Thank you for the opportunity to speak today. Perioperative Pain Management is Narcotic Free America Possible. I wanted to talk a little bit about the team approach to opioids and post-operative care. These are my disclosures. None per se relate to the data that I will be performing, though I will be presenting some personal research that involves devices made by these companies. I don't have to tell anybody listening to this talk about the opioid epidemic. I think what is crucial to know is how we as physicians can help prevent this. In fact, 25 to 41 percent of patients that are given prescriptions for opioids meet criteria for opioid use disorder and 80 percent of heroin users first misuse prescription opioids. So there is a role for thinking about how we prescribe and what medications we give patients access to in our treatment continuum. Surgeons tend to prescribe more opioids than needed in many cases. So here is a figure looking at persistent opioid use based on surgical condition. I think what ends up happening is in residency per se, we just want to discharge the patient and everybody gets the same number of opioids, whether they're having a spinal fusion or whether I've replaced their DBS generator. These are clearly two different operations. Then what do people do when they're given this? They generally don't throw out the medications and they generally keep them for some extended period of time. Patients don't generally receive disposal instructions either from us or from the pharmacy. So how can we prevent people getting excess opioids post-operatively? Well, this is a complicated question and it has a complicated answer. It's something that we need to think about and it's something that involves a team-based approach. So this shows a little bit about the algorithm thinking about pre-hospitalization, intra-hospitalization and post-hospitalization. So there needs to be some discussion with the patient, the surgeon and the anesthetist about what kind of pain should be expected and what strategies patients will use to deal with that pain. We'll talk a little bit about perioperative management. One of the things important in this is the opioid sparing multimodal approach. Sometimes people think about pain control and opioids as synonymous and in fact there are many other medications that can be used very effectively for pain control and those need to be thought about. People need to mobilize early. The longer you're down, the longer you're down and this is a problem and they need to be coached accordingly. Though it would be great for our post-operative results in many ways in terms of infection if we were able to keep our patients in a bubble, this is not the case and nor would it be good for their mobility and or probably their opioid use. We do need to think about how we effectively control their pain and go back and change how we manage this if it's not satisfactory and then the long-term outcomes of these patients. For successful ERAS or enhanced recovery after surgery, you need a team. Who are the potential team members? We named some of them. The patient first and foremost, the anesthesiologist and the surgeon but oftentimes there are multiple other people involved. There's the clinic staff in terms of the person that's rooming the patient, the RN that's calling the patient, potentially the mid-level, the residents and this can happen not only in the surgeon's office but also in the anesthesiologist's office and then there's the patient's primary care doctor and their associated staff. There's multiple people that have to get on point and on message about what the expectations should be. Nothing is more frustrating than setting the best laid plans and then having somebody come in and change the patient's expectations after you've set those plans. This can be done very effectively if you have a policy that's set hard and fast and everybody knows you have this policy. So for instance, I deal with a lot of chronic pain patients in my work with spinal cord stimulators. These are people that are on opioids in the long term often and not and I make very clear that as a surgical practice we only manage the first six weeks of post-operative pain and after that they need to return to who they were seeing before or have an alternative strategy. By just having that simple hard and fast rule, we're all able to stay on message in the office about what expectations are for the patient and setting up parameters is really important and they have to be pretty straightforward parameters because you have so many people touching the patient here that everybody has to deliver the same information. The outside team, well the primary care doctor or the pain management provider needs to be looped in especially in complicated patients who are on high opioid doses, who are taking some Loxone, who are taking a variety of different medications and then there's also a group of people and noted at the bottom of the screen as well as the pain management doctor who can offer multi-modality therapy for the patient as well. Make sure to build cohesiveness of this team and over time things change, over time policies change and expectations change and this is important to make sure that as you change your policy everybody else knows that and as they change theirs you know this and so make sure to build cohesiveness through a multidisciplinary committee, through monthly meetings and through multiple points of contact. You know one thing that seemed intuitively obvious but we didn't do in my practice for a while was having a surgery plan spreadsheet. This helps keep all of us on task about what the next steps are and helps to make sure that all patients get the appropriate care. In that spreadsheet is involving anesthesia or their pain docs in cases of complicated pain. Provide education to the team members. So this was a survey in 2018 looking at general surgery residents and they rely heavily still on opioid medications for post-operative analgesias. They're heavily influenced but their superiors do and they're poorly trained in pain management. This picks on surgeons but we can see this across the board. You know a personal story with my mom who was having back pain. I advised her to call her primary care doc and ask for to try gabapentin or Lyrica and they said they didn't feel comfortable and instead gave her hydrocodone. So there's a lot of room where education can be used. We talked about the prescription policy. If you do prescribe opioids how are you going to do that? What is the drug test parameter? What is the behavior? What is your behavior if the patients don't abide by their contract and or get drugs for many many places? And make sure your patients expectations are set. Having a set policy that is easy for everybody to understand and implement whatever that policy is will mitigate a lot of the issues with patient expectations. And then you don't have to worry about who said what because you know that everybody is on the same page. Develop an ERS protocol. These are good things but they involve multiple stakeholders. This can get complicated in the world of spinal cord stimulation where I live. You know there's often multiple providers doing this so to make sure that everybody is communicating properly with anesthesia and that they don't have to remember or adapt their strategy is essential. This happens in spine surgery all the time based on the number of providers and the number of specialties involved. So gather stakeholders and collect pre-existing data to identify the greatest needs for improvement. Develop pathway or order sets so once you have these there's less one-offs and there's less confusion. Make sure to educate the RNs involved. Monitor compliance and outcomes. So here are two of our spine ERS sheets at our institution and you know I think that it's important to think about what the preoperative medications are. You know when we're talking about ERS we're not just all talking about pain meds. We're talking about optimal anesthetic care in my opinion. We do have some of the pain meds involved here looking at Tylenol, Celebrex, Pregabulin as some of the options. We've taken off preoperative Midazolam here as one change. We note that opioids are only given with attending approval. Then we look at Lidocaine and Ketamine and other drugs that have been shown to have effects on pain control. Make sure that the volume status is optimized because this can lead to pain. Make sure blood pressure is optimized. Use regional anesthesia when appropriate. Do you need a Lidocaine drip post-operatively? What will help the patient? How do you manage breakthrough pain? Again, who's going to be managing the post-operative pain? What about when this is complicated? Making sure that acute pain service is involved and making sure that that acute pain service signs out to the chronic pain service. Oftentimes in the sign out from the surgeon to anesthesia, from the preoperative to intraoperative to post-operative, post-operative to outpatient. This is where the general mistakes can be made and confusion can arise. Lysosomal Bubivacaine. It works very well. Also very expensive. So it depends how you want to use this. Is this appropriate for all people? No. But is this appropriate where pain is going to lengthen stay by three or four days? Probably so. And this needs to be considered as do all new technologies in treatment of pain. Again, when this was used, this can be used in in multiple different arenas. And this is a great option. But do keep in mind the value of, you know, more old-school options in terms of injecting Bubivacaine routinely before the operation, at the close of the operation, whenever it was safe. And think about, you know, kind of change some of your parameters in terms of who can receive what. So for a long time it was taught not to give NSAIDs in any phase of spine surgery recovery. Some people are questioning whether a post-operative dose of Toradol falls into this category. So think about why you do what you do and think about how you can expand those treatment options and your patients will be better served. Monitor outcomes. Again, you know, it's really important to institute change. But it's also important to think about how those changes benefit or don't benefit you. Sometimes we do many, many things for a very minimal change. And then in that case, is that worth it or is that appropriate? How satisfied are your patients? How satisfied is your team? Is everything clear to all parties involved? If not, where are the barriers in the implementation? So you have to think not only about what your plan is, but think about how this can be executed and implemented because that is often cases where the ball is dropped and where there may be some issue. Adapt your long-term strategies based on outcomes. So just because you create a policy doesn't mean that policy has to live in perpetuity. Oftentimes this can be changed. This can be updated based on the new literature. And set a standard as to how often you will update this. Is it every year? Is it every two years? And, you know, what parameters will you use to update this? What objective data are you gathering? Oftentimes in hospitals, we don't collect enough data to think about the next iteration. And that's really important as we go through quality improvement trials. What else can be done in terms of interventions before escalating opioid needs? Talk to people that are experts on the topic. Provide education to all involved in touching the patient. A little bit about spinal cord stim and opioids. We published this paper and it was actually named Neurosurgery Paper of the Year in 2019. We had 88 patients that had thoracic SES and we looked at them at one year. Preoperatively, 33 were not on opioids and 53 were. We were able to wean off 64% of people with opioids. And not surprising, based on other literature, opioid naive or those who had weaned and stopped had better outcomes. So you do have other modalities of treatment even from your peer group that are surgical as well as medical. In summary, opioid reduction needs to be planned. The perioperative management of patients is dependent on team development of a plan and execution of this plan. Patients do better when they're not on opioids and their perioperative metrics will improve. Thank you very much to the great team that supports me and to all our funding sources.

team approach

opioids

post-operative care

patient care

spinal cord stimulation