Enhanced Recovery to Optimize Perioperative Alternatives to Opioids Women in Government, Annual Healthcare Summit Th 05 November 2017, Washington DC Timothy E. Miller, MB, ChB, FRCA Duke University Department of Anesthesia Vice President, ASER, American Society of Enhanced Recovery Julie K. Marosky Thacker, MD, FACS, FASCRS Duke University Department of Surgery President, American Society of Enhanced Recovery
Objectives Define how PERIOPERATIVE PAIN contributes to opioid crisis Share evidence based PERIOPERATIVE CARE PRINCIPLES and PATHWAYS that minimize exposure and minimize contribution to opioid crisis
Postoperative or injury pain and opioids-true or FALSE TRUE The opioid crisis is predominantly been characterized by deaths and severe adverse events in chronic opioid users Patients have pain after surgery TRUE Impact of operations or injuries has barely been discussed Patients have pain after injuries Gan, Curr Med Res Opin. 2014; 30:149-60 Prescribers have inaccurate beliefs about opioid addiction potential and the most likely at risk
1980 We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.
Another false teaching~ Drugs are not bad, people who misuse drugs are bad The idea that there is nothing inherently dangerous about drugs specifically opioids is inaccurate. And with the opioid epidemic spreading throughout the country, it s potentially dangerous.
The average person has 9 operations in their lifetime
Opioid abuse after surgery 3-7 % OF OPIOID NAÏVE PATIENTS STILL TAKE OPIOIDS ONE YEAR AFTER OPERATION Clarke. BMJ 2014 Brummett. JAMA Surg 2017
Why are opioids used so commonly? Very effective Quick onset of action Pain management surrogate of good care Management of pain 5 th vital sign HICAPS metric
Chronic opioid use often begins with a prescription for acute pain, either in the ambulatory or outpatient setting 1 in 7 patients whose opioid use >8 days, continue to use opioids at 1 year 30% of patients whose first opioid >31 days, continue to use opioids at 1 year Alam er al. Arch Intern Med. 2012;172:425 430
Higher opioid consumption during an inpatient hospital stay results in higher chance of prolonged post hospital use On discharge from hospital, patients expect pain medicine and are asked by survey if they are happy with their pain management. 72% of pills prescribed to discharged general surgery patients go unused. Bartels, PLoS One. 2016;11:e0147972 Hill, Annals Surgery. 2017;265:709 714
Leftover pills in the home 60% of Americans have unused prescribed opioids in the home Excess opioid pills are unsecured source for non-medical opioid use In a survey of heroin users, approximately 75% heroin users report starting with opioid pain relievers; often these were not prescribed to them Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain Relievers United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132:95 100 Partnership for a Drugfree America, 2015
In the context of the national opioid epidemic, the perioperative period represents an important opportunity to prevent chronic opioid use, especially in opioid naïve patients
Let s discuss two recent patients Patient 1 I d like to request opioid free anesthesia Patient 2 you are going to need some painkillers
How can we reduce the perioperative use of opioids??
Opioid sparing analgesia as part of Enhanced Recovery Enhanced Recovery New, patient focused care paradigm interdisciplinary, evidence based perioperative care Optimal, procedure-specific, multimodal pain management minimized opioid use facilitated postoperative ambulation and rehabilitation.
Enhanced Recovery Paradigm Patient s Journey Optimization preop intraop postop Recovery Patient-Centric, interdisciplinary care plan
Collaboratively defined, patient focused process measures PREOP Education Risk assessment Surgical planning Informed consent PERIOP Risk reduction Co-management communication Initiation of protocol PRO of education/gap assessment INTRAOP Identification Reinforcement Multimodal analgesia OR time out Intentional fluid mgt OR debrief POSTOP Multimodal analgesia Immediate diet Immediate mobilization Drains, tubes, lines out asap Intentional diagnostics Defined d/c criteria Education Established follow up POSTDISCHARGE Reinforcement of multimodal analgesia regimen Established communication pathways Follow up PRO-experience, recovery, caregivers
www.enhancedrecovery.org
American Society for Enhanced Recovery Mission: To advance the practice of perioperative enhanced recovery, to contribute to its growth and influences, by fostering and encouraging research, education, public policies, programs and scientific progress. www.enhancedrecovery.org
Monotherapy vs. multimodal analgesia
www.poqi.org McEvoy et al. Perioperative Medicine. 2017; 6:8
www.poqi.org McEvoy. Perioperative Medicine. 2017; 6:8
Encouraged changes to current practice Gawande, Ann Surg 2017 Counsel patients preoperatively Function is goal Comfortable to recover, not painless Use non-opioid alternatives Confirm previous prescriptions Provide clear, available disposal options Prescribe minimum quantity necessary ASER/POQI, Periop Med 2017 Set expectations with patients. This education is the mot important aspect of Enhanced Recovery Begin multi-modal analgesia before operation and continue throughout postop recovery Implement optimal analgesia algorithm Provide clear instructions on non-opioid analgesia options with minimal opioids prescribed on discharge as per rescue plan
Encouraged changes to current practice
However, Impact of Enhanced Recovery on Opioids at Discharge None... ERAS intervention can result in opioid-sparing to opioid-free hospital experience, however, no change was observed in prescribing practices at discharge from hospital Anesth Analg 2017;125:1784 92
Factors besides perioperative care that lead to misuse/abuse Providers are accountable to treat to No pain Providers are not trained to manage acute or chronic pain Neither patients nor providers know or value disposal practices Highest risk patients have mental health challenges without access to diagnosis and treatment
In addition to adoption of enhanced recovery analgesia principles, two essential system changes are necessary Providers are accountable to treat to No pain Providers are not trained to manage acute or chronic pain Neither patients nor providers know or value disposal practices Highest risk patients have mental health challenges without access to diagnosis and treatment
Conclusion Experts in perioperative care recommend adoption of evidence based enhanced recovery principles to minimize first exposure and unnecessarily long exposure to perioperative narcotics. Experts have detailed systemic changes to promote opioid sparing management of acute injury and perioperative pain. Intense, wide scale education including patients, community leaders, health ancillary workers, all trainees and providers in medicine, and healthcare administrators to align goals and metrics regarding pain management is essential. Without serious investment into the economic and mental health infrastructure of communities, the root causes of addiction can not be addressed.