Can anesthesiologists reduce persistent opioid use after surgery?

Can anesthesiologists reduce persistent opioid use after surgery? David M. Dickerson, M.D Medical Director, Pain Management Services NorthShore University HealthSystem Department of Anesthesiology, Critical Care & Pain Medicine @DMDickersonMD

Disclosures No conflicts or relationships to disclose @DMDickersonMD

Learning Objectives At the conclusion of this activity, participants should be able to: Define the role surgery plays in persistent opioid use Recognize risks factors for persistent opioid use Illustrate the intersection between the opioid epidemic and surgical care in regards to surplus medications and diversion Employ solutions that reduce persistent use and opioid surpluses available for misuse Emphasizing the role anesthesiologists play in the above facets of the epidemic @DMDickersonMD

Opioid epidemic: the startling numbers 91 deaths per day 500,000 deaths since 2000 Leading cause of accidental death (64,000 last year) Substance Abuse and Mental Health Services Administration, CDC @DMDickersonMD

@DMDickersonMD NY Times, 2014

@DMDickersonMD

Trends in prescribing 16.9% 22.2% AMA opioid task for progress report @DMDickersonMD

Opioid related death continues to rise Annual Surveillance Report of Drug-Related Risks and Outcomes United States CDC National Center for Injury Prevention and Control (2017) @DMDickersonMD

Trend analysis of U.S. opioid prescribing (IMS quintiles data) Annual Surveillance Report of Drug-Related Risks and Outcomes United States CDC National Center for Injury Prevention and Control (2017)

But what does this have to do with me? I m an anesthesiologist!

Surgical opioid Rx: a gateway to dependence? 40% of opioids prescribed are for postoperative indications 75% of misused opioids by first time users are from surplus prescriptions Levy B, Paulozzi L, Mack KA, Jones CM. Trends in Opioid Analgesic Prescribing Rates by Specialty, U.S., 2007 2012. Am J Prev Med. 2015 Sep 1;49(3):409 13 @DMDickersonMD

Surgical opioid Rx: a gateway to dependence? New persistent opioid use after surgery is 6% Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017. 152(6) e170504. @DMDickersonMD

But I don t prescribe opioids

Outcomes in Pain Care Breadth of pain care provided Patient Factors Injury Mechanism (pain diagnosis) Institutional Culture

N=36,177 patients, mean age 44.6y, 66% female, 72% white, 80% minor surg, 20% major surg Primary outcome: Opioid Rx 90-180 days post surgery Results: 5.9 to 6.5%; Non op control group 0.4% Risk factors: tobacco use, substance abuse disorders, mood disorders, anxiety, preoperative pain Patient factors may significantly increase persistent use Ask about preoperative pain! JAMA Surg. 2017. 152(6) e170504.

Outcomes in Pain Care Breadth of pain care provided Patient Factors Injury Mechanism (pain diagnosis) @DMDickersonMD Institutional Culture

n=390k opioid naïve surgical patients, 27k patients received opioids within 7 days of surgery Rx within 7 days of surgery = 44% chance of being on opioids in 1 year (3%) NSAIDS: 0.3% received NSAIDs within 7 days of these patients received NSAIDs Access to a reverse ladder and directives

Our patient population is changing and becoming more challenging

Overlapping complex neurobiology Patients with chronic pain Patients with addiction issues Patients on preoperative opioids

Overlapping complex neurobiology >50mg OME x 7 days Wilson J, Pain Res Manag 2015;20(6):300 Patients with chronic pain 20% of adults have severe pain most or all days Patients on preoperative opioids 18.5% (2.5% in gen pop, Canada) National Health Interview Survey, United States, 2016. MMWR 2017;66:796. Patients with addiction issues 1 8-10% of people over age 12; 20-22 million people 2.5 million from opioids 2013 National Survey on Drug Use and Health: summary of national findings. Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality, 2013.

IMS Use of opioid recovery medications, Sept 2016

Why should preoperative opioid use matter to anesthesiologists?

Preoperative opioid use Increased cost, poor outcomes Prehabilitation that includes opioid reduction may improve outcomes Morris BJ, et al. J shoulder and elbow surg 2016. 25(4):619-623. Nguyen LL, et al. J arthroplasty 2016;31(9):282-287. @DMDickersonMD

Opioid dependence and surgical outcomes Annals of Surgery Volume 265, Number 4, April 2017, 695-701 @DMDickersonMD

Opioid dependence and surgical outcomes @DMDickersonMD Annals of Surgery Volume 265, Number 4, April 2017, 695-701

Annals of Surgery Volume 265, Number 4, April 2017, 715-721

Outcomes in Pain Care Breadth of pain care provided Patient Factors Injury Mechanism (pain diagnosis) @DMDickersonMD Institutional Culture

Nociception persists while the body heals Nociception Day of Surgery (Trauma with consent) @DMDickersonMD Time POD #1 Non pharmacologic or nonopioid therapy POD #3 Return to function

Multi-society guidelines provide a roadmap Chou et al., J Pain, 17(2) 2016: 131-157.

Anesthesiology News, October 2017

Dickerson DM, Anesthesiology Clin 2014;32:495-504. Practical approach to pain management: The three I s Patient-level Identify (EARLY) Patient risk factors Surgical risk factors Unrealistic expectations Implement Expectation management Patient education of risk Multidisciplinary approach Broad multimodal analgesia Coordinated care plan Intervene Escalate when therapy initial plans fail Additional classes of analgesics Regional anesthesia Ensure follow up

Implement: Broad multimodal analgesia Treatment planning: implement multi-society (APS,ASA/ASRA) 2016 guidelines Dickerson, DM: Opioid antagonists, Preoperative assessment and management, 3 rd ed. Sweitzer B, ed. Philadelphia: Wolters Kluwer pp. 517-519, 2017

Just in case prescribing? @DMDickersonMD 21 pills prescribed after surgery yet only 4.3 consumed Elderly Patients needed less Many needed no medication

Targeting the surplus Patient history and expectations Surgery type Approach to pain care Surplus issues Dissatisfaction? Opioid related adverse events Too much? How much is enough? Too little? Pager burden Decreased satisfaction Increased pain

How does your team prescribe? Just enough? -OR- Just in case? @DMDickersonMD

Solutions for surplus: Reduce outgoing quantities Safeopioidprescribing.org/best-practices @DMDickersonMD

Opioidprescribing.info

Potential target: surplus medications Patient history and expectations Surgery type Approach to pain care Surplus issues Patient dissatisfaction? ORAE Too much? How much is enough? Too little? Pager burden Decreased satisfaction Increased pain

Two approaches to prescribing Just enough 20 tabs for all patients After surgery x, 75% of patients need 20 tablets, 95% of patients need 30 tabs 30 tabs for all patients Just in case Minimal surplus, adequate relief Re-eval and EPCS Adequate quantity for the majority of patients, but frequent surplus Minority of patients; possible at risk population Just enough approach allows reevaluation, refill when appropriate, ongoing monitoring

Electronic prescribing of controlled substances (EPCS) Just enough? Ok, maybe a few more, but only a few @DMDickersonMD

Providing an option for safe disposal GAP: March 2016 - Only 7 approved disposal locations within 20 miles of hospital SOLUTION: Registered to become DEA authorized collector Installed 38 gallon MedSafe medication disposal system at our hospital retail pharmacy RESULTS: Greater than one ton of unused prescription medications returned 1 1 1 2 3 4 6 8

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What was the follow up plan for opioid weaning?

pain behavior suffering pain An unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage. nociception [tissue injury] International Association for the Study of Pain (IASP) Pain is biopsychosocial

Recognizing pain as a disease The migration from actual to potential tissue injury provoked pain and the associated maladaptive neurophysiology @DMDickersonMD

Chronic post surgical pain

Refer early and refer often

Solution: Referral for advanced pain care - DRG Stimulation Neuromodulation of the DRG FDA approval/level 1 evidence for CRPS 1 (RSD) and CRPS 2 (Causalgia) CRPS 1 (RSD) Pain out of proportion to injury* Examples: Crush/Strains/Sprains/Fractures CRPS 2 (Peripheral Causalgia) Nerve injury w/persistent pain* Examples: Ilioinguinal causalgia post hernia repair Causalgia post morton s neuroma resection *Meeting Budapest criteria

DRG Stimulation Demonstrates Superiority Over Traditional SCS Implant Only Success (IO) 100% 80% 60% 40% 20% 0% 93.3% 86.0% 72.2% 70.0% 3 months 12 months DRG (n=60 at 3 months, n=57 at 12 months) Superiority Achieved P-value for non-inferiority at 3 months < 0.0001 P-value for superiority at 3 months 0.0011

52 yr old male patient with significant bilateral post-hernia repair pain + allodynia + bilateraly ilioinguinal block with 100% relief for 24h, 25% for 2 weeks. Trial 50% relief, noticed relief of his back pain. Patient with functional improvement. Able to sit without bilateral groin pain.

32 yr old female patient with painful diabetic neuropathy s/p pancreatectomy for SPINK1 mutation Sympathetic features: allodynia, vasomotor symptoms? CRPS Type 1 met Budapest criteria Treatment: PT, LSB, gabapentin, cymbalta 6mo relief of leg pain with bilateral RFA of LSB L2 and L3 needles Pain returned

Pain returned. Decision to trial s1 DRG. 90% relief with trial >90% relief with implant x 2 months 1-2x per week, jolts in soles of feet. Able to run, works 50h work week

62 yo male with FBSS (s/p 2 fusions) with burning pain in soles of feet LSB 10 weeks relief, transitioned to 10 TID methadone from >400mg OME

SCS trial à DRG trial Dorsal column stim, no relief. Hard to cover soles of feet. 100% relief with DRG

Acute pain = 3 days of meds rarely > 7 days Comprehensive approach Assess risk for overdose, give naloxone Review PDMP Recognize benzodiazepine tx MAT for opioid use disorders Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. MMWR Recomm Reports. 2016;65(1):1-49. doi:10.15585/mmwr.rr6501e1er.

Identify Risk: Prescription drug monitoring programs

Via the PDMP (identify): Aberrant behavior - Multiple Rx, multiple prescribers Difficult to control postprocedural pain Other pain issues Benzodiazepine use

Solution: Prescription monitoring Identify aberrant behavior Multiple prescribers ED visit prescriptions Polypharmacy Benzodiazepines, amphetamines, gabapentinoids, muscle relaxants Embedded in our EHR

Solution: Naloxone prescribing Consider the following factors Patient end organ dysfunction Lung disease, CHF, renal or hepatic dysfunction, CNS issues >50mg MME Polypharmacy (benzodiazepines and opioids) Nasal Spray (covered by all insurance) Auto-injector (less covered)

Solution: MAT referral - An opportunity to save lives: Initiating methadone in hospital: 82% present for follow-up addiction care 1 Buprenorphine vs. detox among inpatients: Bupe: 72.2% enter into treatment after discharge 2 Detox : 11.9% enter treatment after discharge Buprenorphine vs. referral in ED: Bupe: 78% engaged in treatment at 30 days 3 Referral: 37% engaged in treatment at 30 days 1. J Gen Intern Med. Aug 2010; 25(8): 803 808 2. JAMA Intern Med 2014 Aug;174(8):1369-76 3. D'Onofrio et al. JAMA 2015 Apr 28;313(16):1636-44

Solution: Enhanced Recovery After Surgery (ERAS) 4 active pathways at NorthShore (Colorectal, open ventral hernia repair, mastectomy, open hysterectomy) 3 pending: Spinal fusion, elective cesarean section, robotic prostatectomy Significant reduction in opioid exposure and length of stay Key points: care coordination, expectation management, standardized care

EMR- Based Order Set for preoperative medications

Tech + Ed = behavioral change with minimal effort Lecture Order set live Post-imp mean: 46.7% Pre-imp mean: 4.9%

Conclusions Surgery hurts, patients get opioids 99% of the time Opioid dependence complicates surgical outcomes, increases cost Develop durable policies and procedures for periop pain care Patients should be instructed how and when to wean, what to do if issues Patient factors predispose to persistent use Utilize the PMP Recommend naloxone for high-risk patients Educate Follow-up Care factors may also put patients at risk Implement ERAS Implement just enough prescribing with a reverse ladder (MMA) @DMDickersonMD

More conclusions Reduce surplus opioids supplies via safe disposal initiatives Provide at risk or chronic pain patients with referrals for comprehensive pain care Anesthesiologists helping anesthesiologists increase patient access to modern pain care @DMDickersonMD

Thanks! ddickerson@northshore.org @DMDickersonMD