The Narcotic Epidemic: Our

Response

Ronald E. Delanois, M.D.

Nicole E. George, D.O.

Jennifer I. Etcheson, M.D., M.S.

Chukwuweike U. Gwam, M.D.

• History of the opioid problem

– Nationally

– Statewide (Maryland)

– Institutionally (Sinai Hospital)

• Orthopaedics & the opioid

epidemic

• Opioid Rx at Sinai Hospital

• Sinai Hospital: addressing the

opioid problem

– Pre-/Peri-operative

– Intra-operative

– Post-operative

Outline

• 2005: national market campaign

to eliminate pain

– Based on the premise that physicians

are not treating pain adequately

• 2010: CMS established Value-

Based purchasing

– Value tied to patient perception of

care (HCAHPS)

– Pain control major component of

HCAHPS

• Providers ↑↑↑ opioid prescriptions

• Opioid epidemic

History of the Problem

• Drug overdose deaths in

the U.S. have tripled

since 2000

– 52,404 drug overdose

deaths in 2015

• Opioid-related overdoses

accounted for 63.1% of

these deaths

– 33,091 opioid-related

overdose deaths in 2014

– ~50% involved

prescription opioids

• Prescription opioid

addiction costs the U.S.

economy $78.5

billion/year

U.S. Opioid Epidemic

Opioid Epidemic in Maryland

• Orthopaedic surgeons

rank 3rd with respect to

writing opioid

prescriptions.

• Account for 7.7% of opioid

prescriptions among all

U.S. physicians.

– #1= PCPs (28.8%)

– #2= Internists (14.6%)

Opioids in Healthcare

• Patient-controlled analgesia (PCA)

– Intravenous or epidural

– Morphine, fentanyl,

hydromorphone

• Opioid Medications

– Short-acting (i.e. morphine,

fentanyl, oxycodone IR,

hydromorphone)

– Long-acting (i.e. Oxycontin)

How Was Pain Historically Controlled in

Orthopaedics?

• 20-30 Rx/day x 12

months

• 4800-7200 Rx/year

• 90 pills/Rx

Narcotic Prescriptions at Sinai

Hospital: 2014

• 2014: Sinai Hospital/RIAO sought to ↓ opioid

prescribing

– How do patients rate their pain?

– What other modalities can be utilized to ↓ postop pain?

What is Sinai Hospital Doing to

Combat the Opioid Epidemic?

1. Questionnaire (to identify

patients at risk of opioid

addiction)

2. Patient education

3. 90-day pain contracts with

patients

4. Staff education

5. Care coordination

6. Partnerships with PCPs &

pain management providers

7. Premedication

Sinai Hospital: Addressing the Narcotic Problem

(Pre-operative)

• Preoperative total joint

education class

• Education on the consequences

of opioid misuse & opioid

addiction

Patient Education

• Implemented to identify

patients at risk for opioid

addiction

Questionnaire

• In order for patients to receive

preoperative and postoperative

opioids for pain control

• Establishes

– Rapport

– Plan of care

– Consequences

• Patients must follow rules or

opioid prescribing ceases

Pain Contracts

• Standardized pain

protocol

• Frequent pain

assessments

• Pain medication

administered based on

pain scores (vs.

scheduling the pain

meds)

Staff Education

• Care coordination team

– 1 patient educator

– 4 nurses

• 1 nurse is designated as the

nurse navigator

• Surgery scheduler

• Orthopaedic surgery team

• Floor supervisor RN

Care Coordination

• Primary care physicians

• Physical therapists

• Anesthesiology team

• Pain control specialists

Partnerships with Other Providers

• To decrease postoperative

opioid requirements

• Regimen consists of:

– Gabapentin

– Celebrex

– Oxycodone IR (5mg)

Premedication

1. Opioid-sparing approach

2. Multimodal pain control

Sinai Hospital: Addressing the Narcotic Problem

(Intra-operative)

• Shift in pain control

method from:

– General anesthesia→

– Spinal anesthesia→

– Peripheral nerve blocks &

adjuvant agents

• Opioids & patient

experience

– Press-Ganey survey scores

related to patient pain scores

Opioid-Sparing Analgesia

• Acetaminophen

• NSAIDs

• Local anesthetics

• GABA agents

• Muscle relaxants

• Others

– Anticonvulsants

– Antidepressants

– Antihistamines

– Psychostimulants

– Anti-spasmodics

Premedication/Adjuvant Pain Control

• Randomized-control trial

– 140 patients undergoing primary unilat. total knee arthroplasty (TKA)

– Local infiltration analgesia (LIA) ± liposomal bupivacaine (LB)

• Endpoints

– Pain scores

– Opioid consumption

– Time to first opioid rescue

– Patient safety

• LIA with LB resulted in significantly improved postop pain, opioid

consumption, & time to first opioid rescue

• No unexpected safety concerns with use of LB

Multimodal Pain Control: Exparel

Multimodal Pain Control: Adductor Canal Block

• Adductor canal block (ACB)

– A peripheral nerve block

– Low incidence of complications

– Excellent pain relief

• Retrospective review

– 110 patients undergoing TKA

– Multimodal periarticular analgesia (MPA) ± ACB

– Pts who received both MPA and ACB had shorter LOS (2.44 vs. 1.98

days)

• NSAIDs

– Celebrex

– Diclofenac vs. ketorolac

• Spinal anesthesia

• Gabapentin

Multimodal Pain Control: Others

1. Interdisciplinary

partnerships

2. HealthLoop

Sinai Hospital: Addressing the Narcotic Problem

(Post-operative)

• Orthopaedic

surgeons

• Anesthesiologists

• PM&R specialists

• PCPs

• Nurses

• Pharmacists

• Social workers

Interdisciplinary Partnerships

• Interactive patient-provider

software platform

• Total joint arthroplasty patients

– Enrolled 14 days prior to surgery

– Continues through 21 days post-

surgery

• 97% patient enrollment at Sinai

Hospital

Patient Engagement Tool

• Nationwide, orthopaedists have

decreased opioid prescribing by 13.4%

from 2014 to early 2017.

• 2014:

– 20-30 Rx/day x 12 mos

– 4800-7200 Rx/year

– 90 pills/Rx

• 2017:

– 1-2 Rx/day x12 mos

– 240-480 Rx/year

– 60 pills/Rx

– ↓↓ # opioid Rx by

22.5x (2250%) since

2014

Narcotic Prescriptions at Sinai

Hospital: How Have We Done?

• Rudd RA, Seth P, David F, Scholl L. “Increases in Drug and Opioid-Involved

Overdose Deaths— United States, 2010-2015.” Weekly. December 2016: 65(50-

51);1445–1452. <https://www.cdc.gov/mmwr/volumes/65/wr/mm655051e1.htm>.

• Schuchat A, Houry D, Guy Jr. G. “New Data on Opioid Use and Prescribing in the

United States.” JAMA. 2017;318(5):425-426.

<https://jamanetwork.com/journals/jama/fullarticle/2643332>.

• Gostin LO, Hodge JG, Noe SA. “Reframing the Opioid Epidemic as a National

Emergency.” JAMA. 2017;318(16):1539-1540.

<https://jamanetwork.com/journals/jama/fullarticle/2652445>.

• Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. “The role of

opioid prescription in incident opioid abuse and dependence among individuals with

chronic noncancer pain: the role of opioid prescription.” Clin J Pain. 2014

Jul;30(7):557-64.

References

• Pts with chronic non-cancer-related pain who took

opioids for >90 days (even at low doses) have a

substantially higher odds (O.R., 14.92) of developing

opioid use disorder compared with those who were

not prescribed opioids.

Orthopaedics & the Opioid Epidemic

• Amount of opioids prescribed in the U.S. is 4x higher than

in Europe.

• Economic costs of the opioid epidemic (health care, labor,

& criminal justice costs) was estimated at $92 billion in

2016.

U.S. Opioid Epidemic

The Opioid Epidemic in Maryland

• In 2011, Maryland

declared a public health

emergency due to the

opioid epidemic.

• In the first 8 months of

2016, there were 1,468

opioid-related overdose

deaths.

Total number of drug- and alcohol-related intoxication

deaths by selected substances, Maryland 2007-2016

The Opioid Epidemic in Maryland

The Opioid Epidemic in Maryland

Number of Opioid-Related Deaths Occurring

in Maryland from January through March of

Each Year

Number of Prescription Opioid-Related

Deaths Occurring in Maryland from January

through March

2014

No.

(Rate)

2015

No.

(Rate)

% change in

rate

(2014 to 2015)

Natural & semi-synthetic opioids 388 (6.2) 398 (6.5) +4.8%

Methadone 153 (2.4) 182 (2.9) +20.8%

Synthetic opioids (other than

methadone)

230 (3.8) 357 (5.8) +52.6%

Heroin 313 (5.2) 405 (6.6) +26.9%

Number and rate of drug overdose deaths in Maryland, 2014 & 2015