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Patel J, Snyder K, Brooks AK. Perioperative pain optimization in the age of the opioid epidemic. Curr Opin Anaesthesiol 2024; 37:279-284. [PMID: 38573179 DOI: 10.1097/aco.0000000000001370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW The opioid epidemic remains a constant and increasing threat to our society with overdoses and overdose deaths rising significantly during the COVID-19 pandemic. Growing evidence suggests a link between perioperative opioid use, postoperative opioid prescribing, and the development of opioid use disorder (OUD). As a result, strategies to better optimize pain management during the perioperative period are urgently needed. The purpose of this review is to summarize the most recent multimodal analgesia (MMA) recommendations, summarize evidence for efficacy surrounding the increased utilization of Enhanced Recovery After Surgery (ERAS) protocols, and discuss the implications for rising use of buprenorphine for OUD patients who present for surgery. In addition, this review will explore opportunities to expand our treatment of complex patients via transitional pain services. RECENT FINDINGS There is ample evidence to support the benefits of MMA. However, optimal drug combinations remain understudied, presenting a target area for future research. ERAS protocols provide a more systematic and targeted approach for implementing MMA. ERAS protocols also allow for a more comprehensive approach to perioperative pain management by necessitating the involvement of surgical specialists. Increasingly, OUD patients taking buprenorphine are presenting for surgery. Recent guidance from a multisociety OUD working group recommends that buprenorphine not be routinely discontinued or tapered perioperatively. Lastly, there is emerging evidence to justify the use of transitional pain services for more comprehensive treatment of complex patients, like those with chronic pain, preoperative opioid tolerance, or substance use disorder. SUMMARY Perioperative physicians must be aware of the impact of the opioid epidemic and explore methods like MMA techniques, ERAS protocols, and transitional pain services to improve the perioperative pain experience and decrease the risks of opioid-related harm.
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Affiliation(s)
- Janki Patel
- Department of Anesthesiology, Section on Pain Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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Carnago L, Knisely MR, Malek J. Ethical considerations and decision making in opioid prescribing for chronic pain: A case study in rheumatology practice. J Am Assoc Nurse Pract 2024; 36:300-306. [PMID: 38330235 DOI: 10.1097/jxx.0000000000001002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/09/2024] [Indexed: 02/10/2024]
Abstract
ABSTRACT Dilemmas regarding opioid prescribing for chronic pain frequently occur within health care settings. The ethical principles of autonomy, beneficence, nonmaleficence, and justice, as well as the principles of care ethics, can assist in addressing these opioid-related dilemmas. The purpose of this clinical case study is to provide a case study highlighting an opioid prescribing dilemma and then identify opioid-related transition considerations; address ethical questions that nurse practitioners (NPs) may encounter in clinical practice when providing care for individuals living with chronic pain who may need or use a prescribed opioid medication; and draw on the ethical principles and care ethics to provide guidance for NPs who face these challenging issues.
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Affiliation(s)
- Lisa Carnago
- Division of Rheumatology & Immunology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
- Duke University School of Nursing, Durham, North Carolina
| | | | - Janet Malek
- Center for Medical Ethics and Health Policy, Baylor College of Medicine, Houston, Texas
- Duke Initiative for Science and Society, Duke University, Durham, North Carolina
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Alessio-Bilowus D, Luby AO, Cooley S, Evilsizer S, Seese E, Bicket M, Waljee JF. Perioperative Opioid-Related Harms: Opportunities to Minimize Risk. Semin Plast Surg 2024; 38:61-68. [PMID: 38495063 PMCID: PMC10942841 DOI: 10.1055/s-0043-1778043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Although substantial attention has been given to opioid prescribing in the United States, opioid-related mortality continues to climb due to the rising incidence and prevalence of opioid use disorder. Perioperative care has an important role in the consideration of opioid prescribing and the care of individuals at risk for poor postoperative pain- and opioid-related outcomes. Opioids are effective for acute pain management and commonly prescribed for postoperative pain. However, failure to align prescribing with patient need can result in overprescribing and exacerbate the flow of unused opioids into communities. Conversely, underprescribing can result in the undertreatment of pain, complicating recovery and impairing well-being after surgery. Optimizing pain management can be particularly challenging for individuals who are previously exposed to opioids or have critical risk factors, including opioid use disorder. In this review, we will explore the role of perioperative care in the broader context of the opioid epidemic in the United States, and provide considerations for a multidisciplinary, comprehensive approach to perioperative pain management and optimal opioid stewardship.
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Affiliation(s)
- Dominic Alessio-Bilowus
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
| | - Alexandra O. Luby
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
| | | | | | | | - Mark Bicket
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Division of Pain Research, Department of Anesthesiology, Michigan Medicine, Ann Arbor, Michigan
| | - Jennifer F. Waljee
- Section of Plastic Surgery, Department of Surgery, Michigan Medicine, Ann Arbor, Michigan
- Opioid Prescribing Engagement Network, Ann Arbor, Michigan
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor, Michigan
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Manoharan D, Xie A, Hsu YJ, Flynn HK, Beiene Z, Giagtzis A, Shechter R, McDonald E, Marsteller J, Hanna M, Speed TJ. Patient Experiences and Clinical Outcomes in a Multidisciplinary Perioperative Transitional Pain Service. J Pers Med 2023; 14:31. [PMID: 38248732 PMCID: PMC10821325 DOI: 10.3390/jpm14010031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 12/18/2023] [Accepted: 12/20/2023] [Indexed: 01/23/2024] Open
Abstract
Siloed pain management across the perioperative period increases the risk of chronic opioid use and impedes postoperative recovery. Transitional perioperative pain services (TPSs) are innovative care models that coordinate multidisciplinary perioperative pain management to mitigate risks of chronic postoperative pain and opioid use. The objective of this study was to examine patients' experiences with and quality of recovery after participation in a TPS. Qualitative interviews were conducted with 26 patients from The Johns Hopkins Personalized Pain Program (PPP) an average of 33 months after their first PPP visit. A qualitative content analysis of the interview data showed that participants (1) valued pain expectation setting, individualized care, a trusting patient-physician relationship, and shared decision-making; (2) perceived psychiatric treatment of co-occurring depression, anxiety, and maladaptive behaviors as critical to recovery; and (3) successfully sustained opioid tapers and experienced improved functioning after PPP discharge. Areas for improved patient-centered care included increased patient education, specifically about the program, continuity of care with pain specialists while tapering opioids, and addressing the health determinants that impede access to pain care. The positive patient experiences and sustained clinical benefits for high-risk complex surgical patient support further efforts to implement and adapt similar models of perioperative pain care.
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Affiliation(s)
- Divya Manoharan
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Anping Xie
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
| | - Yea-Jen Hsu
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Hannah K. Flynn
- Loyola College of Arts & Sciences, Loyola University Maryland, Baltimore, MD 21210, USA
| | - Zodina Beiene
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Alexandros Giagtzis
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
| | - Ronen Shechter
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Eileen McDonald
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Jill Marsteller
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD 21202, USA;
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA;
| | - Marie Hanna
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (A.X.); (Z.B.); (R.S.); (M.H.)
| | - Traci J. Speed
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (D.M.)
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Tierney S, Magnan MC, Zahrai A, McIsaac D, Poulin P, Stratton A. Feasibility of a multidisciplinary Transitional Pain Service in spine surgery patients to minimise opioid use and improve perioperative outcomes: a quality improvement study. BMJ Open Qual 2023; 12:e002278. [PMID: 37336575 PMCID: PMC10314708 DOI: 10.1136/bmjoq-2023-002278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/01/2023] [Indexed: 06/21/2023] Open
Abstract
INTRODUCTION Spine surgery patients have high rates of perioperative opioid consumption, with a chronic opioid use prevalence of 20%. A proposed solution is the implementation of a Transitional Pain Service (TPS), which provides patient-tailored multidisciplinary care. Its feasibility has not been demonstrated in spine surgery. The main objective of this study was to evaluate the feasibility of a TPS programme in patients undergoing spine surgery. METHODS Patients were recruited between July 2020 and November 2021 at a single, tertiary care academic centre. Success of our study was defined as: (1) enrolment: ability to enrol ≥80% of eligible patients, (2) data collection: ability to collect data for ≥80% of participants, including effectiveness measures (oral morphine equivalent (OME) and Visual Analogue Scale (VAS)-perceived analgesic management and overall health) and programme resource requirements measures (appointment attendance, 60-day return to emergency and length of stay), and (3) efficacy: estimate potential programme effectiveness defined as ≥80% of patients weaned back to their intake OME requirements at programme discharge. RESULTS Thirty out of 36 (83.3%) eligible patients were enrolled and 26 completed the TPS programme. The main programme outcomes and resource measures were successfully tracked for >80% of patients. All 26 patients had the same or lower OME at programme discharge than at intake (intake 38.75 mg vs discharge 12.50 mg; p<0.001). At TPS discharge, patients reported similar overall health VAS (pre 60.0 vs post 70.0; p=0.14), improved scores for VAS-perceived analgesic management (pre 47.6 vs post 75.6; p<0.001) and improved Brief Pain Inventory pain intensity (pre 39.1 vs post 25.0; p=0.02). CONCLUSION Our feasibility study successfully met or exceeded our three main objectives. Based on this success and the defined clinical need for a TPS programme, we plan to expand our TPS care model to include other surgical procedures at our centre.
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Affiliation(s)
- Sarah Tierney
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Marie-Claude Magnan
- Department of Orthopedics, Spine Division, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Amin Zahrai
- Department of Clinical Psychology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Daniel McIsaac
- Department of Anesthesiology and Pain Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Patricia Poulin
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Clinical Psychology, Ottawa Hospital, Ottawa, Ontario, Canada
| | - Alexandra Stratton
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Orthopedics, Spine Division, Ottawa Hospital, Ottawa, Ontario, Canada
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