Presentation on theme: "The Opioid Epidemic and Perioperative Implications"— Presentation transcript:
1 The Opioid Epidemic and Perioperative Implications 17th Annual Practical Updates in AnesthesiologyFebruary 2 – February 7, 2014Peter Stiles, MDPaul Hilliard, MS, MD
2 35 year old femaleCC: 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 teamACUTE PAIN SERVICE (APS) consult for severe post-op painNo apparent explanation for 11/10 painThe patient had a working epidural with a level, good IV with IV split opioids; physiologically, it would appear her pain should be well controlled; adjuncts were started, etc.
4 35 year old female Generated 17 notes in 6 days Resulted in multiple episodes of hypotension, significant sedationUnanticipated SICU admission for uncontrollable pain - Multiple infusionsHighly tolerant hydromorphone PCAPatient stating 10/10 pain throughout hospitalizationExtreme dissatisfaction per the patient, regrets surgery
5 35 year old female PSH: Spinal fusion, TAH, bladder suspension No issues after those procedures
7 360mg daily PO morphine equivalents What’s different?Over the preceding months, her abdominal pain had been treated with increasing opioids, up to 80mg Oxycontin TID360mg daily PO morphine equivalents
8 OutlineReview the state of opioid prescriptions and abuse in the United StatesInvestigate how this will impact anesthesia practice and what can be doneIntroduce the Michigan High-Dose Opioid Taper Initiative – suggestions for pre-op managementReview opioid induced hyperalgesiaWhat to do the morning of surgery
9 Pain is relevant to every practice > 100 million people#1 presenting complaint to health professionalsEst. $560 - $635 BillionRoughly 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 Endorsed by 2 separate pain societies in 1996 --Seemed like a great idea… Image Credits: Themanualtherapist, psychologyofpain.blogspot.com, pilothealthadvocates.com
14 Opioid Prescriptions Reach Epidemic Proportions In 3 months of he received at least 11 prescriptions for painkillers from eight doctors – 370 tabletsMay 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 http://www.cdc.gov/nchs/nvss.htm
17 Pay close attention the scales used on the charts, they had to revise the scales for the three on the left because there was such a significant discrepancyInternational Narcotics Control Board uses a calculation of “defined daily doses for statistical purposes (S-DDD) consumed per million inhabitants per day”It extrapolates that while national or regional consumption of opioids cannot be identified as the “the right amount or adequate” they established generalities that consumption of analgesics via the S-DDD metric of was inadequate, thereby meaning that the region or country probably was not appropriately addressing the pain needs of their population. <100 was considered very inadequate.
18 This is killing us….Admissions for treatment of opioid addiction per 100,000 peopleRate (per 100,000) of unintentional drug overdose deathsOfficial statistics are only available through 2007, projected numbers are even higher today
19 Rate (per 100,000) of unintentional drug overdose deaths The figure above shows the rate of unintentional drug overdose deaths in the United States during 1970–2007. In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years has been driven by increased use of a class of prescription drugs called opioid analgesics.National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm
20 Human Development Index (HDI) is a composite statistic of life expectancy, education, and income indices to rank countries into tiers of human development; created by economist Mahbub ul Haq, followed by economist Amartya Sen in 1990, and published by the United Nations Development Programme
26 US makes up 4.7% of the World population, yet we prescribe 80% of all opioids prescribed worldwide
27 Deaths attributable to Heroin, Cocaine and Opioids This trend continues…The figure above shows the number of unintentional drug overdose deaths involving opioid analgesics, cocaine, and heroin in the United States during 1999–2007. Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined.National Vital Statistics System. Multiple cause of death dataset. Available at http://www.cdc.gov/nchs/nvss.htm
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 sufferingand pain, improve the quality of life, and save lives. This is no more evident than in the field of painmanagement. 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 andabuse is a major public health and public safety crisis. As a Nation, we must take urgent action to ensurethe appropriate balance between the benefits these medications offer in improving lives and the risksthey pose. No one agency, system, or profession is solely responsible for this undertaking. We mustaddress this issue as partners in public health and public safety. Therefore, ONDCP will convene a FederalCouncil on Prescription Drug Abuse, comprised of Federal agencies, to coordinate implementation ofthis 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.
30 Why is this a problem for periop patients? SAFETYSATISFACTIONHow is this relevant to us, as anesthesiologists and pain medicine specialists? We certainly use opioids regularily. 3 domains that impact out patients and our healthcare system…that we can directly affect. This ‘untold story’ likely will not make the lay-press, but it is something of which we must be aware.COST
31 Patient SafetyRemember the introductory case?...it’s not uncommonBetween 350,000 to 750,000 in-hospital cardiopulmonary arrests occur annually in the United States.Roughly 80% of the victims don’t survive to dischargeAbout half of patients with in hospital arrests had been receiving opioids.Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today Nov;6(11)
35 Patient SafetyHigher opioid requirements postoperatively, not surprisingly, are associated with more side effects55% of patients receiving opioids required nausea, vomiting and/or constipation pharmacologic treatments.IV opioids had nearly 5x risk of GI side effects compared to oral nonopioid analgesicsUrinary retentionDesign Case-cohort study.Setting Veterans Health Administration (VHA), 2004 through 2008.Participants All unintentional prescription opioid overdose decedents (n = 750) and a random sample of patients (n = 154 684) among those individuals who used medical services in 2004 or 2005 and received opioid therapy for pain.Main Outcome Measure Associations of opioid regimens (dose and schedule) with death by unintentional prescription opioid overdose in subgroups defined by clinical diagnoses, adjusting for age group, sex, race, ethnicity, and comorbid conditions.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;27:508-17
36 Pain ControlDifficult to measureNot many chronic pain patients will be excited about reducing the daily dose of opioidBUT….some evidence exists in support of tighter opioid management
37 Pain Control (Satisfaction) ToleranceA point exists where we cannot further increase opioid doseThis can make treating acute surgical pain, on top of the patient’s baseline pain and opioid dependence very difficult and unsafeOpioid NaiveOpioid TolerantAnalgesic ResponseDose
39 Pain Control Opioid-Induced Hyperalgesia “A state of nociceptive sensitization caused by exposure to opioids”Not yet fully understood, 5 proposed mechanismsAll implicate neuroplastic changes in both the peripheral and central nervous systemsMost widely accepted hypothesis involves the Central Glutaminergic SystemNMDA receptors see increased glutamate from transport inhibition; various linkages implicated – result in apoptotic cell death in the dorsal hornGive example of a patient on 8 hours of remifentanil; we can induce this…but imagine someone on 20 years of oxycontin
41 CostA nation-wide 2005 study demonstrated that a single day admission to the ICU requiring mechanical ventilation was $10,794A prolonged PACU stay can cost $4-$8 per minuteAdverse outcomes can cost the hospital millionsDon’t forget indirect costs…Dasta JF, et al. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005 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 adjunctsWhat can we do before she arrives in pre-op?What can we, and should we, have done – before and after her surgery, to optimize her care? Ideally, decrease opioids, set realistic expectations, planned for appropriate level of monitoring.--Just like we would not go to the OR if a patient’s BP was 200/120 in pre-op, for fear of difficult to control BP intra- and post-op, so to should we be mindful of pre-op pain and opioid needs
45 Goal: optimize perioperative patient safety and pain control Identify high risk patients at the initial visitConnect with and support PCPs/prescribers to set expectations and taper opioidsImprove utilization of opioid adjunctsImprove post-op pain control, safety, satisfaction and cost
57 Michigan Automated Prescription System Detailed history of all the Schedule 2-5 controlled substances that a particular patient has legally obtainedHelpful determining:Dose of medicationContact information of prescriber(s)Number of opioid prescribersED visits for opioidsPolypharmacy
59 Where are the patients getting their opioids? The figure above shows the percentage of patients and prescription drug overdoses, by risk group in the United States. Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner, and these patients account for an estimated 20% of all prescription drug overdoses. Another 10% of patients are prescribed high doses (≥100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses. The remaining 10% of patients seek care from multiple doctors, are prescribed high daily doses, and account for another 40% of opioid overdoses.National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm
64 Patients should be open to opioid adjuncts in the perioperative period It is likely not possible, or safe, to reduce the patient’s postoperative pain score below his or her baselineLimiting the preoperative opioid regimen is in the patient’s best interestPatients should be open to opioid adjuncts in the perioperative periodPain control expectations, patient participation and surgical outcomeThe goal of pain control is to restore functionExpectations and pain management should not end at hospital dischargeIt is likely not possible, or safe, to reduce the patient’s postoperative pain score below his or her baseline – Even if the surgery aims to improve the patient’s chronic pain, there will be an acute component postoperatively. The patient needs to be aware, prior to surgery, that a degree of discomfort is expected after the surgery.Limiting the preoperative opioid regimen is in the patient’s best interest – This may be difficult to convey to patients that are dependent on opioids; limiting pre-op opioids leaves more room for safe escalation of these medications following the surgical insult.Patients should be open to opioid adjuncts in the perioperative period – The perioperative team may suggest procedures (epidurals, nerve blocks) or medications (gabapentin, ketamine, Tylenol, etc) with which the patient may not be familiar. It should be reinforced that such measures are in the patient’s best interest and should be considered with an open mind.Pain control expectations, patient participation and surgical outcome – Poor communication and pain treatment after surgery can impair function, ADL participation/ambulation, physiologic function (circulation, respiration, GI function, etc.), psychological well-being and quality of life. Two-way communication between patients and providers is essential. Further, patients must own an active role in their recovery, working through expected pain, to optimize outcome.The goal of pain control is to restore function – A principle of chronic pain management is functional restoration. This should also be a perioperative goal for patients on high-dose opioids. Providers will work with patients to establish a safe level of pain relief, allowing patients to meaningfully participate in recovery activities (incentive spirometery, physical therapy).Expectations and pain management should not end at hospital discharge – Recovery from surgery takes weeks to months; patients will likely experience increased pain during this period. Depending on the goal and outcome of the surgery, the patient’s baseline pain may be altered. Surgery is not an “easy fix,” it takes dedication and hard work on the part of both patients and primary providers.
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 ConsiderationsTaper opioids down to the lowest tolerated doseCommunicate with opioid prescriber and plan for perioperative considerationsAllay fears of needles, tylenolSET EXPECTATIONS
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 medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
71 Morning of Surgery Set Expectations Regional or Epidural if possible Consider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
72 Morning of Surgery Regional or Epidural if possible Set Expectations Consider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
73 Morning of Surgery Consider available adjunct medications Set ExpectationsRegional or Epidural if possibleConsider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
74 Multimodal Analgesia Treat pain at multiple sites on pain pathway Improved pain controlOpioid-sparingDecreased side effects
76 Morning of Surgery Continue long acting opioids Set Expectations Regional or Epidural if possibleConsider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
77 Morning of SurgerySet ExpectationsRegional or Epidural if possibleConsider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
78 Morning of Surgery Arrange for appropriate post-op destination Set ExpectationsRegional or Epidural if possibleConsider available adjunct medicationsContinue long acting opioidsCalculate the baseline need and ensure that is met and, within safe reason, exceededArrange for appropriate post-op destination
80 Periop Management of Methadone DISCERN INDICATIONIf for chronic pain, continue perioperatively and supplement with opioids and other analgesicsIf for addiction, dose will be very high, saturating opioid receptors and causing patient to act similar to suboxone user
84 Periop Management of Buprenorphine Elective surgery –If not in pain and procedure is amenable (i.e. ambulatory), may continue with surgery with adjunct medicationsIf in pain before procedure or procedure is invasive, refer to prescriber for taper then treat with standard doses of opioids, regional anesthesia, multimodal techniques
86 Periop Management of Buprenorphine Emergent surgeryIf patient is pain-free, continue buprenorphine and use adjunct medications, cautious with opioidsIf patient is in pain,start PCA (likely high dose)consider ICU admissionmaximize adjuncts (tylenol, NSAIDs, gabapentin, ketamine or dexmedetomidine infusions),regional anesthesiaBe 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 fusionCrohn’s disease, LE amputations, bowel resections, at least 6 prior spine surgeries, chronic pain, intrathecal pain pumpExtensive Past surgical hxHuge medication listAllergic to Neurontin, Lyrica, Ambien, RemicadeNo significant Family or Social Hx
88 Preparation pays off: a final case example Intrathecal Dilaudid, 7.991mg dailyPO Dilaudid, 8mg every 8 hoursMethadone, 40mg every 8 hours16546 mg of PO morphine equivalents!!!
92 Post-op managementPlanned ICU admissionDexmedetomidine gttLidocaine patches near surgical sitesDiazepam for spasmsDilaudid PCA followed by a slow weanContinued baseline methadone, intrathecal medsAllergic to gabapentin and pregabalin, so unable to use membrane stabilizersFor 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 SatisfactionSatisfaction: 5/5!
95 Thank you for your attention!! Search “Michigan Opioid Taper” for the resources I’ve introducedSee me for a card with the websiteThanks to:Anesthesiology QA committeeDr. Paul HilliardMy wife, Stephanie (she’s probably by the pool)Department of Orthopedic SurgeryUM Preoperative ClinicsUM School of Computer ScienceHealth Science LibraryUM Hospital Legal TeamMiChart Development TeamECCA (Executive Committee on Clinical Affairs)
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97 Deaths attributable to Heroin, Cocaine and Opioids This trend continues…The figure above shows the number of unintentional drug overdose deaths involving opioid analgesics, cocaine, and heroin in the United States during 1999–2007. Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined.National Vital Statistics System. Multiple cause of death dataset. Available at http://www.cdc.gov/nchs/nvss.htm