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”
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”
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
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
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
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.