How the acute pain physician can help with the opioid crisis

1. Colin J.L. McCartneyColin J.L. McCartney
MBChB PhD FCARCSI FRCA FRCPCMBChB PhD FCARCSI FRCA FRCPC
Professor and Chair of Anesthesiology and Pain MedicineProfessor and Chair of Anesthesiology and Pain Medicine
University of OttawaUniversity of Ottawa
Head of Anesthesiology and Pain MedicineHead of Anesthesiology and Pain Medicine
The Ottawa HospitalThe Ottawa Hospital
Scientist, Ottawa Hospital Research InstituteScientist, Ottawa Hospital Research Institute
Acute Pain Physicians andAcute Pain Physicians and
the Opioid Crisisthe Opioid Crisis

2. MBChB PhD FCARCSI FRCA FRCPC

3. Conflicts of InterestConflicts of Interest
 NoneNone

4. cmccartney@toh.ca
@colinjmccartney

7. SummarySummary
 The opioid crisis and the impact ofThe opioid crisis and the impact of
perioperative careperioperative care
 The problem of acute pain (extent, risks ofThe problem of acute pain (extent, risks of
inadequate treatment, Knowledgeinadequate treatment, Knowledge
TranslationTranslation
 How can we help? (screening, KT forHow can we help? (screening, KT for
multimodal analgesia, support patients inmultimodal analgesia, support patients in
post-op care)post-op care)

12. Soneji N et al Jama Surgery 2016

16. SummarySummary
 The opioid crisis and the impact ofThe opioid crisis and the impact of
perioperative careperioperative care
 The problem of acute pain (extent, risks ofThe problem of acute pain (extent, risks of
inadequate treatment, Knowledgeinadequate treatment, Knowledge
TranslationTranslation
 How can we help? (screening, KT forHow can we help? (screening, KT for
multimodal analgesia, support patients inmultimodal analgesia, support patients in
post-op care)post-op care)

17. A&A 2003

19.  300 patients300 patients
 2/3 had moderate-severe pain after surgery2/3 had moderate-severe pain after surgery
 No change from 10 years earlierNo change from 10 years earlier
Gan TJ et al CMRO 2014

20. Incidence ofIncidence of
Chronic Post-Surgical PainChronic Post-Surgical Pain
 Pain after surgery of primary concern toPain after surgery of primary concern to
patients (Apfelbaum et al 1999)patients (Apfelbaum et al 1999)
 Acute postoperative pain remainsAcute postoperative pain remains
undertreatedundertreated
 Incidence of severe acute pain a problemIncidence of severe acute pain a problem
 Severe acute pain associated with CPSPSevere acute pain associated with CPSP
 Definition: pain >2 months after surgeryDefinition: pain >2 months after surgery
 8% of all surgery leads to pain-disability at8% of all surgery leads to pain-disability at
1 year (Kluger)1 year (Kluger)

21.  5130 patients attending chronic pain5130 patients attending chronic pain
clinicsclinics
 Surgery contributed to pain in 22.5%Surgery contributed to pain in 22.5%
 Research needed into: aetiology andResearch needed into: aetiology and
procedures contributing to highest risk ofprocedures contributing to highest risk of
CPSP.CPSP.
 Preventive strategiesPreventive strategies
Pain 1998

22.  Prevalence of persistent postsurgical painPrevalence of persistent postsurgical pain
 12982 participants/3111 undergone surgery12982 participants/3111 undergone surgery
within 3 yearswithin 3 years
 Persistent pain in 40.4%. Mod-Severe 18.3%Persistent pain in 40.4%. Mod-Severe 18.3%

24. Poulakka PA et al EJA 2010

25. Risk Factors for CPSP?Risk Factors for CPSP?
 Preoperative: Pain, Repeat surgery,Preoperative: Pain, Repeat surgery,
Psychological factors, Female gender andPsychological factors, Female gender and
younger age, Genetic predispositionyounger age, Genetic predisposition
 Intraoperative: Surgical approach andIntraoperative: Surgical approach and
risks of nerve injuryrisks of nerve injury
 Postoperative: Acute Pain, Radiation Rx,Postoperative: Acute Pain, Radiation Rx,
Neurotoxic chemotherapy, Anxiety andNeurotoxic chemotherapy, Anxiety and
Depression, NeuroticismDepression, Neuroticism
McIntyre et al 2010

26. SummarySummary
 The opioid crisis and the impact ofThe opioid crisis and the impact of
perioperative careperioperative care
 The problem of acute pain (extent, risks ofThe problem of acute pain (extent, risks of
inadequate treatment, Knowledgeinadequate treatment, Knowledge
TranslationTranslation
 How can we help? (screening, KT forHow can we help? (screening, KT for
multimodal analgesia, support patients inmultimodal analgesia, support patients in
post-op care)post-op care)

27. How can we help?How can we help?
 Screening for high risk patientsScreening for high risk patients
 Use best pain controlUse best pain control
 Standardize opioid prescription afterStandardize opioid prescription after
surgerysurgery
 KT for multimodal analgesia: ERAS,KT for multimodal analgesia: ERAS,
standardsstandards
 Transitional pain programsTransitional pain programs
 Improve education and support forImprove education and support for
physicians prescribing opioidsphysicians prescribing opioids

28. Risk factors for CPSP?Risk factors for CPSP?
 Preoperative opioid usePreoperative opioid use
 Perioperative painPerioperative pain
 Increased perioperative opioid useIncreased perioperative opioid use
 Negative affect: depression, anxiety, painNegative affect: depression, anxiety, pain
catastrophizing and PTSD symptomscatastrophizing and PTSD symptoms
Katz J et al CJP 2019

29. Acute pain controlAcute pain control
 Use regional anesthesia where possibleUse regional anesthesia where possible
 Use NSAIDS, paracetamol in multimodalUse NSAIDS, paracetamol in multimodal
regimenregimen
 For higher risk cases use ketamine and/orFor higher risk cases use ketamine and/or
lidocaine infusion during surgerylidocaine infusion during surgery
 Gabapentin/Pregabalin useful for acuteGabapentin/Pregabalin useful for acute
pain control and reduction of opioidpain control and reduction of opioid
consumptionconsumption

30. Use Regional Anesthesia Where PossibleUse Regional Anesthesia Where Possible
 Efficacy unquestionedEfficacy unquestioned
 Cultural and systemic barriers remainCultural and systemic barriers remain
 Further studies examining these areasFurther studies examining these areas
neededneeded
A&A 2017

31. Insert recent RA meta-analysisInsert recent RA meta-analysis
Richman JL et al A&A 2006
Continuous RA vs Opioid:

32.  23 RCTs in total23 RCTs in total
 Pooled 3 studies for epidural afterPooled 3 studies for epidural after
thoracotomy and 2 for PVB after breastthoracotomy and 2 for PVB after breast
surgerysurgery
 Unable to pool data from other studies dueUnable to pool data from other studies due
to marked heterogeneityto marked heterogeneity

33. Andreae MH et al BJA 2013

34. Cepeda et al A&A 2005
Use a multimodal regimen
Cepeda et al 2006

35. KetamineKetamine

38. SummarySummary
 The opioid crisis and the impact ofThe opioid crisis and the impact of
perioperative careperioperative care
 The problem of acute pain (extent, risks ofThe problem of acute pain (extent, risks of
inadequate treatment, Knowledgeinadequate treatment, Knowledge
TranslationTranslation
 How can we help? (screening, KT forHow can we help? (screening, KT for
multimodal analgesia, support patients inmultimodal analgesia, support patients in
post-op care)post-op care)

39. Pain Management 2016

40. Transitional Pain Service atTransitional Pain Service at
TGHTGH
 Pre-operative review, acute postoperativePre-operative review, acute postoperative
and long-term follow upand long-term follow up
 Patients identified early and referredPatients identified early and referred
 Co-ordinated care by pain physicians,Co-ordinated care by pain physicians,
psychologists, physiotherapists andpsychologists, physiotherapists and
advanced practice nursesadvanced practice nurses
 Bypasses long wait times for chronic painBypasses long wait times for chronic pain
clinicclinic

41. TPS resourcesTPS resources
 Pain physicians (preoperative screeningPain physicians (preoperative screening
and postoperative management)and postoperative management)
 Physical therapy including acupuncturePhysical therapy including acupuncture
 Psychology: education, mindfulness, CBTPsychology: education, mindfulness, CBT
and hypnotherapyand hypnotherapy
 Administrative assistant and patient careAdministrative assistant and patient care
coordinatorcoordinator
Katz J et al CJP 2019

42. TPS outcomesTPS outcomes
 382 patients: 91 TPS382 patients: 91 TPS
 Outcomes: Pain, pain interference,Outcomes: Pain, pain interference,
Anxiety and depression, catastrophizationAnxiety and depression, catastrophization
and opioid useand opioid use
 Pre-treatment TPS group had significantlyPre-treatment TPS group had significantly
greater pain, opioid use and psychologicalgreater pain, opioid use and psychological
correlatescorrelates
Katz J et al CJP 2019

43. TPS outcomesTPS outcomes
 At end of treatment TPS group had:At end of treatment TPS group had:
– Greater reduction of opioid useGreater reduction of opioid use
– Less pain interferenceLess pain interference
– Greater improvements in moodGreater improvements in mood
Randomized trial across Ontario hospitals nowRandomized trial across Ontario hospitals now
in progressin progress
Katz J et al CJP 2019

45. https://choosingwiselycanada.org/campaign/opioid-wisely/

49. Kumar et al Pain Medicine 2019

50. SummarySummary
 The opioid crisis and the impact ofThe opioid crisis and the impact of
perioperative careperioperative care
 The problem of acute pain (extent, risks ofThe problem of acute pain (extent, risks of
inadequate treatment, Knowledgeinadequate treatment, Knowledge
TranslationTranslation
 How can we help? (screening, KT forHow can we help? (screening, KT for
multimodal analgesia, support patients inmultimodal analgesia, support patients in
post-op care)post-op care)

51. cmccartney@toh.ca