the opioid epidemic and perioperative implications 17th annual practical updates in anesthesiology...
TRANSCRIPT
The Opioid Epidemic and Perioperative Implications
17th Annual Practical Updates in Anesthesiology
February 2 – February 7, 2014
Peter Stiles, MD
Paul Hilliard, MS, MD
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
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
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
35 year old female
• PSH: Spinal fusion, TAH, bladder suspension• No issues after those procedures
What’s different?
What’s different?
360mg daily PO morphine equivalents
Over the preceding months, her abdominal pain had been treated with increasing opioids, up to 80mg Oxycontin TID
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
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.
Image Credits: Themanualtherapist, psychologyofpain.blogspot.com, pilothealthadvocates.com
Endorsed by 2 separate pain societies in 1996 --Seemed like a great idea…
Opioid Prescriptions Reach Epidemic Proportions
• In 3 months of 2008-9 he received at least 11 prescriptions for painkillers from eight doctors – 370 tablets
• May 12th, 2011 he died from a accidental overdose of oxycodone
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 over dose (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 2011. Available at http://www.cdc.gov/nchs/nvss.htm
Rate (per 100,000) of unintentional drug overdose deaths
National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm
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. http:..www.whitehouse.gov/sites/default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan_0.pdf. Accessed October 21, 2012.
Why is this a problem for periop patients?
SAFETY
SATISFACTION
COST
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. 2011 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.
Patient Safety• Difficult to study with RCTs
Patient Safety• Difficult to study with RCTs
Date of download: 3/26/2013Copyright © 2012 American Medical Association.
All rights reserved.
From: Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths
JAMA. 2011;305(13):1315-1321. doi:10.1001/jama.2011.370
Figure Legend:
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;27:508-17
• IV opioids had nearly 5x risk of GI side effects compared to oral nonopioid analgesics
• Urinary retention
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 Naive Opioid Tolerant
Dose
Ana
lges
ic R
espo
nse
Pain Control
• Opioid-Induced Hyperalgesia
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
Copyright © 2013 Anesthesiology. Published by Lippincott Williams & Wilkins.
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.
40
Opioid-induced Hyperalgesia: A Qualitative Systematic Review
Angst, Martin S.; Clark, J David
Anesthesiology. 104(3):570-587, March 2006.
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. 2005 Jun;33(6):1266-71.Weinborum AA, et al. Efficiency of the operating room suite. American Journal of Surgery. 2003;185:244–250
What to do!?• National epidemic• Dissatisfied patients• Uncontrollable pain (both patient and provider….)
• Rising costs our country cannot afford
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?
Goal: optimize perioperative patient safety and pain controlI. 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
Michigan Automated Prescription System
22 states now have instant access!
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
Where are the patients getting their opioids?
National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm
Patient Contact and Education
PCP Contact and Education
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
Why do I need to know all that?!
In the chronic pain population:
Make plan before surgery
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
BEEP, BEEP, BEEEEEEP!!
ADD ON – OR 17, ORIF s/p MVA; pt in resus bay C; pt takes Xanax and Methadone; NPO since 0600.
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
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
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
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
Multimodal Analgesia
• Treat pain at multiple sites on pain pathway
• Improved pain control• Opioid-sparing• Decreased side effects
Multimodal Analgesia• Opioids• Cyclooxygenase
inhibitors• alpha-2 agonists• Membrane stabilzers• Ketamine• Nitrous Oxide• Magnesium• Local anesthetics
(epidural & infiltration)
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
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
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
Special Case Meds
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
A Growing Consideration
Periop Management of Buprenorphine
• Buprenorphine (Suboxone) – partial opioid agonist, blocks opioid receptors, used for addiction and chronic pain
http://www.naabt.org/education/buprenorphine_treatment.cfm
Elective vs. Emergent
Periop Management of Buprenorphine
Periop Management of Buprenorphine
• 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
Periop Management of Buprenorphine
Periop Management of Buprenorphine
• 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)
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
Preparation pays off: a final case example
• Intrathecal Dilaudid, 7.991mg daily• PO Dilaudid, 8mg every 8 hours• Methadone, 40mg every 8 hours
• 16546 mg of PO morphine equivalents!!!
APS consultation
• SET EXPECTATIONS• Discussed goals, ICU admission, adjuncts
• Tapered off short acting opioids• Minimized Methadone• Continued intrathecal opioids• Started on tylenol, SSRI
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!
Satisfaction: 5/5!
Met our 3 goals:• Improved safety
(no hypotension, oversedation, or re-intubation)
• Lowered costs (bypassed PACU, abbreviated ICU stay)
• Optimized Satisfaction
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 committeeo Dr. Paul Hilliardo My wife, Stephanie (she’s probably by the pool)o Department of Orthopedic Surgeryo UM Preoperative Clinicso UM School of Computer Scienceo Health Science Libraryo UM Hospital Legal Teamo MiChart Development Teamo ECCA (Executive Committee on Clinical Affairs)
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. 2003 Aug;97(2):534-40.• Bialosky, JE, Bishop, MD, Cleland JA. Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing
Musculoskeletal Pain. Phys Ther. 2010 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. 2006 Apr 19;26(16):4437-43.• Stomberg MW, Oman UB. Patients undergoing total hip arthroplasty: a perioperative pain experience. .J Clin Nurs. 2006 Apr;15(4):451-8.• 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):1315-1321• Dasta JF, et al. Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med. 2005 Jun;33(6):1266-71.• Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today. 2011 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, 2011.• 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• The White House. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. http:..www.whitehouse.gov/sites/default/files/ondcp/issues-
content/prescription-drugs/rx_abuse_plan_0.pdf. Accessed October 21, 2012.• 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. 2011 Mar;106(3):292-7.• Brummet C. Management of Sublingual Buprenorphine (Suboxone and Subutex) in the Acute PerioperativeSetting.
http://anes.med.umich.edu/vault/1003149-Buprenorphine_Suboxone__Subutex_Perioperative_Management.pdf#pagemode=bookmarks• 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;14:145-161.• Song JW, Lee YW, Yoon KB, Park SJ, Shim YH. Anesth Analg. 2011 Aug;113(2):390-7. doi: 10.1213/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.
2011 Jun;106(6):873-81. doi: 10.1093/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. 2007 Jun;104(6):1545-56• http://ppsg-production.heroku.com/chart• http://www.cdc.gov/HomeandRecreationalSafety/pdf/poison-issue-brief.pdf• http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm#fig1• http://www.medpagetoday.com/Neurology/PainManagement/34650• http://www.cdc.gov/nchs/data/databriefs/db81.pdf• Weinger MB. Dangers of postoperative opioids. APSF Newsletter 2006-2007;21:61-7
National Vital Statistics System. Multiple cause of death dataset. Available at http://www.cdc.gov/nchs/nvss.htm
Deaths attributable to Heroin, Cocaine and Opioids
This trend continues…