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)

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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…