Hello, my name is Jake Ng. I am a pain physician at UCLA. I am the director of the UCLA Pain Medicine Fellowship, as well as the director for the Inpatient Chronic Pain Service at the Ronald Reagan Campus at UCLA. I will be talking to you about preparing the patient on chronic opioid therapy for surgery. I have no conflicts of interest. Goals for this presentation. It's very important that all of our providers understand the pervasiveness of chronic pain and opioid use in our population. Clearly, most of you have already encountered this very important issue. The next goal would be to understand the preoperative assessment of the chronic pain patient, as well as understanding the importance of preoperative planning for post-operative pain in the chronic pain patient. In terms of chronic pain, many patients will come to you with already pre-existing chronic pain issues. Whether that's residual post-operative pain, low back pain, neck pain, cancer pain, neuropathic pain syndrome, such as CRPS, chronic regional pain syndrome, or diabetic neuropathy, myofascial pain syndrome, fibromyalgia, headaches, dental pain, facial pain, and additional pain. These are just some examples of the many ways that chronic pain may manifest in your patients. It's important to understand that chronic pain often has multiple pain generators. In the example of back pain, patient may have pain from muscle spasms as well as neuropathic pain as well as referred pain. Post-surgical pain may result from acute tissue manipulation. This is a result of the release of inflammatory factors, including prostaglandins, bradykinin, and substance P. Post-surgical pain is usually nociceptive, that is pain caused by tissue damage, but may have contributions from other sources, such as neuropathic pain and anxiety. One aspect of pain that is anxiety is often not well-treated or well-managed in the post-operative setting. This can lead to problems in the post-operative period. This slide is really to give you a good understanding of just how prevalent chronic pain is in our society. As of 2002, the National Health and Nutrition Examination Survey estimated almost 15 percent of adults have chronic pain. In 2012, National Health Interviews study showed 11.2 percent of adults had chronic pain. An estimate of 2008 suggested as many as 116 million adults in the US had chronic pain. Another study estimated that as much as 20 percent of the world population has chronic pain. While the exact number may be impossible to pin down, While the exact number may be impossible to pin down, the takeaway should be that chronic pain is very prevalent in society and it is incumbent upon all practitioners to understand that and understand how that might affect their practice. As another example of just how important chronic pain is, one estimate places the annual US cost at $635 billion. That is including direct and indirect costs, so whether it's medical costs or loss of work and productivity. As far as post-operative pain, not surprisingly, most patients have post-operative pain, but a significant number of those patients are at risk for developing chronic pain. Concomitant with the prevalence of chronic pain has been the rise of opioid medications to treat the chronic pain. Clearly, opioid medications have significant issues, including side effects that can be life-threatening, and therefore it is very important for all practitioners to understand just how prevalent and significant opioid use is in our country. From 1999 to 2014, there were an estimated 165,000 fatalities from prescription opioid overdoses. In 2013, there was an estimated 1.9 million Americans abusing or depending on opioid pain medication. In 2014, there were 245 million opioid prescriptions written. The most significant opioid in use today is fentanyl, often used illicitly and with significant complications, side effects, including death. One of the great issues with surgeries is the sheer amount of post-operative opioid prescriptions that have been written. In one survey, 67 to 92 percent of patients reported unused opioids. Of those patients, they report 42 to 71 percent of tablets are unused. Clearly, we have been prescribing too much opioid for patients, not just for the treatment of chronic pain, but also post-surgically. The remnant prescriptions may be used incorrectly or abused. Patients with chronic pain may have concomitant pathology, including psychiatric disorders and substance abuse that may complicate post-surgical pain control. It's important to remember also that patients may have unrealistic expectations regarding post-operative pain control. It is incumbent upon the provider to ensure that the patients have a more realistic expectation, as unrealistic expectations may be associated with poor outcomes. Patients on chronic opioids may also display increased response to painful stimuli. This could be a reflection of opioid-induced hyperalgesia or pre-existing reduction in adverse pain inhibition. The takeaway from this is that patients who come in on a significant amount of opioids may have very difficult-to-control pain, as well as worse outcomes post-surgically, such as increased length of stay. Multimodal analgesia, that is, providing pain relief with medications from multiple classes, is recommended for all patients, as it may be associated with decreased opioid requirement. This should make sense in a theoretical level, as medications from different classes may work together synergistically, while also decreasing combined side effects. As far as the assessment of a chronic pain patient, high-risk patients include those on chronic opioid therapy, opioid maintenance therapy, such as methadone or buprenorphine, prior or active substance abuse, multiple surgeries in the past, or patients with active pain syndromes, such as CRPS, herpes zoster, sickle cell disease, and cancer pain. Here are some examples of patients that you may encounter preoperatively. For example, a 53-year-old female with long-standing history of chronic facial pain. She is on fentanyl patch 225 mcg per hour every 48 hours, fentanyl lozenge 1600 mcg every 4 hours, and Percocet 10-325 4 times a day. She lists a long history of medication allergies, including cataract, nalbufin, and codeine. She is concerned about severe post-operative pain. Clearly, a patient like this may present unique challenges for any provider. She is on a very, very high dose of opioid medication. She is on multiple opioid medications. She is on opioid medications that may be very difficult to obtain, especially in the hospital setting. And the list of medication allergies complicates post-operative management. Another example is a 54-year-old male with psoriatic arthritis. He is on buprenorphine 5.7 mg, naloxone 1.4 mg twice daily. He appears very anxious and does not want to go through surgery unless a robust plan for post-operative pain control is formulated. Here's another example of a patient who presents unique challenges. He is on a medication that is almost certainly not on any hospital formulary, may complicate post-operative pain control as well. And his anxiety may also make post-operative pain management more difficult. These two examples really suggest that a strong perioperative pain management plan must be formulated prior to surgery. And the patient must be on board as well. The goal during the preoperative visit is to obtain as much accurate history as possible related to the patient's pain condition. We all take histories, and there are certain questions that are very pertinent for patients with chronic pain. You really want to understand where the chronic pain is, how long it has been affecting the patient, what is the quality of this pain, how severe is it on average, what makes the pain better or worse. Importantly, is this pain directly related to the condition for which surgery is being treated? And is the surgery amenable to regional anesthesia? Which provider is managing the patient's pain at the moment? Is the patient currently followed by a pain management specialist or an addiction specialist? Does the patient have a significant history of anxiety or other psychiatric illness? Is the patient followed by a psychiatrist or other mental health provider? Is the patient taking anxiolytics, especially benzodiazepines? Does the patient have any significant comorbidities that may influence efficacy or safety of pain medications, especially renal or hepatic failure? Has the patient had prior surgeries? This is very important because this could serve as a guideline for how pain may be managed in the future postoperatively. Did the patient have severe pain following the surgery? How was the pain treated? Did the patient have any regional anesthesia? Was an inpatient pain team involved? Any implanted devices related to pain management, such as a spinal corstimator or intrathecal pump? These special devices may require different or special management perioperatively and postoperatively. Does the patient have any allergies or adverse reactions to pain medications? This is very important because obviously if a patient had a poor reaction to a medication that you're planning to use, then you want to avoid it and find an alternative. Is the patient currently on opioids or has been in the recent past? How much and how often? Does the daily intake exceed 16 mg morphine equivalents? Does the patient feel that these medications are effective? What opioids has the patient tried in the past? This is a very important question because certain opioids the patient may respond to more than others. Has the patient had any significant adverse reactions or side effects with any particular opioid? Similar to the previous point, certain medications that the patient has tried in the past may cause issues. One may cause more sedation, one may cause more itching, one may cause more constipation, one may cause more respiratory depression, and so on and so forth. Or is the patient requiring opioid maintenance therapy, buprenorphine or methadone? Has the patient tried all these other medications in the past, whether it's NSAIDs, acetaminophen, muscle relaxants, neuropathic pain medications, or ketamine? All these medications may be considered as part of a multimodal regimen postoperatively. Does the patient have any history of prior substance abuse, whether it's opioids, cocaine, amphetamines, MDMA, alcohol, marijuana, or benzodiazepines? Preoperative planning really involves contacting the appropriate consultants, whether it's pain management, psychiatry, or addiction medicine. Communication with the patient pain service, if one exists, and the anesthesiologist assigned to the case is very important. This will help coordinate perioperative and postoperative pain management. Coordination with the prescribing physician is also important. If the patient is on a significant amount of opioid, then the prescribing physician should be in the loop regarding a perioperative pain management plan. Patient may also benefit from a preoperative decrease of opioid intake. Escalation in the immediate preoperative period should be avoided if possible. For my practice, if a patient comes in taking Norco 5-325 four times a day, I would strongly encourage that patient to try to take less, whether it's three pills a day, or three and a half pills a day. Something less than what they're normally used to, as this could help assist the surgical provider during the postoperative period. Initiation of neuropathic pain medication preoperatively may allow for full effect on the day of surgery and may be effective as an adjunct in the postoperative period. The literature on this, however, is mixed. All baseline pain medication should be taken on the day of the surgery. This includes all long-acting opioids, such as fentanyl patch, which should remain on the patient and be changed as normally scheduled. We usually recommend taking all medications at least two hours prior to surgery with a small sip of water. So what this means is if a patient is on methadone 5mg TID, our recommendation would be that the patient continue their methadone on the day and the morning of the surgery. This will allow for a baseline amount of pain control to be achieved. If the patient relies on unusual medications that are non-formulary, such as tependadol or fentanyl lozenges, those medications should be brought to the hospital to be dispensed by the pharmacy. If a patient is on buprenorphine therapy, management may be complicated. Strong data regarding preoperative management of buprenorphine is lacking. Buprenorphine is a partial mu-agonist and kappa-antagonist. It has a long half-life, may compete with other opioids, and may be associated with pain relief, though there is or appears to be a sealing effect. One strategy for managing buprenorphine is to discontinue buprenorphine therapy at least 72 hours prior to major surgery and replace it with opioid agonists. This does prevent antagonism of opioids required for postoperative pain, however this strategy may result in relapse. Another strategy would be to continue buprenorphine to supplement with opioid agonists that can compete with buprenorphine. This strategy decreases the risk of relapse as the patient remains on buprenorphine up until the day of surgery, however this may make perioperative pain control more challenging and require higher doses of opioid. If the patient is on buprenorphine therapy, a specific plan must be coordinated with the patient's addiction specialist. Patients should be discharged postoperatively on a very short course of opioids for pain control with a close follow-up with their addiction medicine specialist. Importantly, the entire plan should be clearly communicated to the patient prior to the surgery. Realistic expectations are very important. The patient cannot be promised that they'll have no pain, or even any pain control that's better than their baseline pain. So, for example, if the patient states that their baseline pain is 7 out of 10 on the visual analog scale, then we cannot expect for their pain to be a 5 out of 10 following surgery. Interoperative planning should be per the anesthesiology or pain team and may involve multimodal therapy or regional anesthesia if appropriate. As far as postoperative planning, for opioid therapy, the provider should anticipate higher requirements than normal. So, for example, if the patient is already taking oxycodone 20 mg daily, 5 mg 4 times a day, for example, then the expectation should not be that the patient will rely solely on oxycodone 5 mg postoperatively. They'll most likely require a higher dose. Another strategy would be to do an opioid rotation where, for example, if the patient, once again, were taking oxycodone 5 mg 4 times a day, that a different medication such as hydromorphone may be used. Also, multimodal therapy may be initiated at this point as well, whether that's non-steroidal anti-inflammatories, acetaminophen, gabapentin, or ketamine. So, in summation, early identification of high-risk patients allows for a thorough preoperative assessment and the development of a robust plan for perioperative pain control. Communication is very key. It's important to make sure that the patient, as well as their primary care provider slash prescribing physician, consulting teams, and inpatient teams all be in the loop and understand the plan of care prior to the surgery. And, of course, I cannot emphasize this enough, the patient must have realistic expectations for pain control. Thank you very much for listening.

chronic opioid therapy

surgery preparation

preoperative assessment

post-operative pain

inflammatory factors

chronic pain prevalence