Good evening, and welcome to the AANS webinar, The Use of Opioids in Neurosurgical Practice, How to be Safe, Effective, and Compliant with New Prescribing Laws. If you have any questions during the webinar, please post them in the chat box in the bottom left-hand corner. Posts in the chat box can be seen by all webinar participants. Questions will be addressed at the conclusion of this course. Our faculty tonight are Ellen Ayer, the Co-Director of Functional Neurosurgery Program at Henry Ford Hospital, Jason Schwalb, the Surgical Director of the Movement Disorders and Comprehensive Epilepsy Centers at Henry Ford Health System, Stephen Falowski, the Director of Functional Neurosurgery at St. Luke's University Health Network in Pennsylvania, and our course director is Christopher Winfrey. He is the Assistant Professor of Neurological Surgery at the College of Physicians and Surgeons in New York City. And with that, I will turn it over to Dr. Winfrey. All right, thank you for the introduction, and thank you, everybody, for attending this webinar. I want to spend a minute or two and give everyone some background about why this course exists. In 2011, the Institute of Medicine commissioned a study looking at the status of teen health care delivery in America, and what they saw was there were a lot of things, but one of the main things that there was a large number of untreated and undertreated patients in pain in the U.S., and one of the reasons for that was insufficient physician education. This goes all the way back to medical school, residency training, fellowship training, and even continuing medical education at the attending level. So there was really doctors weren't being given the education they needed to adequately manage these patients. So in recent years, we all know about the opioid crisis, which is a little bit of a different issue. It's not the undertreated patients. It's patients, in a sense, being either over-treated or mistreated with opioids specifically, and all the other issues that can result from that, diversion, overdose deaths, etc. In an effort to address some of these shortcomings in education, the AANS leadership thought it would be prudent to offer a series of educational opportunities for neurosurgeons to educate themselves about some of these issues, and this course is part of that effort. The course is going to be in three parts. The first part, we're going to hear about the management of acute pain in neurosurgical patients that are not on chronic pain medications. These are the straightforward, non-chronic pain patients that most of us have in our practices. Part two will consist of managing acute pain in the neurosurgical practice in patients who do have chronic pain and are on chronic opioids and perhaps other pain medications, a lot more complicated. And then the third part, we're going to hear an update of some of the legislative efforts at state levels and at the federal level that have impacted the way neurosurgeons practice the management of pain health care in their practices, things like prescription drug monitoring programs, time-limited opioid prescriptions, and so forth. So without further ado, I'd like to segue to Steven Falowski, who's going to give us a talk on the management of neurosurgical pain in straightforward, non-opioid-tolerant patients. Okay, well thank you, Dr. Winfrey, very well said for an opening. If we can please bring up my talks. So the first talk we're going to have this evening is on the management of acute post-operative pain in patients who are opioid-naive. These should be your straightforward patients and the majority of the patients that we're used to treating in neurosurgery. The first, you can see a slide of my disclosures here. I do work a lot with industry as well as society, normally revolving around functional neurosurgery as well as pain management. So we do have a few objectives that we're going to cover in this first talk. We're going to be looking at acute post-operative pain in a neurosurgical patient, considerably in the opioid-naive patient. We're going to be thinking of the different types of pain that we're going to be treating, specifically looking at either nociceptive versus neuropathic pain, as this will be the two types of pain patterns that are most important for our neurosurgical patients. We'll look at the different drug options that we have available for these two different types of pain patterns. And what we're going to do is take select cases, most common cases in neurosurgery to look at how we would manage those patients, as well as also the patient who is either discharged the same day or the discharge planning that comes with a patient who underwent a neurosurgery but was hospitalized afterward. So what exactly is acute pain? As we all know, this is pain that's expected from the normal tissue healing following a surgery. Normally this is revolving around incisional pain, and this can or may include neuropathic pain as well from the surgeries we perform. Importantly, it's less complicated to treat this than it is chronic pain, because these are going to be opioid-naive patients, and these are going to be patients who normally – who have not been exposed to longer-term pain management. And this should be easily managed by your normal neurosurgical pain service. So when we break down the two different types of pain patterns, the first one we look at is nociceptive pain, which is likely one of the most common pains we're used to treating postoperatively. And this is usually the pain that comes from the actual or perceived tissue injury. This would come from the introduction of our surgeries through the skin and the subcutaneous tissue as well as the muscle, but can also include the periosteum and the bone, as well as even the dura. This type of pain in general responds pretty well to NSAIDs as well as opioids, and usually doesn't require some of the stronger opioids, which we'll be going over in the next few slides. So neuropathic pain, perhaps a pain that's a little more difficult to treat. This usually arises from the neural elements, and it may also involve the actual tissue injury, but it may not – it is commonly seen with nociceptive pain as well. It's normally commonly described as just abnormal sensations or electrical shocks or burning. Your typical – what patients describe as sciatic-type pain or nerve pain. It's not always very descriptive or specific, but it's one of those things, you know, when your patients describe it exactly what it is. So this is just an image to demonstrate that these two types of pains can occur together, nociceptive as well as neuropathic pain. You can see here in this image some misplaced screws bilaterally, one screw being medial, which can lead to the neuropathic pain component, as well as the screws out of the bone, which can also lead to nociceptive-type pain. This is why it's important to characterize the patient's pain pattern and be able to address both of them appropriately, and may require different medications. So when you look at your different drug options for nociceptive pain as well as neuropathic pain, you usually start with something on the lighter side, such as acetaminophen or Tylenol, but can go on to the nonsteroidals as well as the muscle relaxants. Benzodiazepines can also be used, anywhere from Valium to Ativan, as well as Xanax for your patients. When looking at the neuropathic pain component, you look at a different subset of medications, including the anticonvulsants, or what some have also looked at is called the neuroleptics. These can include gabapentin, Neurontin, Lyrica, as well as your antidepressants, which include amitriptyline and Celexa. There can be some overlap as well in these patients for both nociceptive and neuropathic pain, as you can use opioids in both of these characteristic type pain patterns. So when you look at the side effects that can come from these medications, a lot of these side effects are very specific in what we look for in neurosurgery. Obviously with Tylenol, you worry about the toxicity to the liver. With NSAIDs though, more importantly for a neurosurgical patient, we do worry about the risk of bleeding, as it is a blood-thinning medication, but also the risk of non-fusion following or spinal instrumentation cases. With anticonvulsants and antidepressants, there's a large interaction with other drugs, and this is usually side effects that you worry about in longer term. Ketamine, which can be commonly used, especially by our anesthesia colleagues, has been known to have hallucinogenic effects. These patients do require monitoring in the postoperative period. This is also a medication that if it's used during the operation, it's likely for a patient who would not be going home on a same-day discharge. With muscle relaxants, we worry the most about sedation, which can come whether with our spinal cases or as well as with our cranial cases, which is also most important. Same thing with Baclofen. With opioids, we can also worry about lethargy and sedation, but also respiratory depression, and those patients would need monitoring as well. Most importantly, though, is the effects we worry about for long-term with opioid use and whether or not starting opioids in the acute postoperative period could lead to that long-term use. So what are some of our options for opioids? Here's a list of the options that we can use, listing them with their mode of administering to the patient from the medications which are PO as well as IV, and those that can be instituted with a PCA. Some of the most common medications we use in the postoperative period would be something like oxycodone, as well as even morphine IV. So what are some of our considerations? So the first thing you want to determine is whether they have the type of pain they are experiencing, whether it's nociceptive and neuropathic, and which component of that pain are you treating and whether you're treating both of those pains, and how painful is it expected to be? Is their pain out of proportion to the surgery that they had? And whether or not the patient's in a monitored setting, this is important for a lot of the medications we can use, such as ketamine or opioids. Now does the patient have a history of chronic pain or a history of substance abuse? Even more importantly, do they have a history of taking chronic pain medications or chronic opioids? This is going to be well-described in the next talk coming up. This is also important is to take into effect whether the patient is on opioid blockers. These are becoming more common in our era now, such as naltrexone and methadone. These will obviously affect the interaction or the effect of using opioids at this point. Let me put this up here because this is one of the reasons that we are here today discussing opioids in the neurosurgical patient is it has become a common problem postoperatively where the acute use of opioids has led to a persistent or chronic opioid use. This is why it's important that we need to limit it, but still yet appropriately administer pain relief for our patients, but limit the amount of opioids that we do give them. So to do that, it's important to set expectations for these patients and describe to the patient that some pain is normal, but they are going to have to work their activity levels postoperatively through some pain, and then set the normal limits of what your average patient would take following this procedure. So some examples. So with the modest pain in the opioid-naive patient, you can usually start with something like Tylenol and ice packs, as well as consider NSAIDs and muscle relaxants. At this point, you may also want to consider some of the weaker oral opioids, whether it's codeine or oxycodone, but you can also start with a medication such as Tramadol. This is great for use in opioid-naive patients. It's an alternative to the stronger opioids and can act as a weak mu receptor working on the serotonin or epinephrine reuptake inhibitors. So by doing that, it will be less potent, but there is the lower risk of addiction, as well as side effects such as respiratory depression. When you're looking at both nociceptive and neuropathic pain, you're going to want to start considering NSAIDs, as well as the weaker oral opioids, but also now your anticonvulsants or neuroleptics, such as gabapentin or Lyrica. You may also want to consider a short course of steroids. The more severe pain patients, you're going to have to start thinking about the stronger opioid medications and whether or not you'll need IV opioids. It's usually recommended to start with a strong PO opioid, such as oxycodone or hydrocodone, and if they're a significant breakthrough brain following this, you may consider an IV medication, such as morphine. You may also want to consider, for the more severe patients, treating the neuropathic component with something like gabapentin. I put here on the bottom, plus or minus standing orders. This is something that's becoming more common as hospitals develop protocols requiring that some of these patients in the post-operative period be on standing medications. I do have a slide coming up that will also discuss that. So here's an example of post-craniotomy. Some of the concerns we're going to have with our neurological exam is we're going to want to avoid sedation, but in addition, we're also going to want to avoid under-treatment, which pain can also therefore affect our exam. Lastly, there's always bleeding concern with NSAIDs, which we'll likely avoid in the post-operative period. So medications to consider for your post-craniotomy case would include Tylenol, Tramadol, or Furoset. For your post-laminectomy patients, they can be a little bit more difficult to treat, and they may also have a component of neuropathic pain. You are most concerned with your bleeding concern with NSAIDs, but also your risk of pseudoarthrosis that may occur. So you can consider the same type of medications, but I also want to point out that muscle relaxants may be very helpful in these patients, as well as don't under-utilize the importance of ambulation and physical therapy after the procedure. What most hospitals are doing now is instituting protocols to try to limit the amount of opioids that patients will be taking. So standing orders of muscle relaxants, as well as gabapentin, can be started in the post-operative period, where these patients receive these around the clock. You can also schedule them to receive around the clock, every four to six hours in the first 24 hours, something like Tramadol or Oxycodone, and at this point, you write for a breakthrough medication, such as an IV opioid, which can include morphine. For some of your other patients who've had larger surgeries, larger spinal instrumentation, you may want to consider a standing IV opioid. With most hospital protocols now, they usually have these standing protocols for about 24 hours following the procedure, with the hope of breaking the cycle very early in that acute pain process. For the patients that go home the same day, you may want to consider giving them opioids to go home with. We usually recommend five days of opioid treatment with frequent reassessments. We do not want to necessarily give patients more than a five-day supply of PRN medications for their pain. It's more appropriate to have them reassessed in intervals. The five-day period is something that has come up with federal, as well as state mandates, but in the acute post-operative period for the same-day procedures, this has not been instituted as a law as of yet. You may want to consider patients who do call in the post-operative period, if they are having neuropathic pain, can add on something such as gabapentin, with a ramping up of the dose, starting low, and then slowly working up over several days. So in summary, it's important to determine the type of pain pattern they have in the acute post-operative period. You want to determine their tolerance and whether or not they've had pain medications in the past. Make sure you know your different drug options that you have, and the type of pain you're treating, so that there are some drug options that flow through both those categories, the nociceptive and neuropathic, and ones that only work on either category. You want to tell this to each post-operative patient, knowing that somewhat of our goal at this point is to limit a lot of their narcotic medications and the length of time that they would be on them, and you want to set proper expectations for that patient. It's important to have a proper discharge plan, whether the patient is going home the same day or after several days of hospitalization. So at this point, we're going to be transferring over to our next speaker, Dr. Schwab, who's going to be talking about pain management in patients who are not opioid-naive. Thanks, Steve. You're welcome. So I'm going to talk about what most of our patients are like, which is not opioid-naive. These are my disclosures. You know, many of our patients have been on opioids for months before they get to us for a spine operation especially, and they have what's described as chronic pain, and chronic pain is not just acute pain that's gone on longer than some arbitrary cut-off, like three months. It's defined as pain that lasts longer than expected tissue healing. It's more complicated than acute pain, and essentially what can happen is that you get priming of the nervous system so that the patient sometimes perceives pain even when the nociceptive insult has been removed, and you get changes both infra- and supertentorially. So we all know from our experience, especially if we do spine surgery, that these patients are more difficult. They stay in the hospital longer and it's becoming more and more clear that frankly they don't do as well over the long term. So one of the problems is that the patient comes in and while they're in the hospital they've upregulated all their immune receptors, they're all saturated and you can't make any progress and you can't get good pain control and then they stay several days and they may actually have this condition called opiate-induced hyperalgesia. And some studies have shown that essentially for every 10 morphine equivalents a day, pre-op, expect that they're going to need almost one morphine equivalent per hour over a normal post-op. And if you look at this figure from Armagani from 2014, you see that patients who are on long-term opiates are much less likely at 12 months to be opiate-free. And it's not clear if that's because the severity of the pain is worse or just because they've been on opioids for longer. But many of us have started to talk about what we can do to try and improve these results. Preoperative opioid use is associated with poor outcomes after a lot of different types of surgery, not just spine and neurosurgical procedures. It costs more for the health system. There's an increased rate of complications. And we all see this, you know, the patient who comes back for pain control into the ER. So how do you deal with this? Well, you know, I used the term morphine equivalents earlier. And this is so you can have some standard and some way of talking about what the patient is on. So we need to be able to convert morphine to Norco to oxycodone, et cetera. There are a number of different ways to do this and a number of different tools. What we tend to use in our practice is the New York City Department of Health Morphine Equivalent Calculator app, which works for Android systems and for iPhone. I don't know that it is, you know, superior to others and there's always a lot of argument about which one is better, but it works more or less well for us. For patients who are high risk, we tend to use, and frankly, it's recommended by the AMA and CDC to use prescription drug monitoring programs to see if the patient is getting opiates from multiple providers. And then you should also probably consider getting urine tox screens on patients to know if the patient has been diverting meds or if they're using other illicit medications. Just be careful with the urine tox screens. Urine tox screens will be negative in a patient using oxycodone or fentanyl. So if they're on oxycodone or fentanyl, you actually have to order a special urine tox screen called a quantitative urine tox screen and that will turn up positive for those two meds. And what we do, and I don't know that we have a lot of proof that this is going to help, but we're trying and there are a number of different programs around that are doing similar efforts in our state, is we're talking to patients who are on more than 50 morphine equivalents a day about trying to decrease their narcotic meds prior to surgery. And this is sometimes a hard sell because the patient is having surgery often to treat pain and you're telling them that you want them to be off their medications prior to surgery. So you have to be able to talk to the patient intelligently about the reasoning behind this. And the reason is that the patient is going to come in and they're not going to have any receptors for the medications you give them and you're not going to be able to effectively treat their post-operative pain if they're on the same dose of opiates as they're on when you see them in the office. So we talk to patients about trying to wean them, if we have time to do so, by about 25% each week. And you decrease the long-acting medications first and then the short-acting. And our goal really is to decrease the opiates by half. And we tend to do that with the help of our pain service if it's not really obvious how to do that, especially in more complex patients if they're on buprenorphine or methadone. I don't feel personally comfortable doing that myself. In terms of what we can do, you know, to be honest, I'm not going to do medical management for pain. There are some neurosurgeons that do, but I'm not one of them. I'm hoping to operate on the patient and help them and get them back to their primary care or other treating physician. But I will recommend medical therapy, you know, as per this template based on endorsed guidelines from the International Association for the Study of Pain, which basically talks about these medications for neuropathic pain. The nortriptyline and tacipramine or the SSNRIs or gabapentin or pregabalin and then topical lidocaine. Now one of the questions that you have to decide when you see a patient coming towards surgery is what sort of multimodal analgesia you'll do, at least over the short term. So you have to decide whether you're comfortable prescribing gabapentin or if that's facilitated by sending the patient back to the PCP to prescribe. It's frankly not that hard to prescribe and titrate up gabapentin. This is sort of the standard schedule to move up on that, but even if you don't feel comfortable with that, a patient that's gabapentin naive, it is worth giving the patient 900 milligrams in the holding area. There have been multiple prospective randomized controlled trials, especially for spine surgery, that doing this can decrease opioid needs after surgery and can decrease length of stay. So it will make your patients happier, make your hospital administrators happier if you do this for gabapentin naive patients. Interoperative, we recommend discussing with your anesthesia team. There is a question about remifentanil, especially when used late in the case, that that can actually increase the pain due to this opioid-induced hyperalgesia. Ketamine, magnesium, and dextromethorphan have all been associated with reduction in postoperative opioid use as well as postoperative nausea and vomiting. We like to use dexmethomidine in our practice. We would love to use IV acetaminophen if a pharmacy would let us, but it's a hard sell to really prove to the hospital administrators that the costs of this medication are justified and that it actually makes a difference in post-op stay. So we're still trying to collect data to prove that to administration in our program. Regular use of lidocaine and bupivacaine as preoperative and regional blocks, epidural infusions, incisional agents at the end and beginning of cases, and even postoperatively, intravenously or via patches. These are a number of different references sort of on the topic for multimodal pain therapy. The other thing we recommend is instead of using combinations with Tylenol and an opiate, just give around the clock postoperative acetaminophen and then give opiates alone that are not in combination with Tylenol. If you are going to send a patient home on something that's a combination between Tylenol or acetaminophen and an opiate, don't forget to put in your notes to tell the patient not to take more than 3,000 milligrams a day total if they have normal hepatic function. If not contraindicated for your patient, just like the acute pain patient, postoperative NSAIDs can make a huge difference. There really have not been shown to be a significant difference in postoperative bleeding with the administration of NSAIDs, although obviously there are still concerns in high-dose NSAIDs of interfering with bony healing. One of the changes that's happened in our practice over time is we have a much lower threshold to put patients with high pre-op opiate use on telemetry, especially if there's any history of respiratory disease or sleep apnea. These patients are much more likely to be the ones that have problems on the floor and end up in the ICU from overdose. Frankly, we're having a much lower threshold for consulting our pain service for any patient on more than 50 millimorphine equivalents a day before surgery on methadone or buprenorphine than we did a couple of years ago before Dr. Ayer and I worked on guidelines with our colleagues in the health system. In clinic, as Dr. Falowski says, it's really important to establish expectations. We use a medication contract as to who's going to be fulfilling prescriptions and that the patient won't be getting prescriptions from other providers while we're writing for them and also that we are able to write for urinary tox screens. It's always a touchy issue how to deal with the patient who's violated the medication contract. You don't want the patient to end up in acute withdrawal, but you can get help in those situations from your pain colleagues and how to get the patient directed to detox and safely lowered on their opiates. For patients who are still on prescription pain meds 90 days after surgery, it's really a big sticking point with our primary care colleagues that we often send them back and say, you know, this is no longer acute care, you can go talk to your PCP. We've been trying to work more with our PCPs to develop a plan and to encourage the patient that they don't want to be on opiates the rest of their lives. And with all the concern in press, that's a little bit of an easier sell than it was a couple of years ago. One of the ways to talk to patients about coming off of long-term opioids is to discuss this issue of opioid-induced hyperalgesia, that you've got every receptor revved up and that actually sort of counterintuitively being on long-term opioids can cause worse pain even though when you take the pills it may give you some temporary relief. With men, we often discuss hypogonadism. With women, we often discuss bone density loss from chronic opiates that can usually induce people to be more likely to want to come off them. And for patients who are over 50 morphine equivalents, it's recommended to consider naloxone prescribing, usually intranasal. So take-home messages are really that reducing opioid use is really needed in the United States. That's been pretty clear. Reducing opioid use may actually lead to better outcomes after surgery. But I think the big caveat and one of the problems that I have with what I see in the press about decreasing opiates is that there's really not a lot of discussion about how to treat patients effectively with their pain. And reducing opioid use does not mean that patients just need to live with their pain. And we as treating physicians really need to become comfortable with prescribing other modalities, be it pharmacologic or otherwise, to effectively treat pain. Thank you. And with that, we're going to move on to Dr. Ayer. And I cannot give her control, but I think Sam can. Great. I think we have it. Thank you, Dr. Schwab. So I get the pleasure of discussing all the legal aspects of the opioid legislation that has been affecting us. And let's see, these are my disclosures. You know, it's not new that this has become such an issue. And it's become even more clear recently in the press about how serious the government has been taking this, both on federal and state levels, to the point where just past July, the DEA actually convinced a drug company to pull their long-acting drug from the market, which I think is a significant situation they managed that. The Department of Justice has been taking additional steps. And this past August, let's see, the DEA has proposed cutting Schedule I and II medication production, limiting it, reducing it by 20%. And also this August, the Department of Justice established an Opioid Fraud and Abuse Detection Unit. And this unit has already been very active, but they are really focusing on opioid-related health care fraud and has been using data to identify and prosecute individuals that they feel are contributing to the prescription opioid epidemic. And some of you may have seen this release, which actually is prior to the establishment of the abuse unit, where they had prosecuted over 400 individuals for fraud. And importantly, 120 of those were charged due to their opioid prescribing, and many of them were positioned. So while I'd like to think most of these were bad actors, we obviously have to know how to protect ourselves from these potential issues. So for me, the best defense is always a good offense, and that's knowing what are the rules and regulations and what's been put out there by the various authorities. So the CDC has established guidelines that they've been continuously updating, and they are on several fronts. One, it establishes duration parameters, which initially says three days or less of an opioid is often sufficient, and that more than seven days are rarely needed. And I think these are important because various state regulations have adopted these numbers in various ways. The CDC also recommends that for someone prescribed acute pain, if they are continuing on that medication after seven days, then the benefits and risks need to be re-evaluated in that first month after it's first prescribed. That repeat evaluation should occur then every three months, and there's a real focus on improvement in function, not in pain scores. So if an improvement in function is not documented, the recommendation is that the medication be tapered or discontinued. In addition, it recommends that the PDNP, as Dr. Seheult mentioned, I'll go into this a little bit more, detail is reviewed every three months, sorry, they're coming up out of order, that you carefully reassess when you're increasing the doses to above 15 morphine milligram equivalent per day, and that you need to justify any patient that you're titrating up to over 90 per day. If you are going to be prescribing more than three months, you should do a urine screen at initiation and every year. And they also emphasize that benzodiazepine should not be given in combination with opiates or that combination should be avoided. Now the American Medical Association has been on this putting out guidelines and has had their task force for a number of years. They've continued to update this, and they're pretty much in line with the CDC, but they've added a few additional things. They really are emphasizing the use of state prescription drug monitoring programs, the PDNPs, co-prescription of naloxone, as Dr. Schwab mentioned, for those patients that are at a risk of overdose, so in particular, as mentioned, those who are on more than 50 morphine milligram equivalent per day. And also, to encourage the safe storage and disposal of opioids in all medications, recognizing that many patients who are taking them or overusing them are actually getting them as excess from other individuals. So what are all these things that we have in our toolkit to be able to help us appropriately prescribe and also protect ourselves and our patients? So I mentioned the prescription drug monitoring programs. These are actually administered on an individual state level. They are not administered by the federal government. But each one is intended to be a central database, both scheduled to medications for any particular patient. It turns out that every state has one, with the exception of Missouri, and D.C. is currently working on developing theirs. A number of them do allow and provide regional records. So I'm in Michigan. If I go to do a search on a patient, I can click on a number of additional states to see if patients are getting prescriptions in multiple states. And one thing that is upcoming that I would like to see more broadly available is that these PDMTs are more and more being available through individual institutions, EMR. And I know in Michigan, there's recently been funding to support systems actually incorporating that from the state. so hopefully that will continue. So what's a PDMP report look like? This is when I ran on a patient that was referred to me. You can see the individual medications that the patient were taking, how much, how many days that equates to, and at least in our reports, I'm able to actually get the morphine milligram equivalent available for us, so it's easy to do that calculation, although that is not routinely for every state system, but I already know now that I have a patient who's been referred to me taking both a long-acting, a shorter-acting, as well as a benzo, so I need to be particularly careful about what sort of pain management issues I'm gonna come up with with this patient. Some PDMPs also will provide back a report card to you, the provider, and if you're in this situation, I recommend that you take a close look at it. This is mine, and I will say it says where I am relative to other individuals, similar prescribers, or within my specialty, and for me, I always look at this and say, really, if I have a patient, I'm prescribing more than 30 days, I need to look at that group and see what's going on and make sure that I have them on a pain contract and that the reasons are appropriate. So Dr. Schwab already mentioned the OPUA calculator. There are a number of these, the New York one. There are a couple of free downloads. If you happen to see one that I know why, particularly Ophiolite has the ability to put into combination sublingual, transdermal, oral medication so that you can account for all of this, but sometimes those calculations can be a challenge, but always important to know. So disposal is another thing that I think we have not emphasized enough, and we've really been starting to do that here in our institution because we know that patients will end up getting more medications prescribed to them than maybe they need, particularly those who were originally opioid naive, and any leftover medications that risk for diversion. So while patients may not want to go to this website, I provide this as a resource that you can use to look for disposal locations in your area that you can provide to patients. For us, fortunately, we have now added disposals in all of our pharmacies, so we can give that as a instruction, and particularly, for instance, when a patient is prescribed one medication that does not work for them or they get a side effect from it and you're switching them, we instruct them to come in and bring in the rest of the medication that they had not taken so that it can be disposed of and give them the new prescription. So all of these are kind of the broad pictures, but the state rules at this time are what are really the most important since they apply individually, and currently, they continue to, it continues to be that if a state rule is more restrictive than the federal rule, then the federal rule is going to accede to the state rule. So state rules vary quite a bit by their rules around duration of prescription, whether specific opioid-prescribing CMEs are required, the PDMP and documentation requirements, and here I have provided a link that you can use, and actually, it's great because it lists every single state individually with links to their specific opioid regulations. So I thought I'd give a couple of examples just to show you how these can be quite divergent in two states that are right next to each other and both have had a significant opioid issue. So in Ohio, they've specifically broken it out by acute and chronic pain with no more than a seven-day prescription and 30 morphine equivalents per day. And for them, any exceptions to those require clear documentation, and anything that exceeds those is subject to medical board review, and that documentation is subject to review. It specifically does not apply to inpatient, terminal, palliative, or addiction care, but it does not specifically state postoperative care. There are no CME or PDMP checking requirements in Ohio. However, if you move to prescribing pain medication chronically, more than three months, then it actually requires documentation of the diagnosis concurrent with another physician, regular documentation of their status, as well as regular PDMP requirements. So if we contrast that to Nextdoor in Kentucky, they established using those CDC numbers of a professional standard of a three-day prescribing limit. Now, they do specifically highlight that there is an extension to a 14-day limit following major surgery or trauma, but they also ask or advise a PDMP report be ran before prescribing, and every single prescriber has to have four and a half hours every three years of opioid management-specific CME. So you can see there's quite a bit of variability in how these are and whether or not they've defined these rules related to a surgery or acute trauma and what their documentation requirements are. So the WNS and CNS have been working hard to advocate on our behalf to be able to make this safe for the patients as well as give us a leeway that we need to adequately take care of patients and specifically pushing back against the seven-day limit to narcotic prescriptions, but also to allow for partial prescription pills so that a patient could be given a prescription for, say, 10 days, but only take home five days and not have to fill the remainder of it unless they need it to reduce the number of excess medications out. Also, obviously, we continue to work toward encouraging multimodality treatments and addiction treatment options for patients. So just recently, this is actually not been passed, but it has just been proposed. And luckily, they have been listening to the advocacy from our national organizations on this, but the Opioid Addiction Prevention Act of 2017 has been proposed. And it states that a practitioner will not prescribe any Schedule II, III, or IV opioids for the initial treatment of acute pain and amount in excess of the lesser of either seven days or that prescription limit established under state law. So again, this is where I think, even if this passes on a national level, it's gonna be very important for individuals to know what their state medical boards are setting out as guidelines. It does say that it should not prohibit a practitioner from prescribing for immediate postoperative pain relief or prescribing an amount of excess of seven-day supply if the practitioner provides a specific reason for exceeding that. It's not clear in the documentation whether or not postoperative is exempt from that documentation requirement or not. So we'll have to see how this goes forward. So general recommendations. Review the guidelines specific for your state. Utilize your state's PDMT. Utilize an opioid conversion tool. And certainly, as best you can, document your indications, routine assessments of function and diversion risk. And if you expect to be using a pain medication, certainly any time more than three months, utilize a pain contract. So I think with that, I will hand it back over to Dr. Wintry for discussion. All right, so I think we can move to questions now. If anybody has any questions, type them into the chat box and we can answer them. So if there's no questions, what I'll do is just for, since we have about 15 minutes still, just a couple of points here. One is when you have a chronic pain patient and you're gonna operate on them, I think if, especially if you're just starting out doing this, it's probably worthwhile to enlist the help of one of your pain management colleagues and work with them, with these patients, and really spend some time learning kind of how this is done. Patients who show up on high-dose narcotics, who may be on buprenorphine, which blocks the effects of medications you may give postoperatively, opioid medications, those patients can be really problematic and have runaway postoperative pain. And if you have a pain service with a relationship with the patient, on board from the get-go, you and that patient especially would be much better off. So I think if there's any doubt, talk to your pain colleagues and ask them for help if you need it. Most neurosurgeons are probably not gonna wanna take that on completely without help, and it's completely reasonable to ask help of your pain colleagues. So here's a question I'll put to the group, the faculty. So what are your recommendations for a patient with minimally invasive lumbar fusion who is discharged on postoperative day one? So I think Steve had that. So do you wanna address that? I think that was most consistent with your talk. Yes, absolutely. Do I need to be switched to the leader? Nope, just talk. Nope, okay, just talk, okay. So in a patient like that, I think that's a very typical neurosurgical patient that you're gonna see, that you're gonna have to treat their acute postoperative pain. You would hope with the minimally invasive approach that they're in slightly less pain than the typical open approaches. My practice in general, when I send patients home, either the same day or within 24 hours, we give them between a three and a five day script for PRN medications for a short-acting opioid. The most common one I use is oxycodone, five milligrams over 325, and we'll give them about 20 to 25 pills, especially, you know, this is for the opioid naive patient, and then we usually call them every two days for reassessments. The only time we usually change this protocol is when they have some kind of neuropathic pain component, which we'll add on gabapentin at that point, usually 300 milligrams TID to start for several days. All right, here's another question. Any comment on the use of PCA in opioid naive and opioid tolerant patients after, for example, an open lumbar fusion? I'll answer this just briefly. At our institution, we routinely have patients who undergo open fusions get PCA post-op. It's better to start it early, get it going so you don't lose control of pain, and then discontinue it early if it's not necessary. But I'll defer to Jason, who actually talked about the use of this in opioid tolerant patients, see what his comments are, but that's the habit at our institution. Yeah, I mean, that's been our habit as well. I think, you know, with my other hat, I work with spine surgeons around the state of Michigan on quality improvement, and actually, we've seen with a lot of the opiate naive patients, most of the patients that are most successful are actually not using PCAs, and as a result, our center has actually moved away from PCAs for opiate naive patients. We find that the patients don't do that much better, and they end up staying longer. For a patient who's a chronic opioid user, especially if they're on over 50 morphine equivalents a day, we definitely use PCA, because as Chris said, if you leave a patient in agony, you're playing catch up, and then they're really not doing well, and they end up staying in the hospital much longer because you're trying to reestablish control over their pain. All right, the next question is, what do you do with your patients with GI bleeding disorders regarding non-steroidals? I'll just open it up to anybody with experience with that. Generally, in my practice, we just won't use them, but I'd be happy to hear what other people do. Yeah, I would say, particularly if we're talking about effusion surgery, I still have a habit not to use them, but I lean a little bit more on things like Neurontin, in particular, as an adjunct to the opioids. All right, next question. What are your recommendations on extended-release opioids with spine surgery? I personally don't do spine surgery, so I'll defer to the group about this. So what I would say is, if the patient's already on an extended-release opioid, we generally continue them. Those are patients, we have a low threshold to get the pain service involved. To help give us advice, you have to expect that the patient's gonna need at least 10% over their baseline daily use to get pain control, and so you can continue to use those. You just have to be a little careful about balancing and using the opioid calculator so that you're not either overdosing or underdosing when you're combining extended-release with shorter-release, with PCA. It can get pretty complex. So next question. I have difficulty at time. Yep, go ahead. No, I was just gonna say, I think that for opioid-naive patients, moving towards extended-release opioids would be recommended as a last resort, and you really should be starting with the immediate release. Absolutely. All right, so the next question. I have difficulty at times with PCA. Patients tend to go to sleep and not get enough opiates. Thus, is there consideration for round-the-clock opiates? I find if this happens with my patients, I have a pretty close relationship with the pain service, my institution. We'll call the pain service and say, look, the patient's fallen asleep, they're waking up in pain, is it time to consider either a basal rate or perhaps a longer-dosed oral pain formulation? So something that gives them a more stable baseline dose of medication, either orally or with a basal rate with the PCA, and then to have the patient do their demand dosing with the PCA for the breakthrough spikes of pain. I'd be interested to see what the other group, what other people in the group do. I try and get them on orals as quickly as possible in this sort of situation. This is a dangerous situation. You have to be on top of these patients. These are the patients you have to tell the family that only the patient is allowed to press the button. This is the patient that you sometimes see really bad things happening. I mean, I remember a patient when I was a resident with Down syndrome and the family pressed the button so frequently that he actually died. So I would be really careful with a patient like this. I would have a very low threshold to put the patient on telemetry, and I'd convert to orals as quickly as possible. I mean, I would tell you in the opioid-naive patients that I treat, my hospital has a protocol in place that we have them on standing PO pain medications for the first 24 to 48 hours, as well as standing Neurontin for those first 24 to 48 hours. And usually in an opioid-naive patient, we don't start the PCAs. All right, so I don't see any additional questions. If anybody had their question sort of not answered sufficiently, or if they want to ask a follow-up question, we have time. If everybody's good, we can probably wrap this up, but we definitely have time for more questions if there's some things that the attendees want to bring up. I think the take-home message here is you do the best you can with the knowledge basically you have to treat the patient that's in front of you, and if you find that you're not able to do it, just ask for help. Get the acute pain service involved. It's what they're there for. And don't just delegate to them, but sort of learn from them, and you can actually work together with them and treat a few patients and really learn a lot. You can build on what you hopefully learned here today, build some practical knowledge in your hospital with the resources that are commonly used at your institution, and really learn how to optimize the treatment of these patients. It can really help a lot, and it can really help patients do a painful operation in a way that really makes it as best as possible given the circumstances, and patients really do appreciate the effort. Does anybody else have any thoughts? All right, so Samantha, I don't know if you have any questions. So Samantha, I don't see any other questions. I think we can, if there's nothing else, we can probably finish up. All right, thank you everybody for participating tonight. The AANF does designate this activity for one AMA PRA Category 1 credit with a pain subspecialty. Please confirm with your state on the specific CME requirements and if this course would fulfill any opioid CME requirements. At the conclusion of this webinar, you'll be redirected back to the course homepage to complete your evaluation and obtain your CME certificate. Thank you all and have a great evening.

Opioids

Neurosurgical practice

Safe prescribing

Effective prescribing

Compliant prescribing

Pain management

Opioid crisis

Acute post-operative pain

Chronic pain