Innovative Pain Management Practices in Spine Surgery Patients

Transcription

1 Disclosures Innovative Pain Management Practices in Spine Surgery Patients There are no conflicts of interest or relevant financial interests in making this presentation. Matt Kresl PharmD, BCPS Pharmacist Practitioner Allina Health Clinics Rachel Root PharmD, MS, BCPS Pharmacy Manager Abbott Northwestern Hospital March 28, Objectives Disclaimers Review pain pathways affected by spine surgery Describe where medications may be used in managing pain Define multimodal pain management Not pain specialists Not physiology specialists Information applicable to non spine surgery Not always be focused on medications 3 4 Helpful Metaphors What Makes Spine Pain Tough? Cause?? Chronic pain +/ acute pain Psychologic relationship Often ranked #1 cause of disability, inability to work WHO: Cure is the aim, but it may be difficult to achieve 5 6

2 Types of Pain Pain Medication Mechanisms of Action Somatic Pinprick, stabbing, sharp Localized, periphery Bones, joints, muscles, connective tissue Visceral Pressure, dull Generalized, deeper innervation Organs (e.g., appendicitis, angina) Neuropathic Burning, prickling, tingling Radiating, specific Limb amputation, neuropathy 7 8 Source: Case Study Patient: GM PMH: chronic pain, depression 3 months post spinal fusion Significant post op pain continues (8/10) Engaged in TENS, acupuncture, therapy pool, local anesthetics Current takes gabapentin and Oxycontin Is there anything to additionally consider? Opioids Stops brain from receiving pain signals Mimics bodies own natural endorphins Sedation, constipation, respiratory depression Which one? How long? How much? What route? 9 10 Should we fear opioids? Allina Clinic Goals for Opioid Use Controlled substance prescribing % of patients with at least eight orders for a narcotic in the past 12 months who have an Allina Health controlled substance agreement letter on file, documented on the problem list, an encounter in the past 4 months, and a ToxAssure in the previous 12 months Allina Goal: 42% 11 12

3 Ketamine Blockade of NMDA and more? Hallucinations, nightmares, dissociative thoughts When to use? How long? Optimal dosing? Evidence? Back to Case Describes pain down leg that burns and tingles Describes pain that runs through neck and shoulders that aches Abdominal pain diffuse and belly just hurts Chronic low grade headache Difficult encounter with adult son recently affecting current mood What to do at this point? NSAIDs Inhibit formation of prostaglandins GI bleeding, renal impairment, caution with CV disease Celecoxib mg, ketorolac mg opioid requirements Impaired fusion rates? Acetaminophen Mechanism Undefined and not well understood Generally safe Liver issues IV vs. PO Scheduled dosing Anticonvulsants Muscle Relaxants Inhibit release of neurotransmitters Target neuropathic pain Dizziness, drowsiness, nausea Gabapentin mg, pregabalin mg opioid requirements Adjust for renal dysfunction Duration? Reduce muscle spasms Wide and varied Examples: diazepam, cyclobenzaprine, carisoprodol, baclofen, tizanidine, methocarbamol Use with caution 17 18

4 Topical Medications Other Capsaicin cream/patch Diclofenac cream Lidocaine Patches Considerations: Local vs. systemic relief Absorption Type of pain Cost Dexmedetomidine (Precedex) Improved anesthesia recovery time? Less pain after procedure? Opioid sparing? Liposomal Bupivacaine (Exparel) Limited spine studies show no improvement Chronic opioid user benefit? Epidural & PCA Case Final Thoughts Opioid +/ Local Anesthetic Reserve continuous rates for opioid tolerant Multimodal regimens vs. PCA or epidural Interventions to consider: Have we maximized gabapentin dose? Does patient have long term plan regarding opioids? Schedule acetaminophen? Is this patient constipated (abdominal pain)? What treatments are being used for mood disorder (medications, CBT, hypnosis)? How are these innovative? References Allina Health Clinical Care Goals Chou R, Gordon DB, de Leon Casasola OA, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain Feb;17(2): Devin CJ, McGirt MJ. Best evidence in multimodal pain management in spine surgery and means of assessing postoperative pain and functional outcomes. J Clin Neurosci Jun;22(6): Ehrlich, G. Low back pain. Bulletin of the World Health Organization 2003;81: Ge D J, Qi B, Tang G, Li J Y. Intraoperative Dexmedetomidine Promotes Postoperative Analgesia in Patients After Abdominal Colectomy: A Consort Prospective, Randomized, Controlled Clinical Trial. Hanaoka. K, ed. Medicine. 2015;94(37):e1514. Grieff AN, Ghobrial GM, Jallo J. Use of liposomal bupivacaine in the postoperative management of posterior spinal decompression. J Neurosurg Spine Mar 4:1 6. Hwang W, Lee J, Park J, Joo J. Dexmedetomidine versus remifentanil in postoperative pain control after spinal surgery: a randomized controlled study. BMC Anesthesiol Feb 24;15:21. Rajpal S, Gordon DB, Pellino TA, Strayer AL, Brost D, Trost GR, Zdeblick TA, Resnick DK. Comparison of perioperative oral multimodal analgesia versus IV PCA for spine surgery. J Spinal Disord Tech Apr;23(2): Rivkin A, Rivkin MA. Perioperative nonopioid agents for pain control in spinal surgery. Am J Health Syst Pharm Nov 1;71(21): van Tulder MW, Touray T, Furlan AD, Solway S, Bouter LM; Cochrane Back Review Group. Muscle relaxants for nonspecific low back pain: a systematic review within the framework of the cochrane collaboration. Spine (Phila Pa 1976) Sep 1;28(17):

5 Contact Information Matt Kresl, PharmD, BCPS Pharmacist Practitioner, West Metro Region Allina Health Bloomington, Shakopee, East Lake Street Clinics 7920 Old Cedar Ave S, Bloomington, MN Rachel Root, PharmD, MS, BCPS Pharmacy Manager, Abbott Northwestern Hospital 800 East 28 th St, Mail Route 11321, Minneapolis, MN