Vision Session: Surgical Momentum - Turn Off the Spigot: Opioid Addiction May Start in Acute Care Settings

1. Turn Off the Spigot:
Opioid Addiction May Start in
Acute Care Setting
Rx Abuse Summit: Vision Session
April 8, 2015

2. 2
Our Panel
Laura Clark, MD
Anesthesiology and Acute Pain
Specialist, University of
Louisville (KY) and VA Medical
Centers
.
Gregory J. Mancini, MD
Associate Professor of Surgery
Fellowship Director - Bariatric
and Robotic Surgery
Medical Director - University
Bariatric Center
University of Tennessee
University of Tennessee
Medical Center
Michael A. Kelly, MD
Chairman, Department of
Orthopaedic Surgery,
Hackensack University Medical
Center
Amy Smalarz, PhD, CEO,
Strategic Market Insight
Moderator

3. 3
Our Sponsor
Kevin D. Jackson
President & CEO
Surgical Momentum is a Patient Safety Organization
and a Healthcare Data Analytics firm.
The company brings a specialized knowledge that
allows the community to service patients better, more
economically and with safer outcomes.

4. Opioid crisis in the United
States
01
agenda
Less Is More: Reducing the Use
of Opioids through Multimodal
Pain Management
02
Opioid reduction in action:
Examples from Clinical Practice
03
Too Much of a Good Thing:
Overprescribing Opioids Can
Lead to Misuse, Abuse, and
Diversion
04

5. 5
There is an acute opioid crisis
What is our crisis?
The overuse and presumed safety of opioids leads to
preventable harm to our patients in the hospital.
The overabundance of opioids and access to opioids in
hospitals is a problem.
The opioid addiction is particularly problematic in the hospitals
(awareness and need for non opioids) and the overuse in
prescribing after surgery leading to misuse, abuse, diversion.
opioid crisis in the United States

6. 6
Opioid Epidemic in the US
“Prescription drug overdose is
epidemic in the United States. All
too often, in far too many
communities, the treatment is
becoming the problem” Thomas
Frieden, Director of the CDC
45
45 days
6
Every 6 hours
5
5mg of
hydrocodone
.
Breakdownof the
Storyline
There are enough opioids
prescribed in the United
States so that every
American could have a full
bottle of pills—the
equivalent of…
(Centers for Disease Control and Prevention (CDC) 2011)

7. 7
2014 Guidance and
RecommendationsIn 2014, the CDC, CMS, and JACHO all provided guidance and recommendations regarding
mitigating the risk associated with opioids in the hospital setting.
CDC along with JCAHO have issued public statements urging a
call to action, beginning with a change in opioid-centric treatment
habits.
 Strategies should reflect a [patient]-centered approach and consider the
patient’s current presentation, the health care providers’ clinical judgment,
and the risks and benefits associated with the strategies, including
potential risk of dependency, addiction and abuse.
 With respect to the hospital setting, “An individualized, multimodal
treatment plan should be used to manage pain – upon assessment, the
best approach may be to start with a non-narcotic.”
 Healthcare providers should only use opioids in carefully screened and
monitored patients with non-opioid treatments are insufficient to manage
pain.
opioid crisis in the United States
… patients receiving inpatient
IV opioids need risk
assessment and appropriate
monitoring during and after
medication administration,
particularly for post-operative
patients receiving IV opioid
medications, in order to
prevent adverse events
U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. (2014). National Action Plan
for Adverse Drug Event Prevention. Washington, DC.

8. What is the evidence?
What is the situational
analysis?
How much opioids are really
used?
Do patients want them?
Reducing the
Use of Opioids
through
Multimodal Pain
Management

9. Multiple Organizations Have Urged a Shift Toward
Non-Opioid Options
JCAHO recommends “An individualized, multimodal treatment
plan should be used to manage pain—upon assessment, the best
approach may be to start with a non-narcotic”
CDC recommends “Health care providers should only use opioids
in carefully screened and monitored patients when non-opioid
treatments are insufficient to manage pain”
ASA recommends “a multimodal approach to pain management—
often beginning with a local anesthetic where appropriate”
The Joint Commission. Revisions to pain management standard effective January 1, 2015. Available at:
http://www.jointcommission.org/assets/1/23/jconline_November_12_14.pdf. Accessed November 19, 2014
1. CDC. Vital Signs: Overdoses of Prescription Opioid Pain Relievers --- United States, 1999—2008. Nov 2011;60(43);1487-1492.
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm

10. 10
Pain Opioids
Predominant Current Treatment Has
Consequences
Inadequate
treatment
of pain
Prolonge
d
Recovery
Opioid
Dependence
and
Addiction
Chronic
Pain
Opioid
Side
Effects

11. 11
56,000
Estimated adverse
events
62%
Patients
experiencing and
opioid-related side
effect
700
Deaths
.
Adverse Events
Multimodal pain management avoids an
inadequate over-reliance on opioids
>56,000 adverse events and 700 deaths have
been linked to patient controlled analgesia &
up to 62% of patients may experience an
opioid-related side effect
BUT, it’s more than
just the side-effects….

12. 12
There is a disconnect
multimodal pain management
What makespatients
anxiousorfearful?
• Theirpostsurgical
treatmentregimen
• Theuseofopioids
• Addiction
• Opioid-relatedadverse
events
What dopatients
want?
• Non-narcotic
medications
• Would rather endure
somepain(andnot
takenarcotics)
What dopatientsget?
• 95%ofpatientsreceive
opioids aftersurgery

13. 13
Sophisticated acute pain treatment
is available but underutilized
Acute Pain Specialty –
Culture change is slow
 Difficult to change from the
“single-shot” block therapy
 Access--More trained physicians
The science of pain has exploded in recent years – new knowledge, new drugs
Multimodal Therapy
Regional Infiltration /
Blocks
Combination of Several
Different Medications
targeting different
receptors
Individualized
management and follow-
up during the course of
acute recovery

14. 14
There is a disconnect in delivery of
sophisticated pain treatment
Surgeons
 Many varied beliefs and individual practice patterns
 May not have been exposed
 Pressure to maintain OR schedule
Insurance Companies
 Bundled payment for pain treatment with surgery
 Lag between recognizing new therapies and payment
plans
 Leading to a Lack of specialists
Hospitals- Support
 More Acute Pain Nurses
Patients
 Really do not know what may be available

15. 15
There are alternatives
We MUST treat pain adequately in the acute pain setting
We should be providing Sophisticated multimodal pain
treatment therapy
 Only reserving opioids for rescue therapy
There are non-opioid options that adequately control pain in
the postsurgical setting
 Regional Analgesia
 Liposomal Bupivacaine
 IV Acetaminophen
 Others
-

16. We can do more
It’s possible to reduce opioid
consumption and maintain or
even improve clinical
outcomes
Opioid reduction
in action:
Examples from
clinical practice

17. 17
Who we are
An advanced surgical practice that is
patient-focused
We address pain management
challenges in surgery head-on
opioid reduction in action

18. 18
The State of Tennessee
opioid reduction in action

19. 19
Tennessee At-A-Glance
opioid reduction in action

20. 20
Technique evolution but what about
pain medication evolution?
While there have been advances in techniques of
managing complex ventral hernias, including minimally
invasive surgery, less work has been done when it
comes to perioperative pain planning.
In our practice, we changed that!
 Assessment of current pain levels
and pain management
 Assess patient risk for opioid
dependence based on past history
 Discuss the likely disability or
improvement with the surgical
procedure
 Agree on pain treatment plan and
duration
 Ask for help and collaboration from
medical colleagues
opioid reduction in action

21. 21
Preoperative goals for ME
“Failing to prepare is
preparing to fail.”
- Coach John Wooden
opioid reduction in action

22. 22
Our results
No TAP
Block (51)
TAP Block
(50)
Percent
Change
Length of
stay
4.6 (0-19)
days
2.7 (0-13)
days
Decrease
41%
PACU
Morphine
equiv.
12.0 (0-41.6)
mg
8.2 (0-43.3)
mg
Decrease
32%
No pain in
PACU
8/51 (15.7%) 13/50 (26%)
Total
Morphine
equiv.
159.1 (0-
1019.3) mg
91.9 (0-
546.6) mg
Decrease
42%
No TAP
Block (17)
TAP Block
(43)
Percent
Change
IV/IM
Morphine
equiv.
276.3 mg 99.3 mg Decrease
64%
Oral
Morphine
equiv.
55.6 mg 44.7 mg Decrease
20%
Total
Morphine
equiv.
331.9 mg 143.0 mg Decrease
57%
Length of
stay
6.8 days 4.5 days Decrease
34%
opioid reduction in action
Decreased PACU
and total morphine
equivalent
Decreased IV/IM,
oral and total
morphine equivalent

23. 23
Where surgeons go from here
 Need continued support from states
to facilitate narcotic reporting and
surveillance
 Need to invest time in our patients to
set expectations about pain
management and recovery to
minimize opioid use
 Need Pharma to provide affordable
and effective pain medications that
minimize abuse potential
opioid reduction in action

24. Not providing alternatives to
opioids following surgery has
created an Acute Opioid Crisis
The acute hospitals setting is a
leading source contributing to
the Opioid Epidemic
Too Much of a
Good Thing:
Overprescribing
Opioids Can
Lead to Misuse,
Abuse, and
Diversion

25. 1. http://www.economist.com/news/united-states/21633819-old-sickness-has-returned-haunt-new-generation-great-american-relapse
2. http://usatoday30.usatoday.com/news/health/2002-08-13-detox_x.htm
3. http://health.usnews.com/health-news/patient-advice/articles/2015/01/09/prescription-opioids-pain-relief-comes-with-risks
The New Face of the Opioid
Epidemic
Consequences of Acute Care Opioids are far reaching
Ayounggrandmotherfroma
middle-classsuburb1
• Battlingheroinaddiction
afterdevelopingdependence
onOxyContin®followinghip
surgery
Anaccomplishedathlete2
• Strugglingwith
prescriptionopioidabuse
followingbacksurgery
A16year-oldhighschool
student3
• Diedfromtakingjust1pill
originallyoverprescribedto
someoneelse
too much of a good thing

26. How did we get here?
˃70 million patients per year are prescribed opioids for postsurgical pain1
1 in 15 will go on to long-term use or abuse2,3
Resulting in the rapid proliferation of new opioid users coming from the acute care
setting2,3
too much of a good thing
1.Adamson, et al. Hosp Pharm. 2011;46(6 Suppl 1):1-3.
2.Alam A, et al. Arch Intern Med, 2012; 172(5): 425-30.
3.Carroll I, et al. Anesth Analg, 2012; 115(3): 694-702.
4. Office of National Drug Control Policy. Available at: http://www.whitehouse.gov/blog/2014/06/19/white-house-summit-opioid-epidemic.
Accessed November 25, 2014;. 2. http://www.cdc.gov/vitalsigns/pdf/2014-07-vitalsigns.pdf

27. Long-term use is demonstrated
across surgical settings…
too much of a good thing
In patients undergoing various soft tissue or orthopedic
procedures1:
of patients continued on new opioids after surgery
1 year after elective spine surgery2:
of all patients were still using opioids
of previously opioid-naïve patients were still using1.Carroll I, et al. A pilot cohort study of the determinants of longitudinal opioid use after surgery. Anesth Analg. 2012;115:694-702.
2.Wang M, et al. Predictors of 12-Month opioid use after elective cervical spine surgery for degenerative changes. Spine. 2013;
13(suppl):S6-S7.

28. In patients ˃65 undergoing low-risk surgery who received an opioid Rx within a week of
surgery 1:
were still taking opioids a year later.
There was a in the likelihood they would become long-term opioid
users
Compared to non-athletes, adolescents males who participate in organized sports
have2:
…And across patient types
Both our elderly & children are at risk
too much of a good thing
2x 4x 10x
the odds of
misusing opioids
to get high
the odds of
medical misuse
of opioids due to
taking too much
the risk for being
prescribed an
opioid medication
1.Alam A, et al. Arch Intern Med. 2012;172:425-30.
2. P. Veliz et al. Journal of Adolescent Health 54 (2014) 333e340

29. 29
Over-prescription leads to a high
potential for diversion
In patients undergoing outpatient upper extremity surgery¹
too much of a good thing
1. Rogers J, et al. Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am.
2012;37:645-50.

30. 30
Diversion of pain relievers is common
68% of people using pain
relievers non-medically obtain
them from a friend or
relative.¹
According to a 2009 survey of
substances most easily
bought by teenagers
prescription drugs are easier
to obtain than beer.²
too much of a good thing
Free from
Friend/Relative
(53.0%)
Bought/Took from
Friend/Relative
(14.6%)
Drug Dealer/Stranger
(4.3%)
Internet (0.1%)
Other (4.3%)
One Doctor (21.2%)
More than One Doctor
(2.6%)
Sources Where User Obtained
*Data are from 2012–2013.
1. Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health: Summary of National Findings,
NSDUH Series H-48, HHS Publication No. (SMA) 14-4863. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2014.
2. The National Center on Addiction and Substance Abuse at Columbia University: National Survey of American Attitudes on Substance Abuse XIV: Teens and
Parents. New York, NY; August 2009.

31. 31
Healthcare providers and diversion
too much of a good thing
Substandard care delivered by an impaired healthcare provider
Denial of essential pain medication or therapy
Risk of infection
Therearemanyriskswhen healthcare providers
stealcontrolledsubstancessuchasopioidsfor
theirownuse.

32. 32
Infection and healthcare providers
too much of a good thing
http://www.cdc.gov/injectionsafety/drugdiversion

33. What can we do today?
What can we do tomorrow?
What message should we
share?
Call to Action

34. 34
Why are we here?
call to action
We can do
more
We need to
do more
Patients
need a
choice

35. The time for change is now
The ability to reduce, delay, or eliminate the need for opioids in the
postsurgical setting is critical to curbing the rapid proliferation of new
opioids—and new opioid users—across the United States
Our patients deserve better. Our communities and families deserve better. We
can, and must, do better
call to action

36. Thank you!