Martina; MD, PhD; Rosenberg, Per; MD, PhD; Pere, Pertti; MD, PhD Anesthesia & Analgesia. 103(3): , September DOI: /01.ane e Table 2. Number (0-5) of Different Pain Symptoms (Pain at Rest, Movement-Related Pain, Sharp Pain, Continuous Pain, and Pain from Light Tactile Stimulus) 2006 International Anesthesia Research Society. Published by International Anesthesia Research Society. 2

33 Table 1. Preincisional Paravertebral Block Reduces the Prevalence of Chronic Pain After Breast Surgery. Kairaluoma, Pekka; Bachmann, Martina; MD, PhD; Rosenberg, Per; MD, PhD; Pere, Pertti; MD, PhD Anesthesia & Analgesia. 103(3): , September DOI: /01.ane e Table 1. Pain Intensities (NRS = Numeric Rating Scale; 0-10) Are Presented as Median (Range) 2006 International Anesthesia Research Society. Published by International Anesthesia Research Society. 2

34 Rev Esp Anestesiol Reanim May;58(5): [Chronic postoperative pain after general anesthesia with or without a singledose preincisional paravertebral nerve block in radical breast cancer surgery]. Ibarra MM1, S-Carralero GC, Vicente GU, Cuartero del Pozo A, López Rincón R, Fajardo del Castillo MJ phantom pain neuropathic pain block no block

35 Common problem More acute risk Worse long term outcomes Higher costs

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41 The patient is not likely to recover who makes the doctor his heir Thomas Fuller

42 8 roger chou opioids 9 richard robinson interdisciplinary treatment break 10 roger chou back pain 11 stephanie jones cancer pain 1130 sidarth wakhlu addictionology and MAT

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