Perioperative Pain Clinic

Padma Gulur MDProfessor of Anesthesiology, Duke University

Vice Chair, Operations and Performance

Duke Anesthesiology

DisclosuresNONE

Talking points….

1. Establish the gaps in healthcare today as they pertain to perioperative pain management

2. Elucidate the rationale for pre-operative optimization and ongoing perioperative support for high risk populations

3. Discuss the optimal infrastructure required to establish a perioperative pain clinic.

4. Review the outcomes from a Perioperative Pain Clinic

1 IN 12 PATIENTS ADMITTED ARE OPIOID

TOLERANT (>60MG OME) AT TIME OF

ADMISSION

Length of Stay : No statistical difference

30 day all cause Readmissions: Increased

30 day ED visits: Increased

Adverse Events: Increased

HCAHPS : Significantly lower satisfaction

Burning Platform

Influencing Outcomes -Unique ConsiderationsLogarithmic growth of opioid prescriptions

PATTERNS OF POST HOSPITALIZATION OPIOID PRESCRIBING

1 – Year Follow up on Opioid Use Post Hospitalization

Post operative use of OpioidsDuke IRB approved Study

• 99 nephrectomy and prostatectomy cases performed during January to March 2017.

• 61 responded to survey.• On average patients used 30%

of their prescription• Most patients retain their unused

opioids

Customized Discharge

Prescriptions

Patients with unused opioids

43

Retained 32

Toilet 6

Trash 3

Police 1

Buried 1

Recommended Prescription Amounts

5mg oxycodone

Laparoscopic 11

Open 20

More than analgesic optimization…

Perioperative pain management

Goals of Care

• Optimal pain management • Early mobilization • Reduce length of hospital stay• Patient satisfaction.

Preoperative Optimization• Psychological OptimizationScreen for Fear Avoidance, Catastrophizing, Mental HealthConsider Cognitive Behavioral Therapy, Relaxation response

• Medical OptimizationEvidence to support opioid weanEnhance multimodal approach

• Physical Optimization• Prehabilitation• Nutrition

The optimal strategy for perioperative pain control consists of multimodal therapy to minimize the need for opioids

Increased preoperative opioid consumption, Modified Somatic Perception Questionnaire score, and Zung Depression Scale score prior to undergoing spine surgery predicted worse patient-reported outcomes. This suggests the potential benefit of psychological and opioid screening with a multidisciplinary approach that includes weaning of opioid use in the preoperative period and close opioid monitoring postoperatively.

Lee D,.Preoperative Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in Patients Undergoing Spine Surgery. J Bone Joint Surg Am. 2014 Jun 4;96(11):e89. Epub 2014 Jun 4

Patients with a history of chronic opioid use who successfully decreased their use of opioids before surgery had substantially improved clinical outcomes that were comparable to patients who did not use opioids at all.

Nguyen LC et al Preoperative Reduction of Opioid Use Before Total Joint

Arthroplasty. J Arthroplasty. 2016 Sep;31(9 Suppl):282-7.

Preoperative Opioid Wean, Psychological Screen:Increasing Evidence of Benefit

Opioid use is common before abdominopelvic surgery, and is independently associated with increased postoperative healthcare utilization and morbidity. Preoperative opioids represent a potentially modifiable risk factor and a novel target to improve quality and value of surgical care.

Cron DC et al Preoperative Opioid Use is Independently Associated With Increased Costs and Worse Outcomes After Major Abdominal Surgery. Ann Surg. 2017 Apr;265(4):695-701

Modalities Advantages

Epidural opioida + local anestheticb

• Improved pain scores

Peripheral nerve blocksb

• Generally, improved pain reliefand lower analgesic consumption compared with saline

Intra-articular blocksb

or opioidsa• None noted compared with saline

Infiltration of incisionsb • Generally, improved pain reliefand lower analgesic consumption compared with saline

Drug Pain IntensityAnalgesic Opioid

Consumption

Opioid-related Side

Effects

Ketamine

Gabapentin

IV Lidocaine

Systemic α2 agonist

Modalities Advantages

Acetaminophen(oral, rectal, injectable)

• Similar benefit to intravenous (IV) PCA opioid

• Fewer ADRs

Injectable NSAIDs • Improved pain scores• Reduced analgesic use

Oral NSAIDs (both non-and selective)

• None noted

Neuraxial and Regional Techniques

Multimodal Analgesia

Shankar R et al. Anaesth Crit Care Pain. 2013;13(5):152-157.

Perioperative Pain Mangement Principles

• The panel concluded that optimal postoperative pain management begins in the preoperative period • Recommended multimodal regimens in many situations, although the exact components will vary depending on the patient, setting, and surgical procedure.Chou te al J. Pain 2016

MUSIC THERAPY

TAI CHIICE

MOIST HEAT

ACUPRESSURE

THERAPEUTIC MASSAGE

ACUPUNCTURE

COGNITIVE BEHAVIORAL THERAPY

EXERCISE THERAPY

BIOFEEDBACK

AROMATHERAPYNON PHARMACOLOGICAL

STRATEGIES

Health Care Delivery Models

Perioperative Pain Care Continuum

• Staffed by the same faculty team as the Inpatient Pain Service• Coordinate patients’ pain control before, during and up to 90 days following their

hospital stay• Multimodal approach

Nutrition experts Pain psychologists Physical therapists

• Pharmacogenetic testing

Perioperative Pain Care ClinicStarted March 2017 at DUH

Referring Departments

0

5

10

15

20

25

Mar Apr May Jun Jul August

Perioperative Pain Care Clinic Volume

Patients seen per day Patients scheduled per day

Preoperative Opioid Reduction

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30 days Average days patients seen before surgery.13.5% Average reduction in opioid dose before surgery.32% Average reduction in opioid dose from first preop POP visit to 90 days post op

Perioperative Pain Care Clinic

Patients referred to the Perioperative Pain Clinic preoperatively have improved Observed length of stay vs Expected

compared to patients who were referred postoperatively.

Perioperative Pain Care ClinicOutcomes

Length of Stay ED Visits and Readmissions

Patients referred to the Perioperative Pain Clinic preoperatively have decreased ED

visits and Readmissions compared to patients who were referred postoperatively.

MATCHED CONTROLSPROPENSITY

Page 20

Exclusion Criteria

Pre surgical perioperative Pain Clinic: 85Historical controls: 50,260

Required 30 day outcome data

Perioperative Pain Clinic: 34

41 removed

11,163 removed

Historical controls: 39,097

Same list of DRG codes in Pain clinic cohort

(31 unique DRG’s in cohort)

33,351 removed

Historical controls: 5,746 Perioperative Pain Clinic: 34

Mirrored time frame

4,397 removed

(January –August 2017)

(January –December 2016)

Historical controls: 1,349 Perioperative Pain Clinic: 34

Courtesy John Hunting and Yi-Ju Li

LOS Index

Median (IQR)Control: -1.21 (-2.81, 0.52) Referral: -1.10 (-2.08, 0.87)

P-value = 0.70

LOS: observed LOS – expected LOS

30 Day Readmissions and 30 Day ED

The Periop Pain Group showed lower 30 day and 90 day readmissions and ED visits.While these were not statistically significant yet when compared to a propensity matched historical 2:1 cohort, we believe as the ‘n’ for the perioppain group increases this will be influenced

Control Referral

30 Day Readmission 8 (12.90%) 2 (6.45%)Control Referral

30 Day ED Readmission 9 (14.52%) 2 (6.45%)

DiscussionThank you

Safe Opioid Prescribing: Implementation of a critical imperative

Padma Gulur MDProfessor of Anesthesiology

Vice Chair, Operations and PerformanceDuke Anesthesiology

DISCLOSURES

NONE

I have no financial interest of any nature or kind in any product, service or company that could be construed as influencing the material presented.

Learning Objectives:

• Understand the impact of regulatory guidelines on patient access and provider workload.

• Evaluate health system strategies to enhance safe opioid prescribing in high efficiency clinical care models with minimal impact on provider workflow.

• Describe resources available to support patients and providers optimize pain management

The U.S. makes up 4.6 percent of the world’s populations but consumes 81 percent of the world supply of oxycodone

4.3 million adolescents and adults reported non-medical use of prescription opioids in 2014

4 out of 5 heroin users started on prescription opioids

1.9 million Americans are addicted to opioid painkillers

Prescription Opioids : State of a Nation

CDC Guidelines 2016:Safe Opioid Prescribing Initiative

• Prescribing Opioids for Chronic Pain for Primary Care Providers in 2016 to provide consistent safe opioid prescribing guidelines

Persistent Opioid UseHigher doses of opioids are associated with higher risk of overdose and death.

Even relatively low dosages—considered to be 20 to 50 morphine milligram equivalents (MME) per day—increase risk.

As such, the guideline recommends starting with the lowest effective dosage, and carefully considering dosages above 50 or 90 MMEs per day.

For treating acute pain, the guideline recommends a quantity no greater than what is needed for the expected duration of pain severe enough to require opioids, specifying that three days or less will often be sufficient and more than seven days will rarely be needed.

Role of Prescribing Opioids and Overdose Deaths

*Death rate, 2013, National Vital Statistics System. Opioid pain reliever sales rate, 2013, DEA’s Automation of Reports and Consolidated Orders System

• Legislation limiting opioid prescriptions debuted early in 2016, with Massachusetts passing the first law in the nation.

• By the end of 2016, seven states had passed legislation limiting opioid prescriptions, and the trend continued in 2017.

• More than 30 states considered at least 130 bills related to opioid prescribing in 2016 and 2017.

• 24 states had enacted legislation with some type of limit, guidance or requirement related to opioid prescribing by December 2017.

Opioid regulations by State : Prescribing Policies

Additional State Laws and Regulations

PDMP• Mandate PDMP registration for providers, • Determine who can access the PDMP on behalf of

prescribers,• Set the length of time within which to report

dispensing of prescriptions,• Establish requirements for checking the PDMP

before prescribing.

NALOXONE• Allowed third-party prescriptions,• Naloxone standing orders • Pharmacists to dispense naloxone without a

prescription. • Expanded who is allowed to carry and use

naloxone, such as family and friends, school personnel, law enforcement and emergency/first responders.

PAIN CLINICSState legislators have also considered legislation related to pain clinics—facilities that specialize in treating chronic pain. Pain clinic laws often focus on licensing, regulation or other requirements.

Provider EducationStates have also created requirements for training or education for providers related to opioids, such as training in prescribing controlled substances, pain management and identifying substance use disorders.

More than 1,300 bills on opioid related topics from 2015 to 2017.

New CME requirement

• NCMB has a new requirement for physicians and PAs to earn CME in controlled substances prescribing –Total of 3 hours in your CME cycle (eg: 3 years for Physicians)

Primary objectives: • Reduce inappropriate opioid prescribing

and associated patients deaths and harm• Improve quality of care• Effective date: July 1, 2017

REQUIRED TOPICS• Controlled substances

prescribing• Chronic pain management• Avoiding abuse/diversion

States with pain CME requirements:California North CarolinaMassachusettsIowaTexasOregonRhode IslandWest Virginia

E-Prescribing

Storage and Disposal

Proper Storage and Disposal of Prescription opioids and other controlled substances.

Keep your medication in the container it came in, tightly closed, and out of reach of children in a locked location. Talk to your pharmacist about the proper disposal of your medication. In addition

below are resources you can use to safely dispose of your medications.

What to do with Leftover Medicines

NORTH CAROLINA Follow the links below to find locations and guidance for safe drug take-back and disposal options in your state.

Indicates that a collection site is located within a police station/law enforcement facility.

Indicates that a collection site is located within a pharmacy.

HISTORICAL PERSPECTIVES

“In two persons suffering apparently from the same kind of injury, and with the same detriment, one will writhe with agony, whilst the other will smile with contempt.”

Guthrie, G. J.: A Treatise on Gunshot Wounds, London, Burgess & Hill, 1827, p. 3

Peninsular Wars, 1827

Relationship of Significance of Wound to Pain Experienced

• The frequency of pain severe enough to require a narcotic was studied in 150 male civilian patients and contrasted with similar data from a study of wartime casualties.

• The percentages of patients desiring narcotics were 32 and 83 for the military and the civilian groups respectively.

• The intensity of suffering is largely determined by what the pain means to the patient.

• It also means that the indiscriminate administration of powerful analgesics to all injured individuals is unsound.

Henry K. Beecher, M.D., Boston

CURRENT UNDERSTANDING

OF PAIN

What we are Beginning to Understand…

• Pain is influenced by many interacting processes

• The relationship between injury and pain is highly variable.

• Knowledge of etiology of pain is not sufficient to tell us how much pain a person will have or how much it will debilitate them.

BIOMEDICAL APPROACH –

ANALGESIC AGENT BASED

Analgesic Selection

• The appropriate choice of analgesic agent is best guided by the severity of the pain.

• For mild to moderate pain, use of non-opioids like acetaminophen, ibuprofen or another non-steroidal anti-inflammatory drug (NSAID) may provide adequate pain relief.

• For moderate to severe pain, use of an opioid analgesic may be necessary.

• Understanding the types of pain allows for optimal pharmacologic treatmentTreat Nociceptive pain with nonsteroidal anti-inflammatory drugs (NSAIDs)Neuropathic pain responds to neuropathic pain medications such as gabapentin or pregabalin

Optimize Use of Adjuncts

• NSAIDs• COX-2 inhibitors• Acetaminophen• Neuropathic pain medications• Regional anesthesia/analgesia

Neuropathic Pain Medications

• Antidepressants– TCAs: amitriptyline, nortriptyline– SNRI’s like Venlafaxine and Duloxetine

• Anticonvulsants– Gabapentin, Pregabalin (Lyrica)

• Others like Ketamine, Lidocaine etc

Treatment of Severe Pain with Opioids

Titrating Doses of Opioid Analgesics

• To optimally calculate and titrate doses, it’s often easiest to convert to "oral morphine equivalents" (convert all opioids to same amount that would be given in oral morphine)

• If using online calculators verify reliability of the source

49

Choice of Opioid influences OutcomesMorphine is less ‘reinforcing’ or ‘likable’ than Hydromorphone and preferred in patients with risk factors for dependence/addiction.

OPIOIDS – UNIQUE CHALLENGES

Opioid Induced Hyperalgesia

• Defined as a state of nociceptive sensitization caused by exposure to opioids.

• The condition is characterized by a paradoxical response whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to certain painful stimuli.

• The type of pain experienced might be the same as the underlying pain or might be different from the original underlying pain.

• Could explain loss of opioid efficacy in some patients.

Lee M, et al. A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician, 2011; 14:145-161.

Opioid Related Adverse Events

Journal of Palliative Care, Oderda et al• Large-scale analysis of a national database of patients from 380 hospitals in the

United States who underwent 319,898 inpatient surgeries and received opioids for postsurgical pain management.

Key findings• Were hospitalized 3.3 days longer than patients without an ORAE (7.6 days vs.

4.2 days, P<0.0001) • Had a $4,707 mean increase from the baseline hospitalization cost compared

to patients without an ORAE ($22,077 vs. $17,370, P<0.0001) • Had a significantly greater 30-day, all-cause readmission rate (15.8 percent

vs. 9.4 percent, P<0.0001) compared to patients without an ORAE

Oderda GM, Gan TJ, Johnson BH, Robinson SB. Effect of Opioid-Related Adverse Events on Outcomes in Selected Surgical Patients. J Pain Palliat Care Pharmacother. 2013; 27:62-70.

Post operative use of Opioids in UrologyDuke IRB approved Study

• 99 nephrectomy and prostatectomy cases performed during January to March 2017.

• 61 of these patients agreed to answer our survey questions.

• Most patients received a standard prescription for Oxycodone 5mg tabs, quantity 30 at discharge

• On average patients used 30% of their prescription• The few patients that used all of their prescriptions,

did so either because they suffer from chronic pain or they misunderstood PRN and took it scheduled.

Criteria Average# pills used 13

% prescriptionused

36

Customized Discharge

Prescriptions

Pain management in the Substance User

1. Opioid tolerance can be with acute exposure as well as chronic exposure to opioids. The patients increasing requirements usually help define their tolerance.

2. Opioid tolerant patients should be continued on their home dose long acting medications and will require higher doses and frequency of short acting opiates to manage their acute pain.

3. For patients on Methadone maintenance programs, continue their methadone at home doses and treat the acute pain with other opioids just like other opioid tolerant patients.

4. For patients on Suboxone, for elective procedures discontinue it and replace with full opioid agonist prior to the procedure. For emergencies continue the suboxone and realize they will require high doses of opioid agonists in a monitored settings.

DISCUSSIONQuestions