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The Opioid Epidemic and Perioperative Implications 17th Annual Practical Updates in Anesthesiology February 2 – February 7, 2014 Peter Stiles, MD Paul.

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Presentation on theme: "The Opioid Epidemic and Perioperative Implications 17th Annual Practical Updates in Anesthesiology February 2 – February 7, 2014 Peter Stiles, MD Paul."— Presentation transcript:

1 The Opioid Epidemic and Perioperative Implications 17th Annual Practical Updates in Anesthesiology February 2 – February 7, 2014 Peter Stiles, MD Paul Hilliard, MS, MD

2 35 year old female CC: abdominal pain and bloating x1 year PMH: Rheumatoid arthritis (managed without opioids) Allergies: Reports “severe intolerance” of morphine and codeine PSH: Unspecified spinal fusion, TAH, bladder suspension

3 35 year old female Found a pancreatic cyst – NOT an emergency Gen surg performs an uncomplicated whipple; no pre-op discussion of pain management apart from thoracic epidural placement in pre-op by OR team ACUTE PAIN SERVICE (APS) consult for severe post-op pain No apparent explanation for 11/10 pain

4 35 year old female Generated 17 notes in 6 days Resulted in multiple episodes of hypotension, significant sedation Unanticipated SICU admission for uncontrollable pain - Multiple infusions - Highly tolerant hydromorphone PCA - Patient stating 10/10 pain throughout hospitalization - Extreme dissatisfaction per the patient, regrets surgery

5 35 year old female PSH: Spinal fusion, TAH, bladder suspension No issues after those procedures

6 What’s different?

7 360mg daily PO morphine equivalents Over the preceding months, her abdominal pain had been treated with increasing opioids, up to 80mg Oxycontin TID

8 Outline Review the state of opioid prescriptions and abuse in the United States Investigate how this will impact anesthesia practice and what can be done Introduce the Michigan High-Dose Opioid Taper Initiative – suggestions for pre-op management Review opioid induced hyperalgesia What to do the morning of surgery

9 Pain is relevant to every practice > 100 million people #1 presenting complaint to health professionals Est. $560 - $635 Billion Roughly the cost of cancer, heart disease, and DM…..combined! Committee on Advancing Pain Research, Care, and Education, Institute of Medicine. "Summary." Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, 2011.

10 Image Credits: Themanualtherapist, psychologyofpain.blogspot.com, pilothealthadvocates.com Endorsed by 2 separate pain societies in Seemed like a great idea…

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14 Opioid Prescriptions Reach Epidemic Proportions In 3 months of he received at least 11 prescriptions for painkillers from eight doctors – 370 tablets May 12th, 2011 he died from a accidental overdose of oxycodone

15 Opioid Prescriptions Reach Epidemic Proportions Poisoning is the leading cause of injury-related death in the United States. In 2011, more people died of drug over­dose (mostly accidental) than died of vehicle (car, truck, ATV, etc) accidents! Of all poisoning deaths, about 75% of all poisoning deaths are from legal pharmaceutical grade opioids. National Vital Statistics System. Table 2. Deaths, death rates, and age-adjusted death rates for 113 selected causes, Injury by firearms, Drug-induced Injury at work, and Enterocolitis due to Clostridium difficile: United States, final 2010 and preliminary Available at

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18 This is killing us…. Rate (per 100,000) of unintentional drug overdose deaths Admissions for treatment of opioid addiction per 100,000 people

19 Rate (per 100,000) of unintentional drug overdose deaths National Vital Statistics System. Available at

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27 National Vital Statistics System. Multiple cause of death dataset. Available at Deaths attributable to Heroin, Cocaine and Opioids This trend continues…

28 The White House Responds In response to recent CDC findings the government issued a plan which calls for a multiagency, multispecialty approach with the goal of decreasing opioid use in the United States over the next few years “Research and medicine have provided a vast array of medications to cure disease, ease suffering and pain, improve the quality of life, and save lives. This is no more evident than in the field of pain management. However, as with many new scientific discoveries and new uses for existing compounds, the potential for diversion, abuse, morbidity, and mortality are significant. Prescription drug misuse and abuse is a major public health and public safety crisis. As a Nation, we must take urgent action to ensure the appropriate balance between the benefits these medications offer in improving lives and the risks they pose. No one agency, system, or profession is solely responsible for this undertaking. We must address this issue as partners in public health and public safety. Therefore, ONDCP will convene a Federal Council on Prescription Drug Abuse, comprised of Federal agencies, to coordinate implementation of this prescription drug abuse prevention plan and will engage private parties as necessary to reach the goals established by the plan.” The White House. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. Accessed October 21, 2012.

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30 Why is this a problem for periop patients? SAFETY SATISFACTION COST

31 Patient Safety Remember the introductory case?...it’s not uncommon Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today Nov;6(11) Between 350,000 to 750,000 in-hospital cardiopulmonary arrests occur annually in the United States. Roughly 80% of the victims don’t survive to discharge About half of patients with in hospital arrests had been receiving opioids.

32 Patient Safety Difficult to study with RCTs

33 Patient Safety Difficult to study with RCTs

34 Date of download: 3/26/2013 Copyright © 2012 American Medical Association. All rights reserved. From: Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths JAMA. 2011;305(13): doi: /jama Figure Legend :

35 Patient Safety Higher opioid requirements postoperatively, not surprisingly, are associated with more side effects 55% of patients receiving opioids required nausea, vomiting and/or constipation pharmacologic treatments. Sun D-C, Kim MS, Chow W, Jang E-J. Use of medications and resources for treatment of nausea, vomiting, or constipation in hospitalized patients treated with analgesics. Clin J Pain. 2011;27: IV opioids had nearly 5x risk of GI side effects compared to oral nonopioid analgesics Urinary retention

36 Pain Control Difficult to measure Not many chronic pain patients will be excited about reducing the daily dose of opioid BUT….some evidence exists in support of tighter opioid management

37 Pain Control (Satisfaction) Tolerance A point exists where we cannot further increase opioid dose This can make treating acute surgical pain, on top of the patient’s baseline pain and opioid dependence very difficult and unsafe Opioid NaiveOpioid Tolerant Dose Analgesic Response

38 Pain Control Opioid-Induced Hyperalgesia

39 Pain Control Opioid-Induced Hyperalgesia “A state of nociceptive sensitization caused by exposure to opioids” Not yet fully understood, 5 proposed mechanisms All implicate neuroplastic changes in both the peripheral and central nervous systems Most widely accepted hypothesis involves the Central Glutaminergic System NMDA receptors see increased glutamate from transport inhibition; various linkages implicated – result in apoptotic cell death in the dorsal horn

40 Fig. 2 Fig. 2. Neuroanatomical sites and mechanisms implicated in the development of opioid-induced hyperalgesia during maintenance therapy and withdrawal. (1) Sensitization of peripheral nerve endings. (2) Enhanced descending facilitation of nociceptive signal transmission. (3) Enhanced production and release as well as diminished reuptake of nociceptive neurotransmitters. (4) Sensitization of second-order neurons to nociceptive neurotransmitters.Figure 2does not illustrate all potential mechanisms underlying opioid-induced hyperalgesia, but rather depicts those that have been more commonly studied. DRG = dorsal root ganglion; RVM = rostral ventral medulla. Copyright © 2013 Anesthesiology. Published by Lippincott Williams & Wilkins.40 Opioid-induced Hyperalgesia: A Qualitative Systematic Review Opioid-induced Hyperalgesia: A Qualitative Systematic Review Angst, Martin S.; Clark, J David Anesthesiology. 104(3): , March 2006.

41 Cost A nation-wide 2005 study demonstrated that a single day admission to the ICU requiring mechanical ventilation was $10,794 A prolonged PACU stay can cost $4-$8 per minute Adverse outcomes can cost the hospital millions Don’t forget indirect costs… Dasta JF, et al. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med Jun;33(6): Weinborum AA, et al. Efficiency of the operating room suite. American Journal of Surgery. 2003;185:244–250

42 What to do!? National epidemic Dissatisfied patients Uncontrollable pain (both patient and provider….) Rising costs our country cannot afford

43 35 year old female with abd pain s/p whipple, 11/10 pain despite: - Working epidural - IV PCA - Dexmedetomidine infusion - Appropriate adjuncts What can we do before she arrives in pre-op?

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45 Goal: optimize perioperative patient safety and pain control I.Identify high risk patients at the initial visit II.Connect with and support PCPs/prescribers to set expectations and taper opioids III.Improve utilization of opioid adjuncts IV.Improve post-op pain control, safety, satisfaction and cost

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55 Michigan Automated Prescription System

56 22 states now have instant access!

57 Michigan Automated Prescription System Detailed history of all the Schedule 2-5 controlled substances that a particular patient has legally obtained Helpful determining: Dose of medication Contact information of prescriber(s) Number of opioid prescribers ED visits for opioids Polypharmacy

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59 Where are the patients getting their opioids? National Vital Statistics System. Available at

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61 Patient Contact and Education

62 PCP Contact and Education

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64 I.It is likely not possible, or safe, to reduce the patient’s postoperative pain score below his or her baseline II.Limiting the preoperative opioid regimen is in the patient’s best interest III.Patients should be open to opioid adjuncts in the perioperative period IV.Pain control expectations, patient participation and surgical outcome V.The goal of pain control is to restore function VI.Expectations and pain management should not end at hospital discharge

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66 Why do I need to know all that?! In the chronic pain population: Make plan before surgery

67 Why do I need to know all that?! Pre-Op Clinic Considerations Taper opioids down to the lowest tolerated dose Communicate with opioid prescriber and plan for perioperative considerations Allay fears of needles, tylenol SET EXPECTATIONS

68 BEEP, BEEP, BEEEEEEP!!

69 ADD ON – OR 17, ORIF s/p MVA; pt in resus bay C; pt takes Xanax and Methadone; NPO since 0600.

70 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

71 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

72 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

73 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

74 Multimodal Analgesia Treat pain at multiple sites on pain pathway Improved pain control Opioid-sparing Decreased side effects

75 Multimodal Analgesia Opioids Cyclooxygenase inhibitors alpha-2 agonists Membrane stabilzers Ketamine Nitrous Oxide Magnesium Local anesthetics (epidural & infiltration)

76 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

77 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

78 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medications Continue long acting opioids Calculate the baseline need and ensure that is met and, within safe reason, exceeded Arrange for appropriate post-op destination

79 Special Case Meds

80 Periop Management of Methadone DISCERN INDICATION If for chronic pain, continue perioperatively and supplement with opioids and other analgesics If for addiction, dose will be very high, saturating opioid receptors and causing patient to act similar to suboxone user

81 A Growing Consideration

82 Periop Management of Buprenorphine Buprenorphine (Suboxone) – partial opioid agonist, blocks opioid receptors, used for addiction and chronic pain Elective vs. Emergent

83 Periop Management of Buprenorphine

84 Elective surgery – If not in pain and procedure is amenable (i.e. ambulatory), may continue with surgery with adjunct medications If in pain before procedure or procedure is invasive, refer to prescriber for taper then treat with standard doses of opioids, regional anesthesia, multimodal techniques

85 Periop Management of Buprenorphine

86 Emergent surgery If patient is pain-free, continue buprenorphine and use adjunct medications, cautious with opioids If patient is in pain, start PCA (likely high dose) consider ICU admission maximize adjuncts (tylenol, NSAIDs, gabapentin, ketamine or dexmedetomidine infusions), regional anesthesia Be wary of rapid decrease in opioid tolerance when buprenorphine clears (24-72hrs)

87 Preparation pays off: a final case example 56yo male presenting for spinal traction, then fusion Crohn’s disease, LE amputations, bowel resections, at least 6 prior spine surgeries, chronic pain, intrathecal pain pump Extensive Past surgical hx Huge medication list Allergic to Neurontin, Lyrica, Ambien, Remicade No significant Family or Social Hx

88 Preparation pays off: a final case example Intrathecal Dilaudid, 7.991mg daily PO Dilaudid, 8mg every 8 hours Methadone, 40mg every 8 hours mg of PO morphine equivalents!!!

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90 APS consultation SET EXPECTATIONS Discussed goals, ICU admission, adjuncts Tapered off short acting opioids Minimized Methadone Continued intrathecal opioids Started on tylenol, SSRI

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92 Post-op management Planned ICU admission Dexmedetomidine gtt Lidocaine patches near surgical sites Diazepam for spasms Dilaudid PCA followed by a slow wean Continued baseline methadone, intrathecal meds Allergic to gabapentin and pregabalin, so unable to use membrane stabilizers For most of the patient’s recovery, his pain was at or below his baseline!

93 Satisfaction: 5/5! Met our 3 goals: Improved safety (no hypotension, oversedation, or re-intubation) Lowered costs (bypassed PACU, abbreviated ICU stay) Optimized Satisfaction

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95 Thank you for your attention!! Search “Michigan Opioid Taper” for the resources I’ve introduced See me for a card with the website Thanks to: o Anesthesiology QA committee o Dr. Paul Hilliard o My wife, Stephanie (she’s probably by the pool) o Department of Orthopedic Surgery o UM Preoperative Clinics o UM School of Computer Science o Health Science Library o UM Hospital Legal Team o MiChart Development Team o ECCA (Executive Committee on Clinical Affairs)

96 References Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg Aug;97(2): Bialosky, JE, Bishop, MD, Cleland JA. Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing Musculoskeletal Pain. Phys Ther Sept; 90(9):1345–1355. Keltner JR, Furst A, Fan C, Redfern R, Inglis B, Fields HL. Isolating the modulatory effect of expectation on pain transmission: a functional magnetic resonance imaging study. J Neurosci Apr 19;26(16): Stomberg MW, Oman UB. Patients undergoing total hip arthroplasty: a perioperative pain experience..J Clin Nurs Apr;15(4): Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. JAMA. 2011;305(13): Dasta JF, et al. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med Jun;33(6): Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today Nov;6(11) Weinborum AA, et al. Efficiency of the operating room suite. American Journal of Surgery. 2003;185:244–250 Committee on Advancing Pain Research, Care, and Education, Institute of Medicine. "Summary." Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research. Washington, DC: The National Academies Press, Sun D-C, Kim MS, Chow W, Jang E-J. Use of medications and resources for treatment of nausea, vomiting, or constipation in hospitalized patients treated with analgesics. Clin J Pain. 2011;27: The White House. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. content/prescription-drugs/rx_abuse_plan_0.pdf. Accessed October 21, Maund E, McDaid C, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth Mar;106(3): Brummet C. Management of Sublingual Buprenorphine (Suboxone and Subutex) in the Acute PerioperativeSetting. Berkowitz, B.A., Finck, A.D., Hynes, M.D. & Ngai, S.H. (1979). "Tolerance to nitrous oxide analgesia in rats and mice". Anesthesiology 51 (4): 309–12 Sawamura, S., Kingery, W.S., Davies, M.F., Agashe, G.S., Clark, J.D., Koblika, B.K., Hashimoto, T. & Maze, M. (2000). "Antinociceptive action of nitrous oxide is mediated by stimulation of noradrenergic neurons in the brainstem and activation of [alpha] 2B adrenoceptors". J. Neurosci. 20 (24): 9242–51. Angst, MS & Clark, DJ: Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570–87 Lee M, Silverman S, Hansen H, Patel V, Manchikanti L. A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician 2011;14: Song JW, Lee YW, Yoon KB, Park SJ, Shim YH. Anesth Analg Aug;113(2): doi: /ANE.0b013e31821d72bc. Epub 2011 May 19. Pesonen A, et al. Pregabalin has an opioid-sparing effect in elderly patients after cardiac surgery: a randomized placebo-controlled trial. Br J Anaesth Jun;106(6): doi: /bja/aer083. Epub 2011 Apr 6 Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy and safety. Anesth Analg Jun;104(6): Weinger MB. Dangers of postoperative opioids. APSF Newsletter ;21:61-7

97 National Vital Statistics System. Multiple cause of death dataset. Available at Deaths attributable to Heroin, Cocaine and Opioids This trend continues…


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