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Opioid crisis and acute pain
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
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)
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)
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%
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
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)
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
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)