Hello, thank you for attending the webinar. My name is Chris Zacco, coming from Penn State Health. I am a neurosurgeon, Associate Professor of Neurosurgery and Director of Neurocritical Care, Vice Chair of Quality, and the Co-Director of the Penn State Spinal Cord Injury Center. And thank you for attending our webinar on Perioperative Pain Management, Is Narcotic-Free America Possible? So first, a word on my disclosures, which I have none. Next is the itinerary for today's talk. First, I just want to set the stage. I know most of you probably know this, but it's worth going over some statistics. And we'll be talking about perioperative opioid weaning, next, weaning narcotics in the dependent patient, and lastly, monitoring opioid consumption and compliance. So as background, 33% to 70% of patients seeking elective surgery are already on chronic opioids. And this generally leads to greater doses and longer courses after surgery. So the question we're all asking ourselves is, is this really because surgery causes a more serious pain generator, or is there something else going on with the physiology? And it could potentially be a little bit of both. Probably some of the best advice I can give you all moving forward is just to have a thoughtful assessment, and this is just something else you consider for your surgery, just like you look at their images and their mobility and the narrowing and the stenosis, to have some idea of what their perioperative opioid use is, and there's various scales out there. On the right, you'll see the Penn State Opioid Conversion Table. On the left is one you can find anywhere to calculate it, but essentially to get their idea of morphine equivalents, and to have that in mind is important moving forward. But generally speaking, just to think about their opioid use prior to surgery quantitatively and thoughtfully is pretty well ahead of a lot of people, and I think it's very important moving forward. So next we'll talk about perioperative opioid weaning. So this is interesting. They're waiting for surgery, but can we wean them off of whatever opioid regimen they're on prior to surgery, and should we? So the reason we should consider this is that chronic opioid use is associated with worse post-operative outcomes, meaning longer length of stay, poor functional recovery, and more complications after spinal surgery, and this has been shown in two different papers, 2014 and you're naming it all in 2020. It's also associated with tolerance, and lastly, opioid-induced hyperalgesia. So this is a real problem in that opioids can increase pain sensitivity by increasing demand from your receptors, increases pain, and then increases demand, and this is obviously something that can be very problematic for us as we operate on patients and try to get them through the perioperative period. So the concept of weaning opioids before surgery has been looked into, and this is something I think we need to share with patients and not just tell them we're trying to wean them off opioids, but why, and that's because there's a growing literature base stating that outcomes are better if this can be done. So you can see there I listed five papers, and I'm sure there's more now about superior outcomes noted in the orthopedic literature, and then below, if you can wean them to 50% of their baseline of their opioid use, then outcomes are improved, and they're comparable to a patient who's opioid naive, and that was shown in a paper in 2016. So I think this is really compelling, and I have found at least over the last two to three years that patients are very much paying attention to this issue, and whereas before it would be a little bit of a struggle to talk them into opioid minimization, now they're actively seeking out that particular aspect because I think we've done our job in ADVERT in promoting how opioids can be a problem. So weaning opioids for spine surgery, I haven't found a lot done, but I think there's enough supporting evidence there. There's a paper in 2016 that does describe a case report of five patients, and they had an improved pain and psychological functioning after surgery of their weaned beforehand. I apologize if I've missed any papers. I did a search and did not find anything new on this specific topic in terms of a study looking at weaning opioids in a planned fashion prior to spinal surgery, but I do think this is a growing body of literature to suggest in theory it would be a good idea. So some adjuncts to weaning, so to help is you advise patients, so right, you don't want to do this in isolation. It's better to have more than one tool, so biopsychosocial spiritual support can enhance resilience and coping skills if you have that available. Psychosensation is important. I think we've all done that in spine surgery. Expectation management is critically important. I think to do this, explain why you want to do this, and talk to the patient through this is really what's helped me best in terms of successfully navigating this rather than just coming across as stingy and not wanting to prescribe opioids. Optimizing nutrition and sleep management, I think there's a lot of compelling data surrounding this, particularly when you look at protocols for enhanced recovery after surgery, how important this is to improving outcomes. And then again, if this resource is available to you, conditioning, rehabilitation, so some rehab prior to surgery can all be helpful. Post-operative pain control in the opioid-tolerant patient, and I would even argue for an opioid-naive patient. Multimodal analgesia is really becoming the mainstay, and it can be very, very much effective for these particular patients. Essentially, for the longest time, we would take one class of medications, opioids, and just use them. If they didn't work, prescribe more, and we didn't take into account the fact that more than one classification of medication, when used together, can help decrease the amount you might need of any one, and this is really important, and it's really effective the more you use it and get comfortable with it. So that's my main recommendation. So one particular problem, though, is, and I think we're getting more, you get more experienced and comfort with this as you move forward, is a lot of people will tell you to maintain the patient on their home baseline morphine equivalent after surgery. Well, now you're right back into prescribing opioids, so it can be a catch-22. There has been some studies that tell you that some patients require 50% or more of their preoperative morphine equivalent daily dose, and this is probably the hyperalgesia we discussed a few slides back. In the opioid-tolerant, it may require four times more than the opioid-naive, and that's published in 2017. So while we do want to try to minimize opioid use, I think initially after surgery in the PACU and maybe the first day, I think you have to be a little bit cautious in how much to cut their preoperative use back, and certainly probably not more by 50% as you may actually precipitate withdrawal. Something that can be really helpful for us is just changing our prescribing practices. So you'll see up to now, 80% of patients receive opioids after low-risk surgery. That was published in 2016, and I think we can all agree that's just too much. Patients receiving opioids after a short-stay surgery have a 44% increased risk of long-term abuse. 67% to 92% of prescribed post-op opioids go unused, and that's remarkable, and hopefully that number's going down, and I get a sense it probably is. 60% of people receiving 90 days of continuous opioid therapy remain on opioids years later. So I can't tell you the last time I prescribed more than two weeks of opioids, to be honest, and then 90 days seems to be a relic of the past, but I think there may be some situations where that happens, but I don't worry about that as much and don't see that happening in our institution. Here's a really interesting study just published in April 2020 that I think is really speaking to what we're talking about, and this is opioid-free spine surgery published by Berkman et al. This was 244 patients, a third of which had lumbar fusions. They did this in stages, and I'll just refer you to the paper for the details, but 47% took no opioids from recovery room departure until one month follow-up in that first stage. In their second stage, 88% took no opioids from recovery room until the first month follow-up. So they clearly demonstrated this is possible. They noted that preoperative opioid use was associated with nearly a five times increased risk of post-operative abuse, and what's interesting is 93% of lumbar fusion patients who are opioid-free prior to surgery did not take a single opioid in the post-operative period. So really, really interesting, really interesting paper showing us what might be possible with concerted effort and patient education. So let me get back to some CDC guideline recommendations. So what they'll tell you is, and I spoke to you about getting an idea how much of a morphine equivalent a patient is on, they'll tell you to reconsider going above that 50 morphine milligram equivalent rate, avoid at all costs, really, going above 90, and then they would comment, at least with these recommendations, that acute pain, that in acute pain, three days of opioids is generally enough, and more than seven days is rarely needed. So I think that's where you're seeing a lot of places in the perioperative period limiting their opioid prescribement to three days at most after surgery, maybe seven days, and to me, the key has been to share this data with the patients ahead of time. Let them know prior to surgery, in clinic, as they're signing consent, this is the strategy moving forward, and it's made things much, much easier. Like I said, most patients are on board with this. So let's talk about weaning-dependent patients. So opioid tolerance, the first thing is identifying the patients at risk. We touched on that a little bit earlier. Opioid tolerance is defined by the FDA as 60 milligram oral morphine equivalent for at least one week. The CDC defines long-term use as any use of opioids, or use of opioids on most days for greater than three months. So that can be a lot of patients, right? So just by that definition, addiction rates are cited between 3% to 16%. Weaning narcotics, independent patients, indications are improved outcomes after surgery, failure to benefit from the use, why if they're not helping, don't give them, they have intolerable side effects, they have severe or recurrent adverse drug-related behaviors, ADRBs, a deterioration of function with the use of the opioids, or they get better and there's resolution of pain causing that original condition. So there's really no identified best way. Slower is better, obviously, but we don't always have the benefit of time. So kind of what I've advised, just looking over some things and what I've used to some success, and again, there's different ways to do this, is to decrease by 10% to 25% every one to four weeks. Longer weanings for patients on greater duration, so if they've been on for years, you're going to want to go slower, and I think that's fairly intuitive. Other weaning schedules I saw mentioned in my literature search was really just reduce the dose to the smallest available dosage, so down to five milligrams oxycodone or even lower, and then start to decrease the frequency. I think we commonly do that, and just empirically. The Veterans Hospital proposed something even a little bit more quantitative, so a 20% to 50% reduction per week of tolerating, but still a pretty wide range, obviously based on how much medications they're on, their tolerance of the wean, and how long they've been on them. And then another way, a 10% reduction every five to seven days until 30% of the original dose is reached, and then 10% weekly until off, for those of you who want a little bit more of a quantitative plan. So for quicker weanings, so you can get to as little as 25% of your daily opioid dose needed to prevent withdrawal if you do that quickly, and you can sometimes get to that within seven days. To do it that quickly is ill-advised, and you should probably consider doing that under inpatient observation. In terms of withdrawal, so physical withdrawal is rare if it's done slowly. Psychological distress can be more common, so concomitant psychological treatments, cognitive behavioral therapy, can be useful. This is lacking for weanings, but exists for detoxification. So the onset of opioid withdrawal timeline is really two to three half-lives of the drug that's being used. So they take their last dose, and then they can start to get some symptoms, as you'll see on this particular slide. So physical symptoms can be at their peak at 72 hours. One week they start to lessen. Two weeks you get some psychological, emotional symptoms. One month you can get some craving and depression. So it's really just good to keep these things in mind as you work through it. I'll be frank. I have not taken someone through an opioid wean and dealt with these things myself. We have a chronic pain team here that does great work and helps with some of those. But certainly having the conversation with them on your goals can help get that ball rolling a little bit quicker than just relying on an electronic medical record and that you hope it happens. So how do you treat withdrawal? Again, not something I've typically done myself, but it's good to have some of these ideas in mind if you need to. So alpha-2 adrenergic agonists like clonidine or tizanidine. Opioids long-term. We've heard of naloxone, bupropionate, naloxone, and methadone. If they're starting to have withdrawal, you can slow or pause your taper. And again, cognitive behavioral therapy we talked about as well, but that sometimes it's not as easy to get, at least at our institution, as you'd like. So monitoring opioid consumption and compliance is the next section. So urine drug monitoring is the most common, and abuse rates for this particular system is 18 to 42 percent. Another way is the prescription drug monitoring programs, and I know we use those very frequently and they're mandated in almost all states at this point, if not all. I know Missouri was a holdout a year ago, and I just looked it up, and I did see they seem to have one at least in St. Louis now. And you can also do random pill counts, and that would help with your compliance to your program. For urine drug monitoring, evidence is limited regarding the overall effect on your outcome, but it's used as supported by expert panels published in 2018. There's two basic types. There's ELISA, which is an immunoassay and mass spectroscopy. So the ELISA is a quick turnaround, and it does have limited values. It may not pick up on all opioid reliability, such as synthetic methadone and fentanyl, and semi-synthetic oxycodone. Mass spec can be used to confirm suspicions, and it can be done after separation technique, either liquid chromatography or gas chromatography. Again, this is where I think it would be good to work with your chronic pain team or your psychiatry group, because some of the interpretations can be a little bit nuanced. So metabolism has to be considered. So hybrid morphine is a minor metabolite of morphine, for example. Morphine is also a metabolite of heroin. So it's also a test for metabolite 6-monoacetylmorphine, or 6-MAM. So these are the various ways you can get some testing done. The specimens, there's urine, blood, hair, sweat, saliva. There's a wide variety of patients that we see. So sometimes you have to have more than one tool. So someone who's on dialysis and doesn't make urine, you obviously would need to use something with your blood. So urine's the easiest. It's non-invasive and cheap. It's well-published and can be point of care. Disadvantages are adulteration and substitution, short window of detection, and limitation of sensitivity and specificity. Blood has immediate detection. It can be used in aneuric patients, but it's expensive and invasive. Hair is obviously, again, minimally invasive. Its window of detection can vary with length. Obviously disadvantage of those with short hair, no hair at all. And then use of hair dyes can alter that. So again, there's some disadvantages with that. Saliva is another way, but minimally invasive, but can be a little bit hard and harder to adulterate or sort of substitute, but it does require two visits, and then multiple variables can affect diffusion, so it's a little bit cumbersome. And lastly, saliva, it's non-invasive. It's point of care. The window to detection can be longer. Salivary pH can affect results in lower volumes, make it hard to detect drugs in low concentration is a disadvantage. So the nuances to all these tests are really fascinating and can make a big difference, so it's just something to keep in mind. How often should you test your patients? So you should have a baseline test, and then annually for low-risk patients, two times a year for moderate-risk patients, and three times a year for high-risk patients. And this is really just how much drug they're on, ahead of time, your history with that particular patient, and if they've had any aberrant drug-related behaviors in the past. So at that point, you want to then be more frequent with them, or if they have any kind of inconsistency in the results of their visits. So some aberrant drug-related behaviors, I think we know, but they're worth mentioning. So things like changing the route of delivery, attaining scripts from an alternative source, unsanctioned use, or drug-seeking are all warning signs. So in summary, I think really assess your patients preoperatively is crucial to get an idea of where they are quantitatively, make this as regular as looking at their images or their past medical history. Patient engagement and education is really, really, really important. And again, like I said, when I found, I don't really have to get much brush back with this at all. Patients are really doing it themselves, trying to minimize opioid use, and often actively asking about it. If you can, wean them prior to surgery, as things suggest, it can lead to better outcomes, and I think we'll see more and more of this in the coming years. You can use a multidisciplinary approach in order to improve outcomes. Things such as outlined in ERAS programs, and then multimodal analgesia afterwards can be very effective, and as I mentioned, the one paper that does opioid-free spine surgery and had some promising results. And then change our own prescribing patterns. If we had habits for years, and by and large, we're generally prescribing too much, I think to now really, really start to cut back on that and see what works for your particular practice would be beneficial. So thank you so much for listening to this portion of the webinar. I hope you've enjoyed it, and I hope you enjoy the other talks.

perioperative pain management

narcotic-free approach

chronic opioid use

weaning opioids

multimodal analgesia