Opioid Stewardship Program and Postoperative Adverse Events

Opioid Management Review Committee: Fostering Interdisciplinary Education and Support Amid the Ongoing US Opioid Overdose Crisis

BACKGROUND

Over the past two decades, pain and suffering caused by the U.S. opioid crisis have resulted in significant morbidity, policy reforms and healthcare resource strain, and affected healthcare providers' efforts to manage their patients' pain. In 2017, Cleveland Clinic's Department of Palliative and Supportive Care established their Opioid Management Review Committee (OMRC), which focuses on patient safety, opioid stewardship, education on specialist pain management and addiction medicine skills, and offers emotional and informational support to colleagues managing complex pain cases.

OBJECTIVES

This quality assessment and improvement activity describes the organization and effects of the OMRC on healthcare workers in the department.

METHODS

On February 1, 2023, an online survey was distributed to attendees of the OMRC. Participants were asked to provide their demographic information and free text responses to questions about the purpose of the OMRC, their judgment about the extent to which the OMRC has changed their approach to pain management, the OMRC's impact on their approach to opioid management, its impact on the clinicians' confidence in managing nonmedical opioid use or comorbid substance use, and suggestions to improve future meetings.

RESULTS

Fifty-nine out of 79 clinicians completed the survey (75% response rate). Participants' aggregate responses indicated that the committee fostered interdisciplinary collaboration, provided emotional and professional support, increased awareness of responsible opioid prescribing, and enhanced confidence in managing complex cases involving non-medical opioid use or comorbid substance use.

CONCLUSION

The OMRC represents a comprehensive interdisciplinary approach to safely manage opioid therapy during the contemporary opioid overdose crisis.

Reducing inpatient opioid consumption after caesarean delivery: effects of an opioid stewardship programme and racial impact in a community hospital

Caesarean section is the most common inpatient surgery in the USA, with more than 1.1 million procedures in 2020. Similar to other surgical procedures, healthcare providers rely on opioids for postoperative pain management. However, current evidence shows that postpartum patients usually experience less pain due to pregnancy-related physiological changes. Owing to the current opioid crisis, public health agencies urge providers to provide rational opioid prescriptions. In addition, a personalised postoperative opioid prescription may benefit racial minorities since research shows that this population receives fewer opioids despite greater pain levels. Our project aimed to reduce inpatient opioid consumption after caesarean delivery within 6 months of the implementation of an opioid stewardship programme.A retrospective analysis of inpatient opioid consumption after caesarean delivery was conducted to determine the baseline, design the opioid stewardship programme and set goals. The plan-do-study-act method was used to implement the programme, and the results were analysed using a controlled interrupted time-series method.After implementing the opioid stewardship programme, we observed an average of 80% reduction (ratio of geometric means 0.2; 95% CI 0.2 to 0.3; p<0.001) in inpatient opioid consumption. The institution designated as control did not experience relevant changes in inpatient opioid prescriptions during the study period. In addition, the hospital where the programme was implemented was unable to reduce the difference in inpatient opioid demand between African Americans and Caucasians.Our project showed that an opioid stewardship programme for patients undergoing caesarean delivery can effectively reduce inpatient opioid use. PDSA, as a quality improvement method, is essential to address the problem, measure the results and adjust the programme to achieve goals.

Intravenous lidocaine infusion compared to thoracic epidural analgesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy. A retrospective case-cohort study

BACKGROUND

Intravenous (IV) lidocaine is a proven analgesic therapy but has not been evaluated in extensive procedures such as cytoreductive surgery (CRS). Our aim was to assess the effectiveness and safety of IV lidocaine in this setting.

METHODS

This is a retrospective hybrid case-cohort study investigating analgesic effectiveness and complications of perioperative IV lidocaine at 1.5 mg/kg/h for 48 h compared to thoracic epidural anaesthesia (TEA) among patients undergoing CRS in a high-volume centre.

RESULTS

Sixty patients were included, 20 received IV lidocaine and 40 underwent TEA. Pain scores were low (median ≤2) and similar in both groups (p = 0.88). At 72 h, the lidocaine group had a lower median pain score (p = 0.03). Overall opioid consumption in the first 48 h was lower in the lidocaine compared to the TEA group (median 0 (IQR 0-9.5) mg vs. 45.4 (0-62.4) MME respectively, p = 0.001). Opioid consumption was also lower in the lidocaine compared to the TEA group during the whole 5-day period (median 1 (IQR 1-13.5) mg vs. 112 (36.6-137.85) MME respectively, p = 0.000). The incidence of PONV was significantly lower in the lidocaine group (27.5% vs 5%, p = 0.047) with no difference in other complications or length of in-hospital stay.

CONCLUSION

Intravenous lidocaine infusion may be a safe and effective analgesic approach in CRS and is associated with a significant reduction of opioid use and PONV compared to opioid-containing TEA.

Society of Pain and Palliative Care Pharmacists White Paper on the Role of Opioid Stewardship Pharmacists

Opioid stewardship is one essential function of pain and palliative care pharmacists and a critical need in the United States. In recent years, this country has been plagued by two public health emergencies: an opioid crisis and the COVID-19 pandemic, which has exacerbated the opioid epidemic through its economic and psychosocial toll. To develop an opioid stewardship program, a systematic approach is needed. This will be detailed in part here by the Opioid Stewardship Taskforce of the Society of Pain and Palliative Care Pharmacists (SPPCP), focusing on the role of the pharmacist. Many pain and palliative care pharmacists have made significant contributions to the development and daily operation of such programs while also completing other competing clinical tasks, including direct patient care. To ensure dedicated time and attention to critical opioid stewardship efforts, SPPCP recommends and endorses opioid stewardship models employing a full time, opioid stewardship pharmacist in both the inpatient and outpatient setting. Early research suggests that opioid stewardship pharmacists are pivotal to improving opioid metrics and pain care outcomes. However, further research and development in this area of practice is needed and encouraged.

Effect of Scalp Nerve Block Combined with Intercostal Nerve Block on the Quality of Recovery in Patients with Parkinson’s Disease after Deep Brain Stimulation: Protocol for a Randomized Controlled Trial

Background: Parkinson’s disease (PD) patients who receive deep brain stimulation (DBS) have a higher risk of postoperative pain, which will affect their postoperative quality of recovery (QoR). Scalp nerve block (SNB) and intercostal nerve block (ICNB) can alleviate postoperative pain, yet their effect on postoperative QoR in PD patients has proven to be unclear. Therefore, we have aimed to explore the effect of SNB paired with ICNB on postoperative QoR. Methods: To explore the effect, we have designed a randomized controlled trial in which 88 patients with PD will be randomly assigned to either an SNB group or control group, receiving either SNB combined with ICNB or without before surgery. The primary outcome will be a 15-item QoR score at 24 h after surgery. The secondary outcomes will include: 15-item QoR scores at 72 h and 1 month after surgery; the numeric rating scale pain scores before discharge from the postanesthesia care unit (PACU) at 24 h, 72 h, and 1 month after surgery; rescue analgesics; nausea and vomiting 24 h after operation and remifentanil consumption during operation; emergence agitation; the duration of anesthesia and surgery; time to respiratory recovery, time to response, and time to extubation; the PACU length of stay; as well as adverse events. Proposed protocol and conclusion: Our findings will provide a novel method for the management of recovery and acute pain after DBS in PD patients. This research was registered at clinicaltrials.gov NCT05353764 on 19 April 2022.

Association of Race and Ethnicity with Pediatric Postoperative Pain Outcomes

INTRODUCTION

Inequitable variability in healthcare practice negatively affects patient outcomes. Children of color may receive different analgesic medications in the perioperative period, resulting in different outcomes.

METHODS

Medical records of children 0 to ≤ 18 years old from May 2014 to August 2019 were reviewed. The exposure was racial or ethnic groups: Asian, Black, Hispanic, Pacific Islander, and White non-Hispanic (reference).

PRIMARY OUTCOME

post-anesthesia care unit mean pain score.

SECONDARY OUTCOMES

inpatient mean pain score; opioid, antiemetic, and antipruritic administration in the post-anesthesia care unit and inpatient ward. The association of race or ethnicity with outcomes was modeled using multilevel logistic regression, adjusting for confounders and covariates.

RESULTS

Twenty-nine thousand six hundred fourteen cases are included. In the post-anesthesia care unit, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate-severe pain as compared to White non-Hispanic patients; Asian children had lower odds of receiving opioids and lower odds of having a moderate-severe mean pain score. In the inpatient setting, Black, Hispanic, and Pacific Islander children had no significant difference in the odds of receiving opioids or having moderate severe-pain as compared to White non-Hispanic children, but Asian children had lower odds of receiving opioids and of having a moderate-severe mean pain score.

CONCLUSIONS

Asian children had lower odds of receiving opioids and having moderate-severe pain postoperatively compared to the White non-Hispanic children. These differences may be a function of variation in patient/caregivers culture or healthcare provider care and warrant further investigation.

Feasibility and effectiveness of opioid-free anesthesia in cytoreductive surgery with or without heated intraperitoneal chemotherapy

BACKGROUND

Opioid-free anesthesia (OFA) provides analgesia minimizing opioids. OFA has not been evaluated in cytoreductive surgery (CRS) with or without heated intraperitoneal chemotherapy. We aim to evaluate OFA feasibility and effectiveness in CRS.

METHODS

Retrospective cohort study of adult patients (84) undergoing CRS in a tertiary center from May 2020 until June 2021. Predefined protocols for either opioid-based anesthesia (OBA) or OFA were followed.

RESULTS

OFA protocol patients (41) had better mean pain scores (1 ± 0.8 vs. 2 ± 1; p = 0.00) despite the avoidance of intravenous and epidural fentanyl intraoperatively (220 ± 104 and 194 ± 73 µg, respectively, in OBA vs. 0; p = 0.00). Postoperative epidural levobupivacaine was also lower in the OFA group (575 ± 192 vs. 706 ± 346 mg; p = 0.034) despite the lack of epidural fentanyl without difference in duration (4.3 ± 1.2 vs. 4 ± 1.2 days; p = 0.22). Morphine consumption was very low (4.1 ± 10 vs. 1.7 ± 5 mg; p = 0.16). Intraoperative hypertensive events and postoperative nausea and vomiting (PONV) were higher for OBA (43) (30.2% vs. 7.3%; p = 0.01% and 69.8% vs. 34.1%; p = 0.001, respectively). Postoperative epidural fentanyl was independently associated with PONV (p = 0.004). There was no difference in total complications or length of stay.

CONCLUSION

OFA is feasible, safe, and offers optimal pain control while minimizing the use of opioids in CRS.

Opioids and Public Health: The Prescription Opioid Ecosystem and Need for Improved Management

While U.S. opioid prescribing has decreased 38% in the past decade, opioid deaths have increased 300%. This opioid paradox is poorly recognized. Current approaches to opioid management are not working, and new approaches are needed. This article reviews the outcomes and shortcomings of recent U.S. opioid policies and strategies that focus primarily or exclusively on reducing or eliminating opioid prescribing. It introduces concepts of a prescription opioid ecosystem and opioid pool, and it discusses how the pool can be influenced by supply-side, demand-side, and opioid returns factors. It illuminates pressing policy needs for an opioid ecosystem that enables proper opioid stewardship, identifies associated responsibilities, and emphasizes the necessity of making opioid returns as easy and common as opioid prescribing, in order to minimize the size of the opioid pool available for potential diversion, misuse, overdose, and death. Approaches are applicable to opioid prescribing in general, and to opioid prescribing after surgery.

Perioperative Pain Management for Surgical Patients with Opioid Use Disorder: A Program Development Initiative

PURPOSE

Over the last decade an increased number of individuals have been diagnosed with Opioid Use Disorder (OUD) and state-level regulatory pressure has mounted to develop the capability to provide opioid-free anesthesia (OFA) on clinical indication or at patient request.

DESIGN

A program initiative for OUD patients who require OFA was developed and implemented in two phases.

METHOD

Phase I assessed the needs and knowledge of licensed nurse anesthetists in the state of Florida. Phase II recruited volunteers for a day-long event which involved both didactic and simulation training. Data collection for phase II included: demographics, knowledge, evidence-based practice belief scale (EBPBS), and evidence-based practice implementation scale (EBPIS) which measures the perceived ability to implement those beliefs. Phase II training was divided into three domains: Preoperative, Intraoperative and Postoperative with didactic and simulation experiences for each domain.

FINDINGS

The phase II participants pre-simulation median total knowledge assessment score was 9 with median scores of 5 for questions 1 to 6 and 4 for questions 7 to 12. After participating in simulation, median knowledge assessment scores increased to 11, with median scores of 6 for questions 1 to 6 and 5 for questions 7 to 12. Before simulation training, median scores for the EBPBS and EBPIS were 66 (IQR 8) and 22 (IQR 24) respectively. After simulation, the median EBPBS score increased to 76 (IQR 7.5), a significant improvement from pre-simulation (P = .002).

CONCLUSION

There is a lack of knowledge and training of anesthesia providers on how to manage the growing population of patients with OUD. This program initiative increased perceived ability to provide OFA care to patients with OUD presenting for surgery.

Opioid use, misuse, and abuse: a narrative review about interventions to reduce opioid consumption and related adverse events in the perioperative setting

Opioids remain the most potent and predictable drug available for perioperative analgesia and moderate-to-severe cancer-related pain. However, their efficacy has been questioned in other clinical settings. Moreover, opioids are associated with a wide variety of dose-dependent adverse events, limiting their use. The indiscriminate prescription of opioids has fueled the so-called "opioid epidemic" in the United States and other developed countries. Thus, there has been a significant effort to develop strategies to curtail their unnecessary prescription. Here, we summarize the history, current trends, and new directions in perioperative opioid prescription in an unbiased manner.

A multisociety organizational consensus process to define guiding principles for acute perioperative pain management

The US Health and Human Services Pain Management Best Practices Inter-Agency Task Force initiated a public-private partnership which led to the publication of its report in 2019. The report emphasized the need for individualized, multimodal, and multidisciplinary approaches to pain management that decrease the over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders. The Task Force specifically called on specialty organizations to work together to develop evidence-based guidelines. In response to this report's recommendations, a consortium of 14 professional healthcare societies committed to a 2-year project to advance pain management for the surgical patient and improve opioid safety. The modified Delphi process included two rounds of electronic voting and culminated in a live virtual event in February 2021, during which seven common guiding principles were established for acute perioperative pain management. These principles should help to inform local action and future development of clinical practice recommendations.

An international multidisciplinary consensus statement on the prevention of opioid-related harm in adult surgical patients

This international multidisciplinary consensus statement was developed to provide balanced guidance on the safe peri-operative use of opioids in adults. An international panel of healthcare professionals evaluated the literature relating to postoperative opioid-related harm, including persistent postoperative opioid use; opioid-induced ventilatory impairment; non-medical opioid use; opioid diversion and dependence; and driving under the influence of prescription opioids. Recommended strategies to reduce harm include pre-operative assessment of the risk of persistent postoperative opioid use; use of an assessment of patient function rather than unidimensional pain scores alone to guide adequacy of analgesia; avoidance of long-acting (modified-release and transdermal patches) opioid formulations and combination analgesics; limiting the number of tablets prescribed at discharge; providing deprescribing advice; avoidance of automatic prescription refills; safe disposal of unused medicines; reducing the risk of opioid diversion; and better education of healthcare professionals, patients and carers. This consensus statement provides a framework for better prescribing practices that could help reduce the risk of postoperative opioid-related harm in adults.