1. 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

2. 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

3. 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

4. Case 3

5. Case 4
Presentation Title Footer
3/30/18

6. 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

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

11. 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

12. 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: 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

15. 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

16. 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

17. That was then…

18. N Engl J Med 1980;302:

19. 608 vs 11

20. This is now

21. 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.”

22. 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

23. 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

25. 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

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

27. 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

29. 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 29

30. Naloxone?
Presentation Title Footer

31. Naloxone
Presentation Title Footer
Anesthesiology. 2013

32. Hypofentanylemia

34. Moiniche. Anesthesiology. 2002

35. Opioid Induced Hyperalgesia?

36. Remifentanil

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

38. Fentanyl
Li. BJA

39. Laparoscopic ovarian cystectomy/staging, BMI 56

40. Alternatives to Hypofentanylemia?
Deepening volatile anesthetic
Esmolol
Lidocaine
Labetalol

41. 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

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

43. 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

44. NY Times, 1/27/18

48. 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?

52. https://opioidprescribing.info/

55. 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

56. Perioperative Opioid Touchpoints

57. Questions
Sufentanil nanotab
Fentanyl Ionsys