How opioid-free anesthesia and multimodal pain management can improve care and address a public health crisis

Numerous public health experts and politicians have dubbed the nation's ongoing opioid overdose and addiction crisis the deadliest drug epidemic in American history. The scope of the crisis will likely require a multitude of efforts from governmental, healthcare and public health entities to curb soaring rates of overdose deaths.

                                This content is sponsored by TeamHealth

Provisional data released by the CDC in September 2017 suggests more than 64,000 people died of drug overdoses in 2016, surpassing the 58,200 Americans who died in the Vietnam War and 50,682 people who died from HIV/AIDS in 1995. About three in four of all drug overdoses in the U.S. in 2016 involved an opioid.

Although rising rates of opioid-related deaths are increasingly attributable to heroin and illicitly obtained fentanyl, the crisis is rooted in healthcare. Many people who are currently abusing or addicted to opioids were first introduced and given access to the drug in healthcare settings. Providers, healthcare organizations and drug companies carry a measure of culpability in facilitating the crisis.

In a November 2017 viewpoint article, Toby Cosgrove, MD, CEO of Cleveland Clinic, said because healthcare providers enabled the opioid epidemic, providers should play a key role in bringing about its end.

"One of the most sobering statistics, from a physician's point of view, is that over 75 percent of opioid and heroin deaths begin with a prescription painkiller," Dr. Cosgrove wrote in the article. "The healthcare industry bears some responsibility. That's not to say that patients aren't in legitimate pain. They are, maybe as many as 100 million by some estimates. But we as healthcare providers have to approach pain differently, smarter."

Dr. Cosgrove points to a significant dilemma providers face amid the nation's ongoing public health crisis. While it's imperative to reduce opioid overprescribing, providers and healthcare organizations cannot overlook the importance of pain management. As necessity breeds invention, clinicians and healthcare organizations are working to develop multimodal approaches to pain management with limited reliance on opioids and opioid-free methods of anesthesia to effectively manage pain and reduce the likelihood of patients developing opioid addiction.

Drop the fentanyl, improve outcomes

A growing body of evidence suggests reducing reliance on opioids in the healthcare setting can ultimately improve care outcomes while simultaneously reducing patient exposure to opioids, which ultimately reduces the likelihood of addiction.

A June 2017 study published in JAMA Surgery found prolonged opioid use to be a common post-surgical complication among patients who underwent major and minor surgery and were not previously exposed to opioids. Researchers determined the rate of persistent opioid use — defined as filling an opioid prescription between 90 and 180 days after surgery — was 6.5 percent for major surgical patients and 5.9 percent for minor surgical patients, thus highlighting the possible risk of addiction associated with opioid exposure in the surgical setting.

"[P]rolonged opioid use can be deemed the most common postsurgical complication," wrote the study's authors. "New persistent opioid use represents a … previously underappreciated surgical complication that warrants increased awareness."

David Samuels, MD, medical director of anesthesia at Tampa, Fla.-based Select Physicians Surgery Center and medical director for TeamHealth Anesthesia, is part of a TeamHealth effort to promote practices that curb opioid use during and after surgery.

Dr. Samuels has practiced opioid-free anesthesia for more than two years. Dr. Samuels and his colleagues published a study in the Journal of Clinical Anesthesia in March 2017 demonstrating opioidfree anesthesia can help reduce post-operative opioid use. The study involved hundreds of surgical patients treated with either opioid-based anesthesia, opioid-sparing anesthesia or opioid-free anesthesia. Dr. Samuels and team found the opioid anesthesia group required double the amount of post-operative opioids as the patients who did not receive opioids during anesthesia. Dr. Samuels and his colleagues said these results were partly attributable to the removal of the potent synthetic opioid fentanyl from the analgesic regimen. Exposure to fentanyl can result in opioid induced hyperalgesia, which means patients develop increased pain sensitivity due to exposure to the drug.

"With the removal of fentanyl from the anesthesia regimen, we right away see patients in the recovery room experience less pain, less nausea and less vomiting," Dr. Samuels says. "Those are the really rapid effects we see when we remove the powerful opioid fentanyl, which, by the way, is 50 times more potent than heroin. … I believe [the use of fentanyl in anesthesia] may very well start a process that leads to not only opioid tolerance and dependence, but abuse, addiction and eventually overdose deaths."

Because patients who aren't treated with fentanyl have fewer and less severe post-surgical symptoms, they typically utilize fewer healthcare services and are associated with decreased spending. For instance, researchers associated preoperative opioid use among elective surgical patients with an increased likelihood of being discharged to a rehabilitation facility or readmitted into the hospital within 30 days, thereby driving healthcare spending and utilization, according to study published April 2017 in the Annals of Surgery.

Besides improving pain management, limiting opioid-related side effects carries added fiscal benefits amid a healthcare reimbursement landscape that is increasingly shifting to value-based payment models.

Reduce opioids, reduce costs

Eliminating or reducing opioid-related adverse events in hospital settings has the potential to generate significant cost savings, studies show. Adverse events related to opioid use that occur in the hospital setting include respiratory depression, nausea, vomiting, urinary retention and constipation.

A 2015 study published in the journal American Health & Drug Benefits examined the relationship between healthcare costs and opioid-induced constipation among patients with non-cancer pain. Researchers identified significant increases in inpatient, outpatient and emergency department costs among nonelderly patients with opioid-induced constipation and non-cancer pain. Among elderly patients with non-cancer pain, opioid-induced constipation was associated with higher inpatient and ED costs.

In 2014, the Advisory Board published an analysis estimating the fiscal impact of implementing multimodal pain management approaches and reducing high-dose opioid use. Researchers determined a 250-bed facility could potentially cut unreimbursed charges by more than $1 million dollars every year by reducing the use of opioids in major small and large bowel surgical procedures.

"By removing the bulk of opioids, the hospital can avoid costs [related to opioid side effects]," says Sonya Pease, MD, CMO of the anesthesiology division at TeamHealth. Dr. Pease says multimodal pain management programs, which involve two or more non-opioid analgesics, offer significant opportunities for cost avoidance and cost savings. "You can avoid costs by avoiding complications and you're also using cheaper adjuvant narcotics to treat pain. Less time in the recovery area leads to cost savings. Also, less incidence of nausea leads to savings in medication costs."

Educate the clinician, educate the patient

When outlining the building blocks of opioid-free anesthesia and multimodal pain management programs, Enrico Camporesi, MD, professor emeritus at the University of South Florida in Tampa and director of research for TeamHealth Anesthesia Research Institute, described patient education as crucial to success. However, before patient education can take place, providers must receive education on the substantial benefits of multimodal and opioid-free pain management techniques. Organizations should empower their care teams to gain knowledge on the subject and educate patients on opioid risks and alternative pain management techniques.

"Nurses, surgeons — these are people who for the last 10 to 12 years have been operating in a different culture," Dr. Camporesi says. "Then there is a patient education process. Providers have to convince patients that nothing is being taken away from them, and patients have to buy into the process."

To educate its providers, TeamHealth offers Continuing Medical Education credits through an online platform. TeamHealth clinicians are required to complete about 10 online opioidreduction training modules as part of the organization's risk management training requirements.

Moving anesthesiologists and nurse anesthetists away from opioids represents a major cultural change. Such a shift requires concerted education efforts targeting the entire perioperative staff, according to Dr. Pease. She says these efforts at TeamHealth have spurred "clinician to clinician pollination" of knowledge with regards to opioid use and multimodal pain management.

"Once they see the results [of opioid reduction], the strategy sells itself since patients wake up from surgery with less of the typical side effects we are used to seeing," Dr. Pease says.

Dr. Pease describes the movement away from opioids as a massive but necessary paradigm shift.

"I think most of us that work with narcotics think it's horrifying that we could be adding to the problem," says Dr. Pease.

A call to action

As the number of opioid-related deaths in the United States soared in recent years, the problem stretched far beyond the issue of prescription drug diversion. Increased availability of heroin and illicitly obtained fentanyl from sources overseas has led some healthcare stakeholders to question how healthcare will help end the crisis it helped create. In the face of cynicism, it's important for healthcare leaders to keep in mind the advice of leaders like Dr. Cosgrove and do their part to bring this national crisis to a close.

Few frontline caregivers underestimate the brutal nature of this epidemic — they are the ones treating overdose victims regularly. This too is important to keep in mind: Much of the dying related to the opioid epidemic happens inside hospital walls. According to a Health Affairs study published in December 2017, inpatient mortality for opioid-related hospitalizations increased fourfold from 1993 to 2014.

Opioid-free or reduced opioid anesthesia and multimodal pain management techniques have the opportunity to improve care and reduce costs by reducing opioid-related adverse events. Yet perhaps most importantly, these programs can limit opioid exposure among those who may be vulnerable to addiction and no longer perpetuate pain management practices that helped spur a national crisis.

More articles on opioids:
'Drug czar' office excluded from White House opioid response: 6 things to know 
Indiana county files opioid epidemic lawsuit against 20+ drugmakers, distributors 
Methadone clinics double in Colorado in 3 years — residents still lack access to addiction treatment

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