Perioperative Pain Management:  Challenges in the Era of the Opioid Crisis Roy Soto, MD Professor, Oakland University William Beaumont School of Medicine Residency Program Director, Department of Anesthesiology

Case 1 52yo s/p posterior cervical fusion BMI 34 OR pain meds: 0.5mg hydromorphone PACU pain meds: 2.5mg hydromorphone Hospital course: dead within 4hr of arrival on ward

Case 2 12yo boy fell from bike, suffering skull fracture and concussion Intermittently combative, confused, and unconscious in ER and PICU with breath holding spells and desaturation to 80s Morphine infusion hung for sedation… 3/24/17

Case 3

Case 4 Presentation Title Footer 3/30/18

Overview The opioid crisis: scope of the problem How the surgical setting contributes to the opioid crisis Opioid reduction/opioid safety/opioid free Multimodal analgesia The value of education What’s happening nationally, regionally, and locally

What we are NOT discussing today Management of the chronic pain patient Management of addiction/withdrawal

US vs EU 99% undergoing surgery in US are treated with opioids vs ~60% in Europe Hip/ankle fracture patients in the US and Holland: 85% of American and 58% of Dutch patients prescribed opioids in hospital 77% of American and 0% of Dutch patients prescribed opioids after discharge American patients use more opioids yet report more pain than European patients

State of Michigan 1999 to 2016: opioid related deaths increased 17x in MI In 2015: MI reported 11.4M prescriptions for opioids Approximately 115 prescriptions per 100 people 2016: 2335 MI citizens died from drug OD UM research: one in 10 people who weren’t on opioid drugs before surgery become dependent on them after

Pressures for Opioid Use Patients expect zero pain after surgery If they have pain, they expect opioids Surgeons (at times) “sell” an operation as quick, simple, pain free, and minimally interfering with activities of daily living Opioids are simple to prescribe, inexpensive, and pervasive HCAHPS

Pressures for Opioid Avoidance Opioids delay recovery, prolong length of stay, add costs to a health system, and contribute to abuse Opioids increase morbidity and mortality associated with surgical care Opioid abuse has a tremendous public health cost

That was then…

N Engl J Med 1980;302:123-123

608 vs 11

This is now

Anesthesia Pain Challenges Determine quantity of pain Determine quality of pain Determine ability to tolerate side effects Pain control versus side effects “If you give a patient with no pain an opiate, the patient will have nothing but side effects.”

Surgery Pain Challenges Determine if local anesthetics will help Predict pain as activity/recovery change Decipher pain complaints Transition from IV to oral pain medications

Nursing Pain Challenges Decipher pain complaints Comply with satisfaction initiatives Placate demanding patients/families Sift through a zillion order sets Communicate with non-communicative physicians

Potential Patient Groups Elderly Frail Obese Young At risk for opioid-related ADE and/or addiction OSA/snoring Concomitant use of other sedating drugs History of depression/anxiety Pulmonary or cardiac disease Opioid naïve AND opioid tolerant

Potential Surgical Groups Oral Surgery ENT Minor gyn Minor urology Minor plastics Minor ortho Any procedure where a PNB is appropriate

Multimodal Analgesia ASA Practice Guideline on Acute Pain Management (2004) Facilitate safe and effective pain management Maintain patient functional status Unless contraindicated, all patients should receive around-the-clock regimen of NSAIDs, COX-2 inhibitors, or acetaminophen

Opioid Monotherapy 2012 Premier database 8,023,591 surgical and non- surgical inpatients and outpatients received IV opioids 4,081,079 (51%) received opioid monotherapy Reference Data from the hospital research database maintained by the Premier healthcare alliance. July 17, 2013. Soto. PGA Poster Presentation. 2015 29

Naloxone? Presentation Title Footer

Naloxone Presentation Title Footer Anesthesiology. 2013

Hypofentanylemia

Moiniche. Anesthesiology. 2002

Opioid Induced Hyperalgesia?

Remifentanil

Fentanyl Findings: 10mcg/kg group (vs 1mcg/kg) experienced increased cold, pain, and heat sensitivity for 4.5-6.5hr Mauermann. Anesthesiology. 2016

Fentanyl Li. BJA. 2018

Laparoscopic ovarian cystectomy/staging, BMI 56

Alternatives to Hypofentanylemia? Deepening volatile anesthetic Esmolol Lidocaine Labetalol

Non-Pharmacologic Techniques NMDA receptor antagonists Ice, PT, massage, stretching, acupuncture, counseling Acetaminophen Alpha-2 agonists Gabapentinoids acetaminophen clonidine dexmedetomidine gabapentin Pregabalin Local anesthetics NMDA receptor antagonists NSAIDs Steroids bupivacaine lidocaine liposomal bupivacaine ketamine dextromethorphan magnesium celecoxib ibuprofen ketorolac dexamethasone

Patient Education & Pain Management Apfelbaum. Anesth & Analg. 2003

Expectation Management Patients Reporting Selected Profile (%) “Moderate” V + “good” pain relief No side effects + “fair” pain relief “Severe” C + “excellent” pain relief “Mild” C + “good” pain relief “Severe” I + “excellent” pain relief “Mild” I + “good” pain relief “Moderate” N + “good” pain relief “No” N + “fair” pain relief “Severe” D + “excellent” pain relief “Mild” D + “good” pain relief Gan. Br J Anaesth. 2004

NY Times, 1/27/18

Provider Education Webinars? Live presentations? +/- CME/CE offerings? Surgeon Anesthesia Nursing Dental Primary care Midlevel providers Live presentations? +/- CME/CE offerings? +/- CME/CE requirements? Print vs. digital vs. social media?

https://opioidprescribing.info/

Remaining Challenges Unifying/educating surgeons Educating patients (the Hospital Marketing Machine) Access to “better” drugs (Ofirmev? Exparel?) Overcoming voodoo prejudices (Toradol causes bleeding, steroids hurt healing) Overcoming culture of opioids … hypofentanylemia Overcoming Americana

Perioperative Opioid Touchpoints

Questions Sufentanil nanotab Fentanyl Ionsys