I do not have Post Surgical Pain Management have)...Inguinal hernia 9–43% #- ... • Treatment options for postoperative pain • Discuss plan and goals for postoperative pain •

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#FSHP2019

Post Surgical Pain ManagementPost Surgical Pain ManagementWilliam Terneus Jr, Pharm.D, BCCCP, BCPSPharmacy Site ManagerCleveland Clinic Tradition Hospital

#FSHP2019DisclosureDisclosureI do not have (nor does any immediate family member have):

– a vested interest in or affiliation with any corporate organization offering financial support or grant monies for this continuing education activity

– any affiliation with an organization whose philosophy could potentially bias my presentation

#FSHP2019Objectives

1. Describe the common complications associated with post-surgical pain management.

2. Discuss various pharmacologic acute treatment options, including ERAS.

3. Discuss various options for the post-acute setting (ambulatory).

#FSHP2019Opioid Crisis• Every day more than 116

deaths due to opioid overdose.

• Misuse of prescription pain relievers, heroin, and synthetic opioids.

• Economic burden of prescription opioid abuse alone is $78.5 billion a year.

U.S. Dept. of Health and Human Services.Opioid Overdose Crisis. National Institute on Drug Abuse

#FSHP2019Poorly Controlled Postoperative Pain

• More than 80% of patients experience acute postoperative pain

• 88% of those patients report the pain severity as moderate, severe, or extreme.

• Less than 50% of patients report adequate postoperative pain relief.

1.Apfelaum JL, Chen C, Mehta SS, Gan TJ: Postoperative pain experience: Results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg 97:534-540.2. Gan TJ, Habib AS, Miller TE, White W, Aapfelbaum JL: Incidence, patient satisfaction, and perceptions of post surgical pain: Results from a US national survey. Curr Med Res Opin 30:149-160, 20143. Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Research. 2017; 10:2287-2298.4. Institute of Medicine. Relieving Pain in America: A blueprint for transforming prevention, care, education, and research. Washington: National Academies Press; 2011

#FSHP2019Continued Increases • Surgical procedures continue to

increase annually.• Freestanding ambulatory

surgery centers increased by 300% from 1996 to 2006.

• American adults suffering from at least one painful condition increased from 120.2 million in 1997 to 178 Million in 2014

National Quality Forum. Surgery 2015-2017 Final Report. April 2017.National Center for Complementary and Integrative Health. Two decades of data reveal overall increase in pain, opioid use among U.S.Adults. February 13, 2019.

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#FSHP2019

Comparison of pain intensities between surgical specialties. Worst pain and pain during movement since surgery were assessed on the first postoperative day.

Pain Intensity on the First Day after Surgery:A Prospective Cohort Study Comparing 179 Surgical Procedures. Anesthes. 2013;118(4):934-944.

Pain Intensity by Procedure#FSHP2019Consequences of Poorly Controlled

Postoperative pain• Inadequately controlled pain negatively affects:

• Morbidity• Quality of life• Function• Delayed recovery time• Risk of post-surgical complications• Prolonged duration of opioid use• Higher health-care costs

• Presence and intensity of acute pain during or after surgery is predictive development of chronic pain.

Kehlet H, Jensen T, Woolf C: Persistent postsurgical pain: Risk factors and prevention. Lancet 367:1618-1625.Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Research. 2017; 10:2287-2298.

#FSHP2019Chronic Postoperative Pain (CPOP) • Definition by Macrae and Davies in

1999• Must have developed after surgery• Pain lasts at least 2 months in

duration• Other causes for the pain have

been excluded• Possibility that the pain is

continuing from a pre-existing problem be excluded

Correll D. Chronic Postoperative pain: recent findings in understanding and management. Version 1. F1000RES 2017.

• Definition by Werner and Kongsgaard in 2014

• Develops after a surgical procedure or increases after surgical procedure

• At least 3-6 months duration• Significantly affects quality of life• Continuation of acute post surgery

pain • Localized to the surgical field,

projected to innervation territory• Other causes excluded

#FSHP2019Chronic Postoperative Pain incidence by procedure

Surgery CPOPincidence

Moderate-to-severeCPOP incidence

Abdominal * 17–31% # -Breast 30–60% ‡ 14%

Cardiac 4–43% ‡ -Hysterectomy 26% 9–10%Inguinal hernia 9–43% # -Orthopedic 19–22% -Outpatient + 15% -

Total knee arthroplasty 16–58% 22%Thoracotomy 39–57% # -

Thyroidectomy 37% -

* liver donation, laparoscopic colorectal, emergency laparotomy, and abdominally based autologous breast reconstructionshoulder replacement and ankle or wrist fracture repair

+ those with highest risk are urology, general, plastic, and orthopedic# no decrease in incidence over time‡ decrease in incidence over time

Affects 10 % to 60% of patients after common operations.

#FSHP2019Chronic Postoperative Pain

• Multiple mechanisms for chronic pain development• Inflammatory processes• Tissue and nerve damage• Central sensitization

Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Research. 2017; 10:2287-2298.

#FSHP2019Acute Pain Progressing to Chronic Pain

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#FSHP2019Risk Factors for Chronic Postoperative Pain• Significant predictive risk factors

• Type of surgery• Presence and intensity of postoperative pain

• Other factors• Younger age• Females • Obesity• Smoking• Genetic predisposition• Pre-existing pain• Psychological factors (preoperative anxiety and depression)• Duration of surgery

Gan TJ. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Research. 2017; 10:2287-2298.

#FSHP2019Incidence of New Opioid Continuation by Surgical Specialty

Bicket MC et al., Association of new opioid continuation with surgical specialty and type in the United States, The American Journal of Surgery, https://doi.org/10.1016/j.amjsurg.2019.04.010

#FSHP2019Enhanced Recovery After Surgery (ERAS)• What is it?

• Enhanced recovery after surgery• Umbrella Term for over 20 perioperative evidenced based

recovery protocols• Team based approach with Preop, Intraop and Post op phases

• Pharmacologic options• Multi modal pain management• Control of nausea vomiting

• Nonpharmacologic options• Physical therapy, Nutrition

#FSHP2019ERAS Surgery Specific Guidelines

• Gynecologic/oncology• Gastrectomy• Radical cystectomy for bladder cancer• Pancreaticoduodenectomy• Major Head and Neck Cancer Surgery With

Free Flap Reconstruction• Esophagectomy

• Elective Rectal/Pelvic• Elective Colorectal• Breast Reconstruction• Lung • Liver • Bariatric

Enhanced Recovery After Surgery Guidelines http://erassociety.org/guidelines/list-of-guidelines/

#FSHP2019

ERAS® Society website

#FSHP2019

https://www.aana.com/practice/clinical-practice-resources/enhanced-recovery-after-surgery

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#FSHP2019Preoperative Education

• Patient and family centered education• Tailored education to the patient (or caregiver)

• Treatment options for postoperative pain• Discuss plan and goals for postoperative pain

• Benefits• Reduced opioid consumption • Less preoperative anxiety• Fewer requests for sedative medications• Reduced length of stay

Management of Postoperative Pain: A Clinical Practice Guideline. Journal of Pain. February 2016, Volume 17, Issue 2, Pages 131-157

#FSHP2019Preoperative Evaluation

• Preoperative evaluation should include:

• Assessment of medical and psychiatric comorbidities

• Concomitant medications• History of chronic pain• History of substance abuse• Previous postoperative treatment

regimens and responses• Utilize the Opioid Risk Tool


#FSHP2019Pain Management Plan• Individually tailored developed with:

• Shared decision making approach with patient (or caregiver).• Evidence regarding effective interventions for the specific surgery. • Ability to be modified by factors unique to the patient including:

• Previous experiences with surgery and postoperative treatment • Medication allergies/intolerances• Cognitive status• Comorbidities• Preferences for treatment• Treatment goals

• Adjusted based on reassessmentsManagement of Postoperative Pain: A Clinical Practice Guideline. Journal of Pain. February 2016, Volume 17, Issue 2, Pages 131-157

#FSHP2019Multimodal Management Plan• Target different mechanisms of action in the peripheral and/or central nervous

system with the use of: • Analgesic Medications • Techniques• Non-Pharmacological interventions

• Since this concept’s introduction in 1993, the combined use of local and regional anesthetics, different classes of nonopioid pharmacologic agents, such as NSAIDs, COX2 inhibitors, NMDA-receptor antagonists, and antiepileptics, and opioid analgesics, has become a widely accepted means of reducing acute postoperative pain while limiting perioperative opioid consumption and opioid-related AEs.

Kehlet H, Dahl JB The value of "multimodal" or "balanced analgesia" in postoperative pain treatment.. Anesth Analg. 1993 Nov; 77(5):1048-56.

#FSHP2019Options for Components of Multimodal Therapy for Common Surgeries


#FSHP2019Pharmacological Post Operative Therapies-Opioids• Oral over intravenous administration of opioids in patients

who can tolerate oral route. • Initially pain is continuous and often requires around the clock

during first 24 hours. • Long acting opioids are not generally recommended for

post operative pain• Pre-operative opioids not recommended• Intramuscular administration for opioids not

recommended.Management of Postoperative Pain: A Clinical Practice Guideline. Journal of Pain. February 2016, Volume 17, Issue 2, Pages 131-157

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#FSHP2019Pharmacological Post Operative Therapies-Patient Controlled Analgesia

• Used when parenteral route is needed• Parenteral therapy needed for more than a few hours and

adequate cognitive function. • PCA recommended over health care provider-initiated

intermittent bolus dosing of opioids. • Opioid naive adults should not receive basal rates.


#FSHP2019Pharmacological Post Operative Therapies- Acetaminophen and NSAIDS• Recommend acetaminophen and/or nonsteroidal anti-

inflammatory drugs (NSAIDS)• Less postoperative pain or opioid requirements• Combination of acetaminophen and NSAID might be

more effective than either drug alone • IV or Oral? • Consideration for preoperative celecoxib in adult patients

without contraindications• 200 to 400mg administered 30 minutes to 1 hour pre operatively.


#FSHP2019

• Guideline recommended as a component of multi-modal analgesia

• Reduction in postoperative pain and opioid requirements• Pre-operative

• Gabapentin: 600 or 1200mg administered 1-2 hours pre-op• Pregabalin: 150 or 300mg administered 1-2 hours pre-op

• Post-Operative• Gabapentin: 600 mg as a single or in multiple doses• Pregablain: 150 or 300 mg

• Dose reductions in renally impaired

Pharmacological Post Operative Therapies-Gabapentin/Pregabalin


#FSHP2019Pharmacological Post Operative Therapies- Other• Ketamine (Pre-op:0.5mg/kg Intra-Op: 10mcg/kg/min w/ or

w/out postoperative infusion at a lower dose)• Associated with decreased post-op pain • Decreased risk of persistent postsurgical pain• Useful in opioid tolerant patients or patients difficulty tolerating opioids

• Intravenous Lidocaine (100-150 mg bolus followed by 2-3 mg/kg/hr)

• Open and laparoscopic abdominal surgery• Shorter duration of ileus• No recommendation for post-op


#FSHP2019Pharmacological Post Operative Therapies- Local Anesthetic/Peripheral Regional Anesthesia

• Local Anesthetic• Surgical Site Specific with evidence demonstrating benefit• Providers should be knowledgeable in specific local anesthetic

techniques• Peripheral Regional Anesthesia

• Surgical site specific with evidence demonstrating benefit• Providers should be knowledgeable in specific local anesthetic

techniques• Neuraxial Therapies

• Major thoracic and abdominal surgeries • Appropriate perioperative monitoring


#FSHP2019

Carmichael JC et al. Dis Colon Rectum 2017;60:761-784

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#FSHP2019Management of Postoperative Pain in Patients Receiving Long Term Opioid Therapy

• Conduct preoperative evaluation to determine preoperative opioid use and doses

• Provide education regarding use of opioids before surgery • Recognize that postoperative opioid requirements will typically be

greater and that pain might be more difficult to control • Consider pain specialty consultation (and in some cases behavioral

and/or addiction consultation) for pain that is difficult to manage and complex cases


#FSHP2019Management of Postoperative Pain in Patients Receiving Long Term Opioid Therapy

• Consider nonpharmacological interventions • Transcutaneous electrical nerve stimulation• Cognitive–behavioral therapies

• Consider nonopioid systemic medications • Gabapentin or pregabalin • Ketamine

• Consider local anesthetic-based peripheral regional and neuraxial local analgesic techniques

• Consider PCA with basal infusion of opioids for difficult to manage pain with appropriate monitoring

• Provide education and instructions on tapering opioids to target dose after discharge


#FSHP2019Perioperative Intravenous Methadone

• Murphy et al performed a randomized, double-blinded control trial evaluating 120 patients undergoing spinal fusion

• Randomized and blinded to:• Methadone 0.2mg/kg at the start of surgery or• Hydromorphone 2mg at surgical closure

• Primary Outcome• Intravenous hydromorphone consumption on postoperative day 1

• Secondary Outcomes• Pain scores and satisfaction measured at PACU admission, 1, and 2 hour post

admission, and mornings and afternoons on postoperative days 1 to 3• Hemodynamic variables, potential opioid-related complications, and overall

patient satisfaction

Murphy GS, Szokol JW, et al. Clinical Effectiveness and Safety of Intraoperative Methadone in Patients Undergoing Posterior Spinal Fusion Surgery. Anesthesiology 2017; 126:822-33

#FSHP2019Perioperative Intravenous Methadone• Results

• Similar preoperative characteristics• Patients in both groups treated with hydromorphone PCA then transitioned to

hydrocodone 10mg/325mg APAP


#FSHP2019Perioperative Intravenous Methadone• Mean Visual Analog Scores (reported at rest, coughing and

with movement)• Lower in the methadone group compared to the hydromorphone

group • Patient satisfaction scores

• Overall satisfaction with pain management was higher in the methadone group from PACU admission through the morning of POD 3

• Adverse Effects • No differences in the incidences of nausea, vomiting, itching,

hypoventilation, or hypoxemic events• No differences in sedation scores, respiratory rates, peripheral oxygen

saturation measurements, and mean arterial pressures


#FSHP2019Transition to Outpatient

• Discharge education on Pain treatment plan• Indications• Opioid tapering• Non opioid utilization• Stool softeners/laxatives• Drug interactions• Appropriate disposal• Coordinated follow up appointments

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#FSHP2019Florida CS/CS/HB 21

• Effective July 1st 2018• Opioid 3-day supply or up to a 7-day supply under special

circumstances.• Must use the PDMP for prescribing or dispensing controlled

substances.• All licensed physicians authorized to prescribe controlled

substances must take a board approved 2-hour CE course

#FSHP2019Other Modalities

• Physical Modalities• Transcutaneous electrical nerve stimulation (TENS)

• Weak recommendations , moderate evidence• Acupuncture, massage, cold therapy, or heat therapy

• No recommendation due to insufficient evidence

• Cognitive-Behavioral Modalities• Guided imagery and other relaxation techniques, hypnosis, and

music. • Weak recommendation, moderate quality evidence


#FSHP2019Future Therapies

• HTX-011 (extended release bupivacaine and meloxicam)• FDA Fast Track designation• Under Priority Review• Currently studied in hernia repair, abdominoplasty,

bunionectomy, total knee arthroplasty and breast augmentation• SABER®-bupivacaine (extended release biodegradable

depot)• Phase 3 clinical trials• 72 hour release

#FSHP2019Summary• Inadequate post operative pain control still undertreated• Undertreated pain can lead to post operative complications

and lead to chronic postoperative pain• ERAS refers to surgical specific protocols to enhance recovery

addressing pain, nutrition, mobility, etc.• May not apply to opioid tolerant patients

• Discharge education, counseling, and follow up on opioid use to minimize adverse outcomes

• Research for new techniques and strategies for opioid sparing or ”Opioid free” surgical procedures

#FSHP2019I would like to thank

• Nisha Mathew, Pharm.D, BCPS

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Documents

I do not have Post Surgical Pain Management have)...Inguinal hernia 9–43% #- ... • Treatment options for postoperative pain • Discuss plan and goals for postoperative pain •