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
• 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
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?
Over the preceding months, her abdominal pain had been
treated with increasing opioids, up to 80mg Oxycontin TID
360mg
daily PO
morphine
equivalents
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.
Endorsed by 2 separate
pain societies in 1996 -Seemed like a great idea…
Image Credits: Themanualtherapist, psychologyofpain.blogspot.com, pilothealthadvocates.com
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 overdose (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
• 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.
Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today. 2011 Nov;6(11)
Patient Safety
• Difficult to study with RCTs
Patient Safety
• Difficult to study with RCTs
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:
Date of download: 3/26/2013
Copyright © 2012 American Medical
Association. All rights reserved.
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.
• IV opioids had nearly 5x risk
of GI side effects compared
to oral nonopioid analgesics
• Urinary retention
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
Pain Control (Satisfaction)
Analgesic Response
• 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
Dose
Opioid Tolerant
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
Fig. 2
Opioid-induced Hyperalgesia: A
Qualitative Systematic Review
Angst, Martin S.; Clark, J David
Anesthesiology. 104(3):570-587, March
2006.
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.
Copyright © 2013 Anesthesiology. Published by Lippincott Williams & Wilkins.
40
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 control
I. 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
Elective vs. Emergent
http://www.naabt.org/education/buprenorphine_treatment.cfm
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!
Met our 3 goals:
• Improved safety
(no hypotension,
oversedation, or
re-intubation)
• Lowered costs
(bypassed PACU,
abbreviated ICU
stay)
• Optimized
Satisfaction
Satisfaction:
5/5!
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:
oAnesthesiology QA committee
oDr. Paul Hilliard
oMy wife, Stephanie (she’s probably by the pool)
oDepartment of Orthopedic Surgery
oUM Preoperative Clinics
oUM School of Computer Science
oHealth Science Library
oUM Hospital Legal Team
oMiChart Development Team
oECCA (Executive Committee on Clinical Affairs)
References
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be
undermanaged. Anesth Analg. 2003 Aug;97(2):534-40.
Bialosky, JE, Bishop, MD, Cleland JA. Individual Expectation: An Overlooked, but Pertinent, Factor in the Treatment of Individuals Experiencing
Musculoskeletal Pain. Phys Ther. 2010 Sept; 90(9):1345–1355.
Keltner JR, Furst A, Fan C, Redfern R, Inglis B, Fields HL. Isolating the modulatory effect of expectation on pain transmission: a functional magnetic
resonance imaging study. J Neurosci. 2006 Apr 19;26(16):4437-43.
Stomberg MW, Oman UB. Patients undergoing total hip arthroplasty: a perioperative pain experience. .J Clin Nurs. 2006 Apr;15(4):451-8.
Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association Between Opioid Prescribing Patterns and Opioid
Overdose-Related Deaths. JAMA. 2011;305(13):1315-1321
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.
Overdyk FJ, et al. Improving outcomes in med-surg patients with opioid-induced respiratory depression. American Nurse Today. 2011 Nov;6(11)
Weinborum AA, et al. Efficiency of the operating room suite. American Journal of Surgery. 2003;185:244–250
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.
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
The White House. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. http:..www.whitehouse.gov/sites/default/files/ondcp/issuescontent/prescription-drugs/rx_abuse_plan_0.pdf. Accessed October 21, 2012.
Maund E, McDaid C, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related
side-effects after major surgery: a systematic review. Br J Anaesth. 2011 Mar;106(3):292-7.
Brummet C. Management of Sublingual Buprenorphine (Suboxone and Subutex) in the Acute PerioperativeSetting.
http://anes.med.umich.edu/vault/1003149-Buprenorphine_Suboxone__Subutex_Perioperative_Management.pdf#pagemode=bookmarks
Berkowitz, B.A., Finck, A.D., Hynes, M.D. & Ngai, S.H. (1979). "Tolerance to nitrous oxide analgesia in rats and mice". Anesthesiology 51 (4): 309–12
Sawamura, S., Kingery, W.S., Davies, M.F., Agashe, G.S., Clark, J.D., Koblika, B.K., Hashimoto, T. & Maze, M. (2000). "Antinociceptive action of nitrous
oxide is mediated by stimulation of noradrenergic neurons in the brainstem and activation of [alpha] 2B adrenoceptors". J. Neurosci. 20 (24): 9242–51.
Angst, MS & Clark, DJ: Opioid-induced hyperalgesia: A qualitative systematic review. Anesthesiology 2006; 104:570–87
Lee M, Silverman S, Hansen H, Patel V, Manchikanti L. A Comprehensive Review of Opioid-Induced Hyperalgesia. Pain Physician 2011;14:145-161.
Song JW, Lee YW, Yoon KB, Park SJ, Shim YH. Anesth Analg. 2011 Aug;113(2):390-7. doi: 10.1213/ANE.0b013e31821d72bc. Epub 2011 May 19.
Pesonen A, et al. Pregabalin has an opioid-sparing effect in elderly patients after cardiac surgery: a randomized placebo-controlled trial. Br J Anaesth.
2011 Jun;106(6):873-81. doi: 10.1093/bja/aer083. Epub 2011 Apr 6
Tiippana EM, Hamunen K, Kontinen VK, Kalso E. Do surgical patients benefit from perioperative gabapentin/pregabalin? A systematic review of efficacy
and safety. Anesth Analg. 2007 Jun;104(6):1545-56
http://ppsg-production.heroku.com/chart
http://www.cdc.gov/HomeandRecreationalSafety/pdf/poison-issue-brief.pdf
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm#fig1
http://www.medpagetoday.com/Neurology/PainManagement/34650
http://www.cdc.gov/nchs/data/databriefs/db81.pdf
Weinger MB. Dangers of postoperative opioids. APSF Newsletter 2006-2007;21:61-7
Deaths attributable to Heroin, Cocaine and Opioids
This trend continues…
National Vital Statistics System. Multiple cause of death dataset. Available at http://www.cdc.gov/nchs/nvss.htm