So, for today's lecture, we're going to focus on how to manage pain and narcotics in post-operative patients, which is a fairly significant topic that's gotten a lot of interest nationally lately because of the overuse of narcotics in many of the patient populations. So, I'd like to share some thoughts on this with you in a setting for a AAAS Breakfast Seminar. I do have disclosures, not directly related to anything about pain management, but they are here, and I have worked with some spinal implant companies in the past. So, the issues that we have to focus on is that 33 to 70 percent of patients who have elective surgery are already using chronic prescription opioids. And the problem is that they come in using the opioids, they're going to require greater doses to keep them pain-free after surgery. And the question is, once they have their surgery, how long are we going to give them their narcotics, and how are we going to wean these off? Many studies have shown that there's an association between pre-op chronic opioid use and worse outcomes after a surgery, especially spinal surgery. So let's consider some of these issues. So there were 22.2 percent fewer opioid prescriptions filled in 2017 compared to 2013. So the total is 196 million opioid prescriptions were filled in 2017. That's a 9 percent decrease from 2016. There's been a reduction since 2013 in every state, with five states having decreases of more than 30 percent since 2013. So in general, what's been going on is that there's been a trend nationally to prescribe less of these narcotic pain medications over time. This is the opioid analgesic prescription rate by state in 2017. And you can see the states which are darker pink or red in color have a higher opioid prescription per capita, and the states which are darker green have fewer. So on the coast, we have California and New York, which have amongst the lowest rates of opioid prescription history. And then in the south, some states like Louisiana, Mississippi, Alabama, Arkansas, Tennessee have higher rates. The opioid prescriptions by payer type a couple of years ago is what's in this slide. At the national level, about one-half of the opioid prescriptions were paid by commercial plans, and those are in the dark blue there. Another one-third was paid by Medicare Part D, and the remainder was split evenly between Medicaid and patients paying cash. This proportion was not uniform across the country, but this is roughly who's paying for these. So, you know, private payers are paying for roughly half of these narcotic pain prescriptions. The Quality Outcomes Database, which is the data arm from the NeuroPoint Alliance, has looked at some of these issues. Using nationally maintained neurosurgical registry, the goals of the study of looking at the opioids was to compare the clinical and patient-reported outcomes after surgery for degenerative spine disease between opioid-naive patients and opioid-tolerant patients. And then we wanted to look at the association of post-operative opioid consumption with patient-reported outcomes. So let's look at the patients as they come in for surgery in the pre-op arena. So when patients come in looking for surgery, some of them have been sent to the pain clinic, and the patients should get screened for excessive post-operative pain. So patients who are really highly tolerant, we get our pain clinic involved here at UCSF, and we have them engage in pre-op evaluation and counseling. Sometimes they have outside pain management doctors, so we'll, you know, use the outside pain management doctors, which are closer to the patient's home, in order to do the same function. It enables calculation of an equal analgesic dose and quantifies the baseline opioid requirement for the patient. And that is important for the anesthesiologist to know the day of surgery and for the pain management team to know post-op, so that we know what they were taking before they even came in. If you're able to do that, you can develop individualized post-op pain management strategies for these patients based on their pre-operative opioid use. And this allows for a continuum of care while the patient is inpatient and having treatment immediately after surgery. There are some risk factors for using a lot of narcotics, and these are the risk factors. A history of a chronic pain syndrome, patients who are catastrophizing, have issues with anxiety, depression, or substance abuse. There's also been an association of using more narcotics in women who are at a younger age and who have pre-op pain at the surgical site. And who are not college educated and who are of lower socioeconomic status. Those are some of the risk factors for higher use of narcotics pre-op and post-op, and it's important to keep these demographics in mind. It's important to educate the patients and set post-operative expectations in terms of pain control. So the expectation post-op is not to have zero pain, but it's to have pain control to the extent that they can get up, walk around, and do some of their regular everyday activities. So it's not zero pain, it's a controllable rate of pain. I think that's an important patient education tip that I would share with you. Pain management options that will be utilized during the hospitalization after discharge should be shared with the patient so they know what to expect. We also let the patients know how long we're going to be dealing with their narcotic pain medications after surgery so they have an expectation of when the stuff is going to be weaned off and that this narcotic is not going to go on forever. Pre-op optimization is really important if feasible. We try to reduce the pre-op opioid dosing. Opioid induced hyperalgesia, meaning that the nociceptive sensors are reset because chronic exposure to opioids is something to be aware of. So if you have increased demand for the M.U. receptor agonist, you have increased pain and you have increased demand for post-operative pain medications. You want to initiate multimodal analgesics pre-operatively and try to get them off some of these narcotics. We like to use acetaminophen, nonsteroidals, and galpentin type of agents if we can to try to get them on lower doses of pre-op opioids so that they don't reset all the receptors and make it difficult for us to control the pain afterwards. On the day of surgery, we found that giving acetaminophen and galpentin is very useful and helpful in order to create lower pain medication requirements after surgery. Intraoperatively, there are several maneuvers that can be used as well for pain control. Let's review what those are. It's important to target different mechanisms of analgesia for these patients. And if you target different mechanisms, then you may be able to reduce requirements of any single agent. So using IV lidocaine, ketamine, intravenous opioids in combination with intravenous tolenol, and perhaps an alpha-2 adrenergic receptor antagonist like dexmetamidine will help you to lower the dose of the opiates that are necessary for these kinds of cases. During surgery, certainly you can inject local analgesics like liposomal bupivacaine, which has an extended release of lidocaine, happens after surgery for a couple of days, and provides very nice analgesic pain control. That is a maneuver that I use for some of my awake T-lift surgeries. You can use spinal anesthetics in appropriate cases. We've certainly done that here for decompressions and for T-lift surgery. And using minimally invasive approaches to limit the size of the incision and tissue manipulation can also help in terms of pain control. Let's talk about what we can do for these patients after surgery. Muscle therapy is important after surgery, just like it is important before and during the operation. Neuropathic pain medications, specifically gabapentin, are very helpful. Giving muscle relaxants to patients who have deep muscle tissues is very helpful because using baclofen is much better than using an opiate to control muscle spasm. Acetaminophen is our preferred non-narcotic pain medication after surgery because for spine surgery, in many of the cases where we do fusions, we don't want to give them non-steroidal anti-inflammatories because it inhibits the bone graft from healing. Lidocaine patches can be used. I want to caution that we only use lidocaine patches in situations where we did not inject liposomal bupivacaine. We don't want to inject liposomal bupivacaine, which has a slow release, and then put a lidocaine patch on top on the skin because that might give too much local analgesic into the system. So we only use lidocaine patches if we did not use liposomal bupivacaine. Ketamine may be used post-operatively. It does dissociate the patient a bit. We prefer not to do ketamine if we can avoid it, but some patients are really in a lot of distress with pain issues and have to be put on ketamine for a day or two, in which case we put them in our step-down unit and monitor them closely. Lidocaine infusion is another maneuver that can be done. Typically, our pain management team does this, and it's limited to use only in the critical care units. We do work closely with our pain pharmacist post-operatively. We want to maximize non-opioid medications and limit the amount of opioids that we're giving. We do try to limit injections of opioid because injections of opioid, especially intravenous boluses, promote more rapid opioid tolerance and hyperalgesia. So we tend to avoid that. We do review medications and doses prior to discharging the patient from the hospital. The team will come in and review those medications and doses with the patient, and we also review our plan of tapering these medications and provide discharge instructions to taper them as well so that the patient has expectations that are meeting our expectations. Some patients do benefit from additional therapies like cognitive behavioral therapy, acupuncture, massage, or psychological counseling in order to help them to get through the post-operative stressful situation. Let's talk about a case example of using multimodal methods to control pain. This is a 63-year-old man who has low back pain with any activity. He has left leg and foot pain, worsens with walking, and he has no weakness or bowel-bladder control problems, and he's failed epidural steroids, and he's failed physical therapy and wants to have an operation. Here's his past medical history. Preoperatively, we had him on anti-inflammatories and gabapentin, trying to limit his narcotic exposure preoperatively, and we determined that this patient was going to be a good candidate for surgery, and we decided to try to do the surgery with a local analgesia as well as with a spinal anesthetic rather than doing a general anesthesia. He has an intact neurological exam, except for that he has difficulty with heel and toe and tandem gait due to pain, but not really due to weakness. And when you look at his imaging, you can see his L5 is sacralized, and he has a calcified herniated disc at L4-5 sticking into the foramen, especially the left side. You can see that here as well on the axial imaging, and it's really showing up very nicely on the CT scan, especially on that top right image where you can see on the axial that he's got a large lip and calcified osteophyte protruding into the foramen and really crushing his exit nerve root. He also has up-down foraminal stenosis on the left side, which you can see on the middle image there in the left foramen. And this patient does have a scoliosis, which you can see here. And when you see his dynamic x-rays, you can see that the osteophyte on extension is really in the foramen quite a bit. So this patient initially tried a minimally invasive laminal foraminotomy. He did not want a fusion because he didn't have a lot of back pain. That only gave him a few weeks of pain relief, and the pain returned. And the reason the pain returned is because he has up-down foraminal stenosis at L4-5, and he has a large lip and osteophyte into the foramen there, which is really hard to take out if you're just trying to do an MIS decompression. So we decided to offer this patient a more extensive operation. The surgery that I offered him was an L4-5 awake T-lift, and we did this with spinal anesthesia and using navigation. We brought him in the operating room. He had a spinal anesthetic placed at the L3 level, and then he had liposomal bupivacaine injected after we prepped and draped him. He's awake for the procedure. We did it minimally invasively and injected liposomal bupivacaine down each of the screw tracks for the four screws. And then on the left side, we did a small incision and exposed the facet joint and took it off and took out that lip and osteophyte and put it in her body cage. EBL was only 100 cc. He didn't have a Foley for this because we didn't want to keep him with a Foley afterwards either. Postoperatively, we got him up immediately as soon as the spinal anesthetic wore off and he was walking the day of surgery. He did get oxycodone around the clock because we did not give him any IV narcotics. He did get acetaminophen, baclofen for his muscle spasms, and pregabalin as an additional form of pain control. We did not give this patient lidocaine patches after surgery because we injected liposomal bupivacaine during the operation. So we did not want to give him too much local anesthetic because liposomal bupivacaine is released over 48 hours due to the liposome releasing the drug. The patient was discharged home on post-op day one, was back at work about four weeks later and taking very rare narcotics. By that time, he essentially had weaned off. This is his immediate post-op x-ray. You can see the T-lift there with the small little drain on the left side, which we took out on post-op day one. So you can see from this case that we used multi-modality maneuvers to control his pain. We got his pain under control before surgery without narcotics. We did not use a general anesthetic and were able to control his pain during the operation with a spinal anesthetic and with liposomal bupivacaine and then we gave him no IV narcotics post-op and gave him around the clock for a week or so opioids and then weaned them off by three to four weeks and then had him return back to work. And by thinking about the amount of pain meds that we're giving these patients and how to manage them pre-op, intra-op, and post-op, we certainly can limit the amount of narcotics these patients see and the amount of narcotics they take and avoid issues like constipation, et cetera, which slow people down in the post-operative period. I know that this is a virtual conference, but if any of you have questions, feel free to email me. Thank you so much.

management of pain

narcotic use

post-operative patients

chronic prescription opioid use

weaning off medications