Julie K. Marosky Thacker, MD, FACS, FASCRSDuke University Department of Surgery

President, American Society of Enhanced Recovery

Timothy E. Miller, MB, ChB, FRCA

Duke University Department of Anesthesia

Vice President, ASER, American Society of Enhanced Recovery

Enhanced Recovery to Optimize Perioperative Alternatives to Opioids

Women in Government, Annual Healthcare SummitTh 05 November 2017, Washington DC

Objectives

• Define how PERIOPERATIVE PAIN contributes to opioid crisis

• Share evidence based PERIOPERATIVE CARE PRINCIPLES and PATHWAYS that minimize exposure and minimize contribution to opioid crisis

Postoperative or injury pain and opioids-TRUE or FALSE

• The opioid crisis is predominantly been characterized by deaths and severe adverse events in chronic opioid users

• Patients have pain after surgery

• Patients have pain after injuries

• Prescribers have inaccurate beliefs about opioid addiction potential and the most likely at risk

TRUE Impact of operations or injurieshas barely been discussed

TRUE

Gan, Curr Med Res Opin. 2014; 30:149-60

“We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.”

1980

The idea that there is nothing inherently dangerous about drugs — specifically opioids — is inaccurate. And with the opioid epidemic spreading throughout the country, it’s potentially dangerous.

Another false teaching~

“Drugs are not bad, people who misuse drugs are bad”

The average person has 9 operations in their lifetime

Opioid abuse after surgery

3-7 % OF OPIOID NAÏVE PATIENTS STILL TAKE OPIOIDS ONE YEAR AFTER OPERATION

Clarke. BMJ 2014Brummett. JAMA Surg 2017

Why are opioids used so commonly?

• Very effective• Quick onset of action• Pain management surrogate of good care

• Management of pain–“5th vital sign”–HICAPS metric

1 in 7 patients whose opioid use >8 days, continue to use opioids at 1 year

30% of patients whose first opioid >31 days,continue to use opioids at 1 year

Alam er al. Arch Intern Med. 2012;172:425–430

Chronic opioid use often begins with a prescription for acute pain, either in the ambulatory or outpatient setting

• Higher opioid consumption during an inpatient hospital stay results in higher chance of prolonged post hospital use

• On discharge from hospital, patients expect pain medicine and are asked by survey if they are happy with their pain management.

• 72% of pills prescribed to discharged general surgery patients go unused.

Bartels, PLoS One. 2016;11:e0147972

Hill, Annals Surgery. 2017;265:709–714

Leftover pills in the home

• 60% of Americans have unused prescribed opioids in the home

• Excess opioid pills are unsecured source for non-medical opioid use

• In a survey of heroin users, approximately 75% heroin users report starting with opioid pain relievers; often these were not prescribed to them

Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain Relievers — United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132:95–100

Partnership for a Drugfree America, 2015

In the context of the national opioid epidemic, the perioperative period represents an important opportunity to prevent chronic opioid

use, especially in opioid naïve patients

Let’s discuss two recent patients

Patient 1 – “I’d like to request opioid free anesthesia”

Patient 2 – “you are going to need some painkillers”

How can we reduce the perioperative use of opioids??

Opioid sparing analgesia as part of Enhanced Recovery

• Enhanced Recovery–New, patient focused care paradigm

–interdisciplinary, evidence based perioperative care

• Optimal, procedure-specific, multimodal pain management

–minimized opioid use

–facilitated postoperative ambulation and rehabilitation.

Enhanced Recovery Paradigm

Patient’s Journey

Optimization preop intraop postop Recovery

Patient-Centric, interdisciplinary care plan

Collaboratively defined, patient focused process measures

PR

EO

PP

RE

OP

EducationRisk assessmentSurgical planningInformed consent

EducationRisk assessmentSurgical planningInformed consent

PE

RIO

PP

ER

IOP

Risk reductionCo-managementcommunicationInitiation of protocolPRO of education/gap assessment

Risk reductionCo-managementcommunicationInitiation of protocolPRO of education/gap assessment

INTR

AO

PIN

TRA

OP

IdentificationReinforcementMultimodal analgesiaOR time outIntentional fluid mgtOR debrief

IdentificationReinforcementMultimodal analgesiaOR time outIntentional fluid mgtOR debrief

PO

STO

PP

OS

TOP Multimodal analgesia

Immediate dietImmediate mobilizationDrains, tubes, lines out asapIntentional diagnosticsDefined d/c criteriaEducationEstablished follow up

Multimodal analgesiaImmediate dietImmediate mobilizationDrains, tubes, lines out asapIntentional diagnosticsDefined d/c criteriaEducationEstablished follow up

PO

STD

ISC

HA

RG

EP

OS

TDIS

CH

AR

GE

Reinforcement of multimodal analgesia regimenEstablished communication pathwaysFollow up PRO-experience, recovery, caregivers

Reinforcement of multimodal analgesia regimenEstablished communication pathwaysFollow up PRO-experience, recovery, caregivers

www.enhancedrecovery.org

American Society for Enhanced Recovery

Mission: To advance the practice of perioperative enhanced recovery, to contribute to its growth and influences, by fostering and encouraging research, education, public policies, programs and scientific progress.

www.enhancedrecovery.org

Monotherapy vs. multimodal analgesia

McEvoy et al. Perioperative Medicine. 2017; 6:8www.POQI.org

McEvoy. Perioperative Medicine. 2017; 6:8www.POQI.org

Encouraged changes to current practice

Gawande, Ann Surg 2017

• Counsel patients preoperatively– Function is goal– Comfortable to recover, not ”painless”

• Use non-opioid alternatives

• Confirm previous prescriptions

• Provide clear, available disposal options

• Prescribe minimum quantity necessary

ASER/POQI, Periop Med 2017

• Set expectations with patients. This education is the mot important aspect of Enhanced Recovery

• Begin multi-modal analgesia before operation and continue throughout postop recovery

• Implement optimal analgesia algorithm

• Provide clear instructions on non-opioid analgesia options with minimal opioids prescribed on discharge as per rescue plan

Encouraged changes to current practice

Anesth Analg 2017;125:1784–92

However, Impact of Enhanced Recovery on Opioids at Discharge

• None...

• ERAS intervention can result in opioid-sparing to opioid-free hospital experience, however, no change was observed in prescribing practices at discharge from hospital

Factors besides perioperative care that lead to misuse/abuse

• Providers are accountable to treat to “No pain”

• Providers are not trained to manage acute or chronic pain

• Neither patients nor providers know or value disposal practices

• Highest risk patients have mental health challenges without access to diagnosis and treatment

In addition to adoption of enhanced recovery analgesia principles, two essential system changes are necessary

• Providers are accountable to treat to “No pain”

• Providers are not trained to manage acute or chronic pain

• Neither patients nor providers know or value disposal practices

• Highest risk patients have mental health challenges without access to diagnosis and treatment

Conclusion• Experts in perioperative care recommend adoption of evidence based

enhanced recovery principles to minimize first exposure and unnecessarily long exposure to perioperative narcotics.

• Experts have detailed systemic changes to promote opioid sparing management of acute injury and perioperative pain.

• Intense, wide scale education including patients, community leaders, health ancillary workers, all trainees and providers in medicine, and healthcare administrators to align goals and metrics regarding pain management is essential.

• Without serious investment into the economic and mental health infrastructure of communities, the root causes of addiction can not be addressed.