Pain Management and Opioid Abuse in the Surgical Patient

Transcription

1 The 13 th Annual Perioperative Medicine Summit Fort Lauderdale, Florida Pain Management and Opioid Abuse in the Surgical Patient Darin J. Correll, M.D. Department of Anesthesiology, Perioperative and Pain Medicine Brigham and Women's Hospital Assistant Professor of Anaesthesia Harvard Medical School

2 2018 Perioperative Medicine Summit March 7-10, 2018 Darin J. Correll, M.D. Pain Management and Opioid Abuse in the Surgical Patient Darin J. Correll, M.D. has disclosed that there is no actual or potential conflict of interest in regards to this presentation. The planners, editors, faculty and reviewers of this activity have no relevant financial relationships to disclose. This presentation was created without any commercial support.

3 Learning Objectives At the conclusion of this course participants will: Be familiar with national opioid epidemic statistics and be armed with information to decide whether the Joint Commission standards & patient satisfaction scores have contributed to the problem. Understand methods of predicting opioid use and abuse postoperatively. Be acquainted with acute perioperative pain guidelines including the benefits of opioidsparing preoperative, intraoperative, and postoperative analgesics as well as the concept of preventive analgesia.

4 The Story of the Magic Pendulum

5 The Story of the Magic Pendulum

6 The Story of the Magic Pendulum

7 The Story of the Magic Pendulum

8 The Story of the Magic Pendulum

9 The Story of the Magic Pendulum

10 The Story of the Magic Pendulum

11 The Story of the Magic Pendulum

12 The Opioid Epidemic - How We Got Here WHO Universal Declaration of Human Rights: relief from pain is a fundamental human right. 1948

13 The Opioid Epidemic - How We Got Here A Few Publications: claim addiction to opioids is rare when used to treat pain s Ann Intern Med 1973;78: J Clin Pharmacol 1978;18: NEJM 1980;302:123. Pain 1986;25:

14 The Opioid Epidemic - How We Got Here Pharmaceutical Companies: intense marketing to physicians that opioids were safe s 1990s-2000s Note: in 2007, 3 executives of Purdue Pharma found guilty of misdemeanor misbranding of OxyContin s addiction risk.

15 The Opioid Epidemic - How We Got Here Survey of 300 US Hospitals: 77% patients had post-op pain; in 80% it was moderate to extreme s 1990s-2000s 1995 Anesthesiology 1995;83:

16 The Opioid Epidemic - How We Got Here American Pain Society: deemed pain to be the 5th vital sign ; the Veterans Health Administration and Joint Commission adopt the idea s 1990s-2000s Note: in 2018, TJC changed its standards around pain management to emphasize involving patients in their treatment plans and setting realistic expectations and goals, as well as promoting safe opioid use.

17 The Opioid Epidemic - How We Got Here Review Article: questions the opioid safety data s 1990s-2000s J Opioid Manag 2006;2:16-22.

18 9 low quality studies with conflicting findings it is not known whether the risk for iatrogenic addiction among patients treated with opioids for acute or subacute pain is relatively high (> 10 percent) or low (< 0.1 percent).

19 The Opioid Epidemic - How We Got Here HCAPS survey: 3 questions on how well hospital staff help patients manage pain; used for Hospital Value-based Purchasing program s 1990s-2000s Note: in 2018, 3 questions changed to focus on communication about pain; pain dimension removed from HVBP program score.

20 The Opioid Epidemic - How We Got Here American Academy of Pain Medicine: issued a patient guide stating opioids are rarely addictive when used appropriately for pain s 1990s-2000s Note: between 2012 and 2017 they accepted $1.2 million from opioid makers.

21 The Opioid Epidemic - How We Got Here IASP Declaration of Montreal: All people have the right to have access to appropriate assessment and treatment of pain by adequately trained health-care professionals s 1990s-2000s

22 Where is Here? Americans represent 4.6% of the world s population, but consumed 80% of the global opioid supply in 2016 Use of opioid analgesics has increased, but remains low in Africa, Asia, Central America, the Caribbean, South America, and eastern and southeastern Europe. Identified impediments to use urgently need to be addressed by governments and international agencies. In the US, amount of opioids prescribed per capita in 2015 was 640 MME (~4x higher than Europe) vs 180 MME in 1999 S-DDD = defined daily doses for statistical purposes The Lancet 2016; 387:

23 Where is Here? Peak: 81.2 prescriptions per 100 persons in prescriptions per 100 persons in 2015 what are we doing for our patients instead? Significant prescribing variability clustered by US counties (highlights lack of consensus, inconsistent practice patterns) IMS Health Opioid Omission is Not Opioid Sparing Anesth Analg 2018, ahead of print

24 Where is Here? Drug OD death rates increased 5x b/w 1980 and out of 5 new heroin users started misusing prescription opioid pain medications Annual cost of opioid addition: $29.1 b $78.5 b $115 b 11.8 million people misused opioids in 2016

25 Who Caused the Problem? The 2001 Joint Commission standards required health care facilities to: recognize the right of patients to appropriate assessment and management of pain assess pain in all patients record the assessment in a way that facilitates regular reassessment and follow-up establish policies that support appropriate prescription or ordering of pain medicines Many clinicians jumped to the conclusion that pain intensity had to literally be documented each time vital signs were recorded and in effect chased pain ratings with escalating opioid doses. In order to ensure the incentives from the CMS Hospital Value-based Purchasing program more and more opioids were prescribed.

26 Who Caused the Problem? Pharmaceutical companies were all to happy to have increased sales. The addiction potential of opioids was grossly underestimated (misconceptions: pain protects from addiction; only long-term use produces addiction; only patients with certain characteristics are vulnerable). Patients came to expect opioids as part of surgery and that they are entitled to have no pain it is their RIGHT! Recent study showed 70+% of patients had unused opioids after general surgery and kept them around.* Older studies also show majority of patients keep unused opioids after surgery. # Anesth Analg 2017;125: * Ann Surg 2017;265: # PLoS One 2016;11:e

27 What Caused the Problem?

28 Was Pain Control Better During High Opioid Use Times? 2014 study showed that 86% of post-op patients experienced pain; 75% reported moderate to severe pain; 74% had moderate to extreme pain during the 2 weeks post discharge. In addition, 88% received analgesics, 80% had adverse effects and 40% had moderate to severe pain even after taking the med. Curr Med Res Opin 2014;30:

29 February 2018 IASP Statement on Opioids Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life (e.g., pain associated with cancer). Currently, no other oral medication offers immediate and effective relief of severe pain. Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals. For these reasons, IASP supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events and at the end of life. In some cases, there is no substitute for opioids in achieving satisfactory pain relief. IASP strongly advocates for access to opioids for the humane treatment of severe short-lived pain, using reasonable precautions to avoid misuse, diversion, and other adverse outcomes.

30 February 2018 IASP Statement on Opioids Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life (e.g., pain associated with cancer). Currently, no other oral medication offers immediate and effective relief of severe pain. Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals. For these reasons, IASP supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events and at the end of life. In some cases, there is no substitute for opioids in achieving satisfactory pain relief. IASP strongly advocates for access to opioids for the humane treatment of severe short-lived pain, using reasonable precautions to avoid misuse, diversion, and other adverse outcomes.

31 Patient Risk Factors for Longer-term Opioid Use or Misuse h/o addiction in patient or family age ( younger in Canada* vs > 50yo in US # ) life stressors depression/antidepressant use anxiety/benzodiazepine use poor social support use of other agents (e.g., alcohol, cigarettes) prior misuse or aberrant behaviors * BMJ 2014;348:g1251. # JAMA Int Med 2016;176:

32 Other Risk Factors for Longer-term Opioid Use or Misuse Patients who received an opioid prescription within 1 week after ambulatory surgery were > 40% more likely to still be using them at 1 year. # Surgeries at risk for chronic use: TKA, THA, open and lap chole, mastectomy, open appy and C-Section. As opposed to dose, each refill and additional week of opioid use increased the risk of misuse by 44%.* # Arch Int Med 2012;172: JAMA Int Med 2016;176: * BMJ 2018;360:j5790.

33 Assess Opioid Use Risk Factors NIDA Quick Screen and modified-assist: questions about illicit and nonmedical prescription drug use during past year and lifetime, respectively ORT (Opioid Risk Tool): 5-item checklist completed by the clinician that predicts future aberrant drug-related behaviors SOAPP-R (Screener and Opioid Assessment for Patients with Pain-Revised): 24- item self-administered tool to predict aberrant drug-related behaviors in chronic pain patients DIRE (diagnosis, intractability, risk, and efficacy): a clinician-rating scale to predict suitability for long-term opioid treatment for noncancer pain COMM (Current Opioid Misuse Measure): 17-item questionnaire to identify chronic pain patients who are currently misusing their prescribed opioids

34 Assess Opioid Use Risk Factors Scores from any tool are not necessarily reason to deny opioids, but rather provide an estimate of the level of appropriate monitoring. These clinical assessments are useful to estimate risk of noncompliant opioid use but are not 100% diagnostic.

35 N/V Ileus Somnolence Urinary Retention Respiratory depression Death Hyperalgesia Other Downsides of Opioids

36 theoretic pathologic physiologic Preventive Analgesia Preemptive Analgesia

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38 The Strong Recommendations with High-Quality Evidence Offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in children and adults. Provide adults and children with acetaminophen and/or nonsteroidal antiinflammatory drugs (NSAIDs) as part of multimodal analgesia for management of postoperative pain in patients without contraindications. Consider surgical site specific peripheral regional anesthetic techniques in adults and children for procedures with evidence indicating efficacy. Offer neuraxial analgesia for major thoracic and abdominal procedures, particularly in patients at risk for cardiac complications, pulmonary complications, or prolonged ileus.

39 The Strong Recommendations with Moderate-Quality Evidence Use oral over intravenous administration of opioids for postoperative analgesia in patients who can use the oral route. Avoid using the intramuscular route for the administration of analgesics for management of postoperative pain. Use IV PCA when the parenteral route is needed but avoid routine basal infusion of opioids in opioid-naive adults. Consider giving a preoperative dose of oral celecoxib in adult patients without contraindications. Consider gabapentin or pregabalin as a component of multimodal analgesia. Use continuous, local anesthetic based peripheral regional techniques when the need for analgesia is likely to exceed the duration of effect of a single injection.

40 Non-pharmacologic Options Hypnosis reduces pain associated with procedures. Virtual reality reduces pain and unpleasantness from certain procedures. Cold to reduce inflammation or heat to reduce spasms. Acupuncture and electroacupuncture reduce both pain and side effects from opioids. (The APS can neither recommend nor discourage acupuncture, massage, or cold therapy as adjuncts to other postoperative pain treatments - insufficient evidence). Transcutaneous electrical nerve stimulation (TENS) has evidence of effectiveness in chronic pain. (The APS says to consider TENS as an adjunct to other postoperative pain treatments - weak recommendation, moderate-quality evidence). Cognitive-behavioral, relaxation, guided imagery, mindfulness and attentional techniques have benefits in chronic pain. (The APS says to consider the use of cognitive behavioral modalities in adults as part of a multimodal approach - weak recommendation, moderate-quality evidence).

41 Will Anything Actually Help the Crisis? ERAS in colorectal patients resulted in increased opioid-free anesthesia and multi-modal analgesia, however no impact on discharge opioids.* No association between nerve blocks and risk of persistent postop opioid use in abdominal surgery, TKA or shoulder arthroplasty. # IV lidocaine use has also not shown a reduction in persistent postop opioid use. # Intraop ketamine reduces immediate postop opioid use but no studies have examined effect on longer term use. # Acetaminophen also reduces immediate postop opioid use but again no studies have examined the long-term effect. # Gabapentin use for multimodal analgesia has negligible effects on postop opioid use. * Anesth Analg 2017;125: # Anesth Analg 2017;125: Acta Anaesthesiol Scand :

42 What About Abuse-Deterrent Formulations? ADF opioids prevented 2,300 new case of abuse per 100,000 patients over 5 years at a cost of $533M (note: use for acute pain not analyzed). It therefore cost the healthcare system $231,500 to prevent 1 new case of abuse. Even if the ADF opioids were 100% effective, it would still cost $113M over 5 years. Cost neutrality is only achieved if ADF opioids were discounted by 41%. If the analysis takes into account loss of productivity, criminal justice and incarceration costs the ADF opioids still cost $393M more than non-adf opioids over 5 years. Abuse-deterrent Formulations of Opioids: Effectiveness and Value. Institute for Clinical and Economic Review (ICER), Aug 8, 2017.

43 What About Abuse-Deterrent Formulations?

44 Where to Go From Here? The APS recommends that clinicians provide patient and family-centered, individually tailored education to the patient, including information on treatment options for management of postoperative pain, and document the plan and goals for postoperative pain management (strong recommendation, low-quality evidence). They also recommend that clinicians conduct a preoperative evaluation including assessment of medical and psychiatric comorbidities, concomitant medications, history of chronic pain, substance abuse, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan (strong recommendation, low-quality evidence).

45 The Preop Clinic s Role Administer an opioid use risk assessment. Risks and harms of unnecessary opioid use discussed with patient and family. Multimodal approaches should be introduced. Patient and family should be told about proper storage and disposal of opioids. Realistic expectations of pain control should be given. Anesth Analg 2017;125:

46 Where to Go From Here? The information gained by documenting pain intensity has to be used in the context of the complexity of pain management, keeping in mind not just pain related goals but those of goals of functional recovery and safety. Need to individualize discharge prescribing based on actual inpatient usage, since patients exhibit wide variability in opioid needs after similar surgeries. Transitional Pain Service work with at-risk populations (e.g., chronic pain/opioid use, h/o opioid abuse or risk of, high-ppsp surgeries) starting pre-op to come up with an analgesic plan, then follow patients inpatient and importantly post-discharge to aide with opioid weaning and monitor for/treat PPSP.* *Anesth Analg 2017;125:

47 Critical Points at and after Hospital Discharge Check Prescription Monitoring Program Ensure adequate analgesia prior to discharge and that it continues after Explain likely course of pain over time Be in contact with the patient s PCP or other outpatient prescriber Consider co-prescribing naloxone with any opioid prescription at discharge Ensure the patient understands the side effects, addiction potential and other potential issues related to the meds they are prescribed (e.g., no driving, no drinking, safe storage and disposal of opioid medication) Continue non-opioid adjuncts Have medication weaning plan(s) in place Consider non-pharmacologic treatments Anesth Analg 2017;125:

48 Final Points Tramadol is addictive too - more than 7 million Americans over the age of 12 used tramadol for recreational purposes in Euphoric potential does not differ from that of heroin or methamphetamine.* So is gabapentin! One study showed gabapentin misuse in 40-65% of individuals with prescriptions and between 15 and 22% of people who abuse opioids. # Another study, of adults who abused opioids, found that 15% also misused gabapentin in the past six months to get high. *Biomed Res Int 2013;2013: # Addiction 2016;111: Am J Psychiatry 2015;172:487 8.

49 - Max Born (physicist)