S

The Role of Multi-Modal Analgesia and the Burden of Opioids

Jacob Hutchins MDDirector of Regional Anesthesia, Acute Pain, and Ambulatory Anesthesia

Department of AnesthesiologyUniversity of Minnesota

Disclosures/Off-Label

S Speaker’s bureau, consultant, and research funds from Pacira Pharmaceuticals

S Speaker’s bureau for Halyard Health

S Consultant for Atricure

S Consultant for Worrell

S I will talk about off-label medication use but it will be of my own experience

Is Improved Pain Control Needed?

SYes!

Current State of Pain Control

S Pain control remains the number one concern for patients leading up to surgery

S Opioids remain the mainstay of post surgical pain regimens

S Non opioids are often prescribed prn and thus depends on the nurse to give to patient

S Pain as fifth vital sign has led to emphasis on undermedication and less focus on overmedication

Why is Pain Control Important?

S Uncontrolled postoperative pain can lead toS Longer Hospital stay and increased PACU/Phase 1 timeS Readmissions for painS Decreased satisfaction and quality of lifeS Progression to chronic painS Major stress response from body

S Increased sympathetic toneS Increased Heart rate and blood pressureS HypercoagulabilityS Decreased Immune functionS Urinary retentionS Endocrine changes: increased ACTH, cortisol, epinephrine, aldosterone, ADH, Ang

IIS Decreased GI motility

Risk Factors for Acute Postoperative Pain

S Females

S Young age

S Increased BMI

S Preop use of opioids

S General anesthesia

S History of Chronic pain

Why Minimize Opioids?

S 70 million patients receive opioids in hospital or clinic following surgery each year1

S Opioids have multiple adverse eventsS Nausea/vomiting, pruritis, constipation, urinary retentionS May play role in cancer recurrence

S JCAHO sentinel event respiratory depression and even death for increased risk patientsS Elderly, OSA, chronic pain, and obese

1. Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.

Oversedation is a problem

Why Minimize Opioids?

S Postoperative opioid use contributes to misuse of opioidsS 1 in 15 patients with acute opioid use go on to long term use1,2

S Due in part to rapid proliferation of new users from acute care setting. S 46 Americans die each day from opioid overdoseS 5.1 million Americans used opioids illicitly last monthS The number of opioid/heroin related deaths in Minnesota each year

is similar to number killed in MVA

1. Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30.2. Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702.

Why Minimize Opioids?

S 18% of opioid naïve patients were still on opioids 1 year after elective spine surgery

S 6% of patients after orthopedic procedures were still on opioids 150 days after surgery

United States’ Opioid Problem Our Elderly and Children are at Risk

S In patients ˃65 undergoing low-risk surgery who received an opioid Rx within a week of surgery 1:

S were still taking opioids a year later

S There was a in the likelihood they would become long-term opioid users

S Compared to non-athletes, adolescents males who participate in organized sports have2:

1.Alam A, et al. Arch Intern Med. 2012;172:425-30. 2. P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340

10.3%44% ↑

2x 4x 10xthe odds of misusing opioids to get high

the odds of medical misuse of opioids due to taking too much

the risk for being prescribed an opioid medication

Overprescription Leads to a High Potential for Diversion

S In patients undergoing outpatient upper extremity surgery1

1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am. 2012;37:645-50.

55%Obtained for

free from friend or relative

Prescribed by one Doctor 17.3%

Bought from friend or relative 11.4%

Took from friend or relative w/o asking 4.8%

Got from drug dealer or stranger 4.4%

Other source7.1%

Resulting in Access to Excess Pills From Multiple Sources1

1. Centers for Disease Control. Policy Impact: Prescription Painkiller Overdoses; Nov 2011. Available at: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

Minnesota’s Opioid Epidemic Minnesota’s Opioid Epidemic

Minnesota’s Opioid Epidemic Multiple Organizations Have Urged a Shift Toward Non-Opioid Options

S JCAHO recommends “An individualized, multimodal treatment plan should be used to manage pain—upon assessment, the best approach may be to start with a non-narcotic”

S CDC recommends “Health care providers should only use opioids in carefully screened and monitored patients when non-opioid treatments are insufficient to manage pain”2

S ASA recommends “a multimodal approach to pain management—often beginning with a local anesthetic where appropriate”

1.The Joint Commission. Revisions to pain management standard effective January 1, 2015. Available at: http://www.jointcommission.org/assets/1/23/jconline_November_12_14.pdf. Accessed November 19, 2014

2.CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008. Nov 2011;60(43);1487-1492. Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

Multimodal Analgesia

S Utilization of more than 2 analgesics which act at different sites in CNS and PNS

S Goal to Minimize pain as well as minimize opioids

S Should be started prior to surgery and continued in acute postoperative period

S Requires coordination between Preoperative, Intraoperative, and Postoperative periods

S Surgeon, Anesthesiologist, Providers, and Nurses all on same page

Options for Multimodal Analgesia

Sample Multimodal Approach

S SETTING EXPECTATIONS

S Preoperative MedicationS Gabapentin or Pregabalin: started evening before surgeryS Acetaminophen: IV or oral started evening before surgeryS NSAIDs if allowed by surgeonS Regional AnesthesiaS Attempt to minimize opioids preop even with block sedation

Sample Multimodal Approach

S IntraoperativelyS Regional anesthesia if not done in preop phaseS Surgeon Infiltration in select procedures: liposomal bupivacaine or

catheter technique preferredS Minimal Opioids and only short acting (rare need for opioids on

induction and premedication with 2mg versed)S Continue acetaminophen intraop (redose 4 hours after last dose)S Ketorolac at closure if appropriateS Lidocaine, ketamine, or dexmedetomidine infursions where

appropriate

Sample Multimodal Approach

S PostoperativelyS Scheduled Acetaminophen every 6-8 hours for up to

one week post operatively: Oral as soon as ableS Intermittent opioids: Oral as soon as ableS NSAIDS as soon as possible and then scheduled for

up to one week post operativelyS Gabapentin (300mg) or Pregabalin (75mg) continued

for one week S Lidocaine infusions, ketamine intermittent or

infusion, and dexmedetomidine infusion where appropriate.

Additional Multimodal

S Muscle relaxants or Diazepam for muscle spasms

S Topical medications or lidocaine patches for pain

S Non pharmacologic interventionsS Ice to areaS Healing touchS MassageS Pet TherapyS AcupunctureS Relaxation techniques

Regional Anesthesia

S Interscalene: Shoulder procedures

S Supraclavicular: Arm and Hand procedures

S Adductor canal/Femoral: Thigh and Knee procedures

S Popliteal/Distal Sciatic: Foot and ankle

S Lumbar Plexus/Fascia Iliaca: Hip

S Transversus abdominis plane blocks for abdominal procedures

S Pec blocks for breast and chest procedures

S Paravertebrals for thoracic and abdominal procedures

Why Regional Anesthesia?

S Provides Pre-emptive Analgesia

S Decreases likelihood of development of Chronic Pain

S More precise placement of local anestheticS Able to use less local anesthetic in most cases

S Low failure rate

S Quick and low risk to place

S Can be either single injection or catheter infusion

Single Shot

S Can be Long Acting Local AnestheticsS Bupivacaine or RopivacaineS Last 6-12 hours postoperatively

S Or Short ActingS Mepivacaine or LidocaineS Last duration of procedure 1-4 hours

S Additives can extend duration of actionS EpinephrineS ClonidineS DexamethasoneS Dexmedetomidine

Catheters

S Can remain in place for 1-7 days after placement

S Usually run low dose bupivacaine or ropivacaine

S Can titrate to effect

S Allows intermittent bolus

S Risk of dislodgement and infection as are indwelling

Local Anesthetics

S Are an essential part of a multimodal pain control regimen

S Can be used to provide pain control that targets the site of surgery via infiltration of skin and subcutaneous tissue (liposomal bupivacaine)

S Also used for regional anesthesia to target specific peripheral or central nerves (single shot or catheter technique)

S Finally can be given intravenously to provide effective postoperative pain control (IV lidocaine)

Liposomal Bupivacaine

S On-label use for infiltration (surgeon infiltration, TAP, Pec)

S Off-label use for peripheral nerve blocks

S Provides 40-72 hours of analgesia via single shot

S Multivesicular liposome formulation of 1.3% bupivacaine

S Provides Day 1 dense block, day 2 50-75% block and day 3 25-50% blockadeS Minimal motor blockade after day 1S Unable to bolus or titrate dosage

TAP Blocks

S Transversus Abdominis Plane Block

S Provides analgesia to skin muscle fascia and parietal peritoneal layers but not viscera

S Ultrasound Guided and can be done prior to surgery intraoperatively or in PACU

S Catheters can be kept in for up to 7 days, Liposomal Bupivacaine provides 40-72 hours pain relief

Hutchins et al. Ultrasound Guided Subcostal Transversus Abdominis Plane (TAP) Infiltration with Liposomal Bupivacaine for Patients Undergoing Robotic Assisted Hysterectomy: A Prospective Randomized Controlled Study.

Data presented at IARS Honolulu, Hawaii 2015

S Liposomal bupivacaine TAP vs. bupivacaine TAP

S LB TAP had decreased total opioids, decreased nausea/vomiting, and decreased maximal pain at all time points studied.

S Trend towards decreased length of stay (p=0.055) 11 +/- 9.1 hours in LB TAP group vs. 17 +/- 13.9 hours in bupivacaine group.

S No adverse events noted in either group

Paravertebral Blocks

S Unilateral blockade of spinal nerves outside vertebral canal

S Single Shot with Bupivacaine or Liposomal Bupivacaine (off label use) or Catheter

S Injection level depends on surgical site

S Lasts 12-24 (bupivacaine) or 40-72 hours (liposomal bupivacaine) or 72 hours or longer (catheter)

Paravertebral Blocks Pec Blocks

S Pecs 1 targets lateral and medial pectoral nerves

S Pecs 2 targets lateral and medial pectoral nerves, intercostobrachial, intercostals III, IV, V, and VI, and long thoracic nerve

S Used for breast procedures, subclavian TAVR, chest wall, and even thoracic procedures.

Pec Blocks

PM

Pm

PM

SA Pm

Interscalene

S Used for Shoulder and distal clavicle procedures

S Blocks brachial plexus at level of roots/trunks

S Frequent sparing of C8-T1

S 100% will have some phrenic nerve involvementS Perform suprascapular to avoid phrenic

S May cause intermittent Horner’s syndrome

S Single shot (15-25 mL) 6-12 hours

Interscalene Literature Support

S Park et al: Interscalene single shot (ISB) decreased pain scores compared to intraarticular injection

S Lehman et al: ISB superior to GA and GA + ISB in terms of recovery and pain medications used

S Ullah et al: ISB had improved pain control compared to no block and ultrasound ISB had less complications compared to nerve stimulator ISB

S Hughes et al: ISB decreased supplemental analgesics and decreased pain

Supraclavicular

S Useful for surgery below shoulder level

S Blocks brachial plexus at level of divisions

S Misses suprascapular nerve (60-70% of shoulder)

S Risk of Pneumothorax and phrenic nerve involvement

S Single shot (15-25 mL) 6-12 hours

S Catheter not ideal (infraclavicular better position)

Supraclavicular

Brachial Plexus

First Rib

Pleura

A

Literature Support

S Gamo et al: Supraclavicular block permitted operating conditions without general in 99.5% of cases and 96.7% were satisfied with analgesia

S Ahsan et al: 26% failure on day 1 after hand surgery for supraclavicular catheter

S Renes et al: U/S guided supraclavicular decreased diaphragm paralysis compared to nerve stim

S Lam et al: improved satisfaction with distal blocks compared to supraclavicular

Other Brachial Plexus Blocks

S Infraclavicular: good for catheter placement for arm procedures

S Axillary: superficial and may be easier in super obese population as it poses no lung risk.

S Suprascapular and Axilary for shoulder procedures as described by Checucci et al with no phrenic involvement

Adductor Canal

S Useful for TKA, ACL, other knee procedures, and for foot/ankle

S Distal block of Femoral nerveS Saphenous nerve, nerve to vastus medialis, obturator branches

S Block occurs mid thigh

S Decreased quad weakness compared to femoral

S Single Shot (15-20 mL)

Adductor Canal

VastusMedialis

Nerve

Sartorius

A

V

Literature Support

S Jaeger et al: Adductor 8% weakness, Femoral 49% weakness

S Jenstrup et al: Adductor decreased pain and improved PT compared to placebo

S Hanson et al: Adductor catheters provided pain relief up to 48 hours and improved quad strength

S Shah and Jain: Adductor provided improved early ambulation with no difference in pain compared to femoral

S Perlas et al: Adductor plus local infiltration had best early ambulation and highest incidence of home discharge.

Femoral Nerve Block

S Useful for knee surgery, thigh surgery, femoral neck fractures

S Increased weakness of quad compared to adductor canal

S Single shot (15-25 mL)

S Liposomal bupivacaine (off label) Phase 3 data showed improved pain control and no difference in weakness compared to placebo

Femoral Nerve

Femoral Nerve

A

Fascia Lata

Fascia Iliaca

V

Literature Support

S Minkowitz et al: showed femoral with liposomal bupivacaine superior than placebo up to 72 hours after injection with no increased motor

S Luo et al: Femoral nerve block associated with persistent strength deficits at 6 months after ACL repair in pediatric and adolescents

S Chisholm et al: Saphenous equal to Femoral nerve block with regards to analgesia after ACL

S Krych et al: No difference in return to sport for femoral nerve block patients but decreased motor/function at 6 months post ACL

Popliteal/Distal Sciatic

S Block of sciatic nerve just prior or just after split into fibular and tibial divisions

S Useful for calf, tibia, ankle, foot, and toe surgery

S Saphenous is only nerve of foot/ankle not covered by this block

S Blockade of sciatic nerve will cause foot drop (fibular)S Selective Tibial or IPACK blocks will provide back of knee pain relief

without foot drop

S Single shot (20-40 mL)

S Onset of action is slowest of all major nerve blocks

Popliteal/Distal Sciatic

A

Tibial Nerve Fibular Nerve

Literature Support

S Saporito et al: no difference in cost or readmissions in those who had continuous regional block…popliteal block decreased costs and allowed surgery to be performed as outpatient

S Gallardo et al: continuous popliteal block for total ankle arthroplasty decreased pain, decreased opiates, and increased satisfaction

Lumbar Plexus

S Covers T12 to L4

S Useful for hip, femoral neck, and knee surgery

S Deep block and increased patient discomfort compared to other blocks

S Block with increased risk of morbidity and mortality

Lumbar Plexus Literature Support

S Karlsen et al: No best intervention for total hip arthroplasty

S Amiri et al: Lumbar plexus and MAC anesthesia were sufficient for femoral neck fracture surgery

S Lee et al: Continuous lumbar plexus decreased total opioids after total knee replacement

S Nye et al: Continuous lumbar plexus block for hip arthroscopy had risk of significant complications (3.8%)

Fascia Iliaca

S Proximal blockade of lumbar plexus

S High Volume Block

S Useful for femoral neck fractures and total hip replacement (?)

S Allows for ease of spinal placement in femoral neck fractures

Fascia Iliaca

Iliacus Fascia

Ilium

Literature Support

S Foss et all showed FICB decreased Pain scores and opioid use after femoral neck fractures

S Shariat et al no difference between fascia iliaca vs sham for total hip arthroplasty

S Hanna et al: FICB decreased pain after femoral neck fractures

S McRae et al: FICB performed by paramedics for femoral neck fractures decreased pain scores compared to standard of care

Other Lower Extremity Blocks

S Obturator

S Lateral Femoral Cutaneous

S Ankle Blockade