The rising tide of opioid use and abuse: the role of the anesthesiologist

Koepke, Elena; Manning, Erin; Miller, Timothy E.; Ganesh, Arun; Williams, David G. A.; Manning, Michael W.

doi:10.1186/s13741-018-0097-4

Cited by 125 publications

(95 citation statements)

References 73 publications

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“…There are multiple opportunities for the anesthesiologist, surgeon, and institution to reduce opioid exposure and minimize patient harm. 16,31,33 The best-characterized clinical strategies include the use of multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) initiatives to standardize care and improve outcomes while providing satisfactory perioperative pain control. MMA has been consistently demonstrated to minimize opioid consumption and related side effects and is considered a vital component of ERAS pathways.…”

mentioning

confidence: 99%

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

111

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OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

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mentioning

confidence: 99%

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

111

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“…Established peri‐operative clinics include: anaemia, diabetes, heart failure, cardiac ischaemia, cardiac devices (pacemakers, implantable cardiac devices), chronic obstructive airways disease, sleep/obstructive sleep apnoea and pain. Pre‐operative pain clinics have become increasingly important with the emergence of the ‘opioid epidemic’, particularly in the US . Peri‐operative management of opioid dependence, whether from prescription, ‘bystander’ (consumption of someone else's prescription) or illicit drug use, is rapidly becoming more sophisticated with the extensive experience being accumulated in the US.…”

Section: Peri‐operative Care Pathwaysmentioning

confidence: 99%

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

et al. 2019

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Elective surgical pathways offer a particular opportunity to plan radical change in the way care is delivered, based on patient need rather than provider convenience. Peri-operative pathway redesign enables improved patient experience of care (including quality and satisfaction), population/public health, and healthcare value (outcome per unit of currency). Among physicians with the skills to work within peri-operative medicine, anaesthetists are well positioned to lead the re-engineering of such pathways. Re-engineered pre-operative pathways open up opportunities for intervention before surgery including shared decision-making, comorbidity management and collaborative behavioural change. Individualised, risk-adapted, intra-operative interventions will drive more reliable and consistent care. Risk-adapted postoperative care, particularly around transitions of care, has a significant role in improving value through peri-operative medicine. Improved integration with primary care providers offers the potential for minimising errors around transitions of care before and after surgery, as well as maximising opportunities for population health interventions, including lifestyle modification (e.g. activity/exercise, smoking and/or alcohol cessation), pain management and sleep medicine. Systematic data collection focused on quality improvement is essential to drive continuous clinical improvement and will be enabled by technological development in predictive analytics, systems modelling and artificial intelligence.

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“…The use of multimodal analgesia has also become increasingly popular with the concurrent evolution of the opioid epidemic. 33,34 It is well known that opioid prescription following surgery can potentially lead to long-term use and can be a significant source of misuse and abuse. This is especially true for a few subsets of the population, including acute post-surgical patients.…”

Section: Pain Scoresmentioning

confidence: 99%

Opioid-Free Analgesia for Supratentorial Craniotomies: A Systematic Review

Darmawikarta

Sourour

Couban

et al. 2019

Can. J. Neurol. Sci.

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ABSTRACT:Background: Post-craniotomy pain can be severe and is often undermanaged. Opioids can interfere with neurological monitoring and are associated with adverse effects. This systematic review aimed to identify measures of opioid-free analgesia and compare their effectiveness with opioid analgesia for post-craniotomy pain in patients with supratentorial tumors. Methods: EMBASE, MEDLINE, and Cochrane databases were searched from their inception to February 14, 2017, for randomized controlled trials (RCTs) evaluating opioid versus non-opioid analgesia post-supratentorial craniotomy. Two reviewers independently carried out study selection and data extraction. Risk of bias assessment was performed using the Cochrane Collaboration’s tool. Outcomes were pain control (changes to pain scores or use of rescue analgesia) and adverse effects. Considering the number of studies and heterogeneity, a narrative synthesis was done without pooling and results were summarized using tables. Non-opioids were assessed for the potential to be equivalent to opioid-based analgesics for pain relief and adverse effects. Results: Of 467 RCTs, 4 met our inclusion criteria (n = 186 patients). Patients with scalp blocks (2 RCTs) had less post-operative nausea and vomiting (PONV), but scalp block was not superior to morphine for analgesia. Acetaminophen (1 RCT) was less likely to induce PONV but provided inadequate pain relief compared to morphine and sufentanil. Dexmedetomidine (1 RCT) was not superior to remifentanil for analgesia although it delayed time to rescue analgesia. Conclusions: Limited evidence suggests that scalp blocks and dexmedetomidine have the potential to eliminate the need for opioid analgesia. Multimodal analgesia should be considered as significant opioid-sparing effects have been shown.

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The rising tide of opioid use and abuse: the role of the anesthesiologist

Cited by 125 publications

References 73 publications

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Peri‐operative care pathways: re‐engineering care to achieve the ‘triple aim’

Opioid-Free Analgesia for Supratentorial Craniotomies: A Systematic Review

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