Preventing Persistent Post- Surgical Pain & Opioid Use in ...€¦ · The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder.

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Preventing Persistent Post-Surgical Pain & Opioid Use in At-

Risk Veterans: Effect of ACT

Katie Hadlandsmyth, PhDUniversity of Iowa, Carver College of Medicine, Iowa City, IA

Barbara St. Marie, PhD, AGPCNP, FAANPUniversity of Iowa, College of Nursing, Iowa City, IA

Midwest Pain Society 43rd Scientific Meeting

Chicago, Illinois

October 4-5, 2019

Disclaimer

Conflicts of Interest/Disclosures

• Hadlandsmyth: Nothing to disclose.

• St. Marie: Receives funding from the National Institute on Drug Abuse (5K23DA043049-03); serves on the Faculty Advisory Panel for CO*RE REMS and is a paid consultant for CO*RE REMS.

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Objectives

1. To appraise the value of an Acceptance and Commitment Therapy (ACT) workshop among patients undergoing orthopedic surgeries.

2. To differentiate the contribution of mixed methods to this study on (ACT).

3. To understand barriers and facilitators of implementing ACT for patients preparing for surgery.

Acknowledgements• Co-PIs: Barb Rakel, RN, PhD; Lillian Dindo, PhD• Investigators:

• Toni Tripp-Reimer, RN, PhD, FAAN• Barbara St. Marie, RN, PhD• M. Bridget Zimmerman, PhD (Stat)• Jim Marchman, PhD• Nicholas Noiseux, MD

• Personnel:• Katie Hadlandsmyth, Project Director• Jennie Embree, Data Manager• Katie Geasland, Blinded Research Assistant• Judy Allen, Qualitative Analyst• Edin Sabic/Roohina Wajid, Research Interns• Clevenger, Van Liew, Grekin, Kroska (Psych Grad RAs)• Benjamin, Benschoter, Eschar (BSN Students)

Background/Rationale

• Rates of persistent post-surgical pain:

• 50-85% amputations

• 50% Thoracotomy

• 20% Total Knee Arthroplasty

• 20-50% breast surgeries

(Correll, 2017)

• Distress-based conditions put patients at risk for persistent pain and prolonged opioid use following surgery (Otis, Keane, Kerns et al., 2009; Kerns, Otis, Rosenberg et al., 2003).

• Preventing these problems for the thousands of patients who undergo surgery each year can have a dramatic impact on quality of life, productivity, and reduced risk of life-threatening issues, such as opioid misuse and suicidal ideation.

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• ACT reduces pain, depression/anxiety.

• Pre-surgery predictors of persistent pain 6 months post TKR.

• ROM pain (p=0.0005),

• Anxiety (p=0.02),

• Depression (p=0.05)

Logic Model

Dindo et al, 2014Noiseux et al, 2014

Study Aims

Primary Aim #1: Determine the feasibility of providing a 1-day ACT workshop and individualized booster session with at-risk veterans before and after surgery.

Primary Aim #2: Determine if an ACT workshop & booster reduces the length and/or amount of pain and opioid use following surgery when compared to TAU.

• Mixed Methods• Guided open-ended interviews

• Single-blinded, prospective, randomized, experimental design with random assignment to one of two groups:

1. Treatment As Usual (TAU)

2. Acceptance and Commitment Therapy (ACT) plus TAU (ACT + TAU)

• Iowa City VAMC – orthopedic surgery clinic• Serves over 184,000 veterans living in 50 counties in Eastern Iowa, Western Illinois

and Northern Missouri.

• Tri-level care system; primary, secondary, and tertiary care to patients requiring orthopedic surgery.

Design/Setting

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• Inclusion Criteria:• Veterans, ≥ 18 years old, scheduled for orthopedic surgery• Identified to be “at-risk” at screening visit:

• Preoperative Pain (movement) > 7 OR > 3 and

• HAM-A (anxiety) ≥15 or

• HAMD (depression) ≥17

• Exclusion Criteria:• Mental incapacity or a language barrier• History of brain injury• Bipolar or psychotic disorder• Complications following surgery requiring reoperation

• Sample Size:• 70% power at p < 0.05, a 50% reduction in median time to pain or opioid cessation OR hazard ratio

for quitting of 2.0.

Participants

Methods

Inclusion Criteria Not Met (n=221)

Surgery timing/surgery not scheduled (n=195)Absent anxiety/depression/pain (n=26)

Excluded (n=40)Bipolar, psychotic disorder (n=24)

Cognitive disorder, dementia, brain injury (n=13)Non-English speaking (n=1)

Malingering, suicidal ideation (n=2)Declined (n=187)

Unable to contact (n=92)

Enrollment Assessed for eligibility (indicated for eligible surgery) (n=628)

Randomized (n=88)

CONSORT Diagram

Allocated to ACT (n=44)

Received Surgery and Attended Workshop (n=32)Received Surgery and Did Not Attend Workshop (n=8)

Surgery Cancelled, Attended Workshop, (n=2)Surgery Cancelled, Did Not Attend Workshop (n=2)

Allocated to TAU (n=44)

Received Surgery (n=36)Surgery Cancelled (n=8)

Allocation

Lost to follow-up (n=0)

Excluded due to AE (n=1)Lost to follow-up (n=0)

Excluded due to low pain at enrollment (n=1)

Follow-Up

Intent-to-treat analysis (n=35)

Protocol analysis (n=35)

Intent-to-treat analysis (n=40)

Protocol analysis (n=31)

Analysis

Not interested (n=87)

Too busy (n=58)Trav el difficulties (n=36)Other (n=6)

Workshop mentioned as a factor (n=28)

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Sample Characteristics

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4

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ACT TAU

Average of BPI Measures at Enrollment

BPI Least BPI Ave BPI Worst

0%

10%

20%

30%

40%

50%

60%

70%

ACT TAU Total

Subjects above Cut-offs

Anxiety ≥ 15 Depression ≥ 17 Max ROM Pain ≥7

• Workshop – 34/44 (77%) attended a workshop

• 1st scheduling attempt: 26 (76%)

• 2nd attempt : 6 (18%)

• 3rd attempt : 2 (6%)

• Never attended: 10/44 (20%) • Health-4; Work-2; Caregiving-2; Unspecified-2

• Booster received – 29/32 (91%) following surgery

• 4 Feasibility Issues: 1) Workshop logistics; 2) Workshop size; 3) Workshop Content and Structure; 4) Use of Manual and Booster Session.

Aim 1: Feasibility

0 1 2 3 4 5 6 7

Unspecific

Vacation

Caregiver Needs

Lost

Surgery Timing

Travel Difficulties

Medical Appt

Sick

Work

Barriers to Scheduling Workshop

St. Marie et al (in progress)

Aim 2: Potential Efficacy

Pain > 3

Opioid Use

Dindo et al (2018). J Pain

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Aim 2: Mediation by CPAQ and CPVI

Dindo et al (2018). J Pain

Pain >3

Opioid Use

Qualitative Research

• Qualitative purpose• Examined ACT skills reported used a 1 week following workshop and 3

months after surgery

• Map the skills to the theoretical constructs of ACT

• Prospective, longitudinal data

• Data collection• Phone interviews at 1 week and 3 months lasting 20-40 minutes

• Semi-structured interview guide

• Two qualitative researchers and a research assistant

• Content analysis – Nvivo®

Results: Feasibility

• Barriers• Description of ACT and what it does

• Travel difficulties – Rural, Winter

• Scheduling conflicts – other medical appointments, pre-operative timeframe

• Workshop size – 2-3 participants

• Facilitators• Group format

• Engaging content and trainers

• Use of manual and booster session

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Mapping skills to ACT theoretical constructsOpenness Awareness Engagement

ACT processes Acceptance Cognitive defusion Present moment Self as context Values Committed action

Participants’Skills Themes

• Acceptance• Acknowledge feelings

• New approach to thinking

• Mindful breathing

• Focus on now

• Self-awareness • Re-prioritizing• Choice awareness

• Setting goals• Choice awareness

Openness

Acceptance Cognitive defusion

Acceptance

Acknowledge feelings

New approach to thinking

One participant stated he was “… accepting maybe some of the pain, … then still carrying

on with my life” rather than focusing on things he could not do.

“What I took home from that [workshop] … is how to distance myself from – it helps out with

my depression and everything ‘cuz I get frustrated a lot, … It’s taking too long to heal… Instead of internalizing all of that into myself,

and just thinking ‘I’m no good,’ and ‘It’s my fault that this isn’t working…’ It helped me step outside of the box and look at it in a different

direction.”

Awareness

Present moment

Self as context

Mindful breathing

Focus on now

Self-awareness

“… if I live in the now, I’m not regurgitating all the pain from yesterday and I’m not stressing myself out on what

might be tomorrow.”

“[now he was] just trying to be aware of the pain, and that it’s gonna get better…

Since then, I’m really getting’ around great, doin’ a lot of walkin’, and a lot of

talkin’ to people. Before [the workshop], I was at home and not doin’ much and

bein’ angry.”

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“…relate to your family and your kids, and what’s important to you. You what’s important to you, but you just don’t think about it in certain ways. That [ACT workshop] made you think about it a little different way.”

Choices after this surgery compared to previous surgery:“I don’t need the tramadol so much.”Previously he thought pain was “boss” and now he chooses to not allow pain to stop the valued life, and to relax with the pain.

EngagementValues Committed

actionRe-prioritizing

Choice awareness

Setting goals

Choice awareness

Sustained goals

• Understanding and clarifying about what’s important

• Build goals around these important values

• One participant stated well:• First interview – set his goals to be more active, to engage in something, and

to re-establish good health• Three months later – still kept his goals, continued his rehabilitation on his

own.

• Another participant stated before the workshop or the surgery, pain created a “… constant battle of whether I wanted to get up and move around, or not.”

• Their goals helped to reduce impediment created by pain.

Conclusion

• Findings from this pilot feasibility study indicate:• Potential efficacy

• Feasibility with some modifications

• Qualitative findings: Participants seemed to understood the ACT model of engaging in values-based living even in the presence of aversive internal content (such as pain).

• Next Steps: Larger multi-site RCT

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References

1. Noiseux, N.O., et al., Preoperative predictors of pain following total knee arthroplasty. J Arthroplasty, 2014. 29(7): p. 1383-7.

2. Otis , J.D., Keane, T.M., Kerns, R.D., Monson, C., Scioli, E. (2009). The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder. Pain Medicine, 10,1300-1311.

3. Kerns, R.D., Otis, J, Rosenberg, R., Reid, M.C. (2003). Veterans’ reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. Journal of Rehabilitation Research Development, 40,371-379.

4. Rakel, B.S., Glodgett, N.P., Zimmerman, B.M., et al. (2012). Predictors of postoperative movement and resting pain following total knee replacement. Pain, 153,2192-2203.

5. Lamberts, M.P., Lugtenberg, M., Rovers, M.M. et al. (2013). Persistent and de novo symptoms after cholecystectomy: a systematic review of cholecystectomy effectiveness. Surgical Endoscopy, 27, 709-718,

6. Puolakka, P.A., Rorarius, M.G., Robiola, M., Puolakka, T.J., Nordhausen, K., Lindgren, L. (2010). Persistent pain following knee arthroplasty. European Journal of Anaesthesiology, 27,455-460.

7. Dindo, L., et al., One-day behavioral intervention in depressed migraine patients: effects on headache. Headache, 2014. 54(3): p. 528-38.

8. Dindo et al (2018). Acceptance and Commitment Therapy for Prevention of Chronic Post-surgical Pain and Opioid Use in At-Risk Veterans: A Pilot Randomized Controlled Study. J Pain, May 16. [Epub ahead of print]

9. Hayes, S.C., Luoma, J.B., Bond, F.W., Masuda, A., Lillis, J. (2006). Acceptance and commitment therapy: Model, processes and outcomes. Behaviour Research and Therapy, 44,1-25.

10. Hayes, S.C., Vallatte, M., Levin, M., Hildebrandt, M. (2011). Open, aware, and active: Contextual approaches as an emerging trend in the behavioral and cognitive therapies. Annual Review of Clinical Psychology, 7,14—168.

11. McCracken, L.M., Vowles, K.E. (2008). A prospective analysis of acceptance of pain and values-based action in patients with chronic pain. Health Psychology, 27,215-220/.

12. Vowles , K.E., McCracken, L.M., Zhao O’Brien, J. (2011). Acceptance and values-based action in chronic pain: a three-year follow-up analysis of treatment effectiveness and process. Behaviour Research and Therapy, 49,748-755.

Self-Assessment Questions

1. What outcome(s) did this intervention have a positive impact on?

a) Reduction of opioids use following surgery

b) Improvement of pain following surgery

c) A and B

d) None of the above


1. What outcome(s) did this intervention have a positive impact on?a) Reduction of opioids use following surgery

b) Improvement of pain following surgery

c) A and B


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2. Select outcome that was confirmed by both qualitative and quantitative data analysis.

a) Improve ability to communicate feelings

b) Improve function and return to activities

c) Use of values-based activities

d) All of the above


2. Select outcome that was confirmed by both qualitative and quantitative data analysis.

a) Improve ability to communicate feelings

b) Improve function and return to activities

c) Use of values-based activities

d) All of the above


3. Select one barrier to providing ACT in a perioperative time frame.a) Timing of surgery

b) Patient readiness for surgery

c) Location of ACT training

d) All the above

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3. Select one barrier to providing ACT in a perioperative time frame.a) Timing of surgery

b) Patient readiness for surgery

c) Location of ACT training

d) All the above


4. What are indicators that a 1-day ACT workshop is feasible among Veterans

a) Participants completed the workshop

b) 1-day ACT workshops have been successful in other populations

c) A and B



4. What are indicators that a 1-day ACT workshop is feasible among Veterans

a) Participants completed the workshop

b) 1-day ACT workshops have been successful in other populations

c) A and B


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The Dynamics of Managing Acute Postoperative Pain in the Current Opioid Sparing Environment

Robert L. Barkin, MBA, Pharm D, DAAPM, DACFE, OFRSM


Chicago, Illinois

October 4-5, 2019

Summary statements regarding postoperative pain Rx with a focus on the impact of scheduled analgesics versus no scheduled analgesics related to the management of in-hospital acute postoperative pain management

Robert L. Barkin, MBA, Pharm D, FCP, DAAPM, DACFE, OFRSM, Professor (Anesthesiology, Family Medicine, Pharmacology) Rush Medical College of Rush University (Chicago, IL); Clinical Pharmacologist, Department of Anesthesiology NorthShore University HealthSystem, Pain Centers The Orthopedic and Spinal Institute at Evanston & Skokie Hospitals Illinois

Disclaimer

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• Nothing material to disclose on this subject

Objectives

1. Explain how to create a patient-specific, structured, time contingent postoperative hospital pain management plan

2. Discriminate established medical diagnosis vs. testimonial and catastrophizing

3. Explain how to integrate patient family collateral HCP in facilitating treatment initiation and pursuit of therapeutic benefit

▪Initially: PMHx, PSHx, PΨHx, social Hx, Rx Hx (Rx, OTC, phytopharmacueticals), “Allergies v. S/E’s,” PPMP, (multisource medications), OLD Rxs, friends, spouses, internet, external to USA travel, laboratory, EKG evaluation, (QTc)

• Pt (spouse, family), age, experiences, fears, education, expectations, postop and pre-op opioid consumption and Pt unique needs.

• Multimodal pharmacotherapy, scheduled structure, overlapping intervals, PRN’s for BTP to decrease higher doses of scheduled opioids, comorbid painful syndrome/DX (often patient amalgamated), neuroaxial opioids, ESI, IT routes.

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▪ Timely pre-surgical discussion in joint collaboration with patient, concerned others, collateral providers and the surgical team, structured decremental changes (opioid naïve v. tolerant). Create a patient-specific, patient focused, patient centered, personalized time contingent Rx plan accepted fully by patient and concerned others.

▪ Pathways: transmission, transduction/conduction, perception, modulation

▪ Scheduled analgesia v. anesthesia

▪ Focus: diminish pain and suffering in quality and quantity through scheduled analgesic Rx plan with PRN for BTP and episodes. Diminish fear/anxiety of pain and improve postop functionality, ADLs, PT/OT performance; personal past experience and preferences; diminish pharmacotherapy iatrogenic effects, etc. (constipation, GU, CNS, neuro, pulmonary, cardiac events); Address: nociceptive, neuropathic pain, collateral comorbid pains, reduce, LOS facilitated by initiating a structured time contingent scheduled dosage regimen.

▪ Negotiate catastrophizing cognitive distortion as an exaggeration, magnification or irrational thought pattern. A triad of rumination, magnification, helplessness.

▪ Addressing these focused events. “Predict and control.”

▪Pharmacotherapy: (time contingent structured Rx plan with an exit strategy for BTP)

APAP (IV, PO)

NSAIDS (ketorolac IV, PO NSAIDS), w/ or w/o anesthetics

AD – SNRI

SMR – Tizanidine, Orphenadrine, baclofen

AED – Gabapentinoids, (avoid for foot/ankles surgery), topiramate

NMDA: ketamine (IV), Subdissociative-dose (0.25 to 0.5mg/kg) MG++, N20, DM., Orphenadrine, Memantine, Meperidine, Levorphanal, Methadone Tramadol

Opioids: PO, Buccal, IV schedule doses, with limited short acting for BTP.

Anesthetics: Na+ channel blockers IV (short or long acting), topical

Tx plan exit strategy: 5 to 7 days up to 21 days (a function of extensiveness procedures, simulate home discharge environments routine (ECF/NH)

▪Time contingent plan (arise, asleep), nocturnia, periods of antecedent pain.

▪ Insurance/PBM coordination.

▪Time schedule for detrimental change to lowest effective dose to participate in home; patient without precipitating abstinence or withdrawal behavior

▪Stop all former historical opioid pain medications once at home or before Tx initiation in conjunction with pre-surgical evaluation plan.

▪Surgical team to maintain bilateral open dialogue with patient/family/care givers following hospital discharge with Pain Center staff as consultation.

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Case 1

▪1) A 49 y/o male 73” H, 270#, BMI=33 presents for TKR due to sports trauma injury

▪Vocation: MBA, JD, CPA, CEO of 180 person firm.

▪Avocation: Runner, basketball, biking, gym, golf weekends

▪Pain 4-10/10 a function of movement, comfortable with 4/10, achy, dull, neuropathic, nociceptive, if with pharmacotherapies present.

▪PMHx: Migraine, hyperchol, GERD, OSA (CPAP – non-compliant)

▪PSHx: Abd. hernia (repair - wt. lifting), clavicle repair from sports injury, ankle FX (repair, running)

▪Allergies: NKDA, FA, EA, No RX side effects reported

Case 1 (Cont)

▪ SOC Hx: Married, 2 children, ETOH (states 1.5 oz whisky/ day 7d/wk) Spouse reveals an amount in excess of this. (must stop), nicotine Hx (cigars 1/day 7/week) (must stop), cannabis (weekend 1/d), SRDU – denies

▪ PΨHx – denies; DIMS (sleep 11pm 3A/d).

▪ Note: Spouse and pt describe on cellphone and laptop “all the time”, confirmed by house staff & nursing, OT/PT

▪ OTC: Ibuprofen (2 to 3 200mg Ø 6 hr PRN, not daily), DPH- to stop use.

▪ Herbals: Melatonin

▪ PPMP: Hydrocodone and Oxycodone alternates monthly with 2 different prescribers with different practices, not jointly aware

▪ Labs: WNL, Cr.8, LFT’s WNL, CUDT: (+1 oxycodone, hydrocodone, cannabis)

▪ Test: QTc 412, EKG = NSR

▪ INPT TX plan: PT/OT Pharmacotherapy to transfer to ECF for PT/OT in 2 days.

Case 1 (Cont)

▪Pt “needs”: Expressed: “I do not want to ask for medications or “buzz” the nurses for it”, discussed structured time component to plan and rational.

▪Plan: 1) schedule Rx plan in full

2) schedule the Tx plan with plans for BTP

3) use PRN to evaluate needs for outpatient ECF/N.H., P.T.

4) use PRNs and request pt. to F/u with one PCP for opioids if needed for functionality with whom he has a fiduciary relationship.

5) CPM of presurgery and add gabapentinoids and SMRs, opioids 5-7 days (consult w/ surgery team) a function of extent of surgery.

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Case 2

▪A 61 y/o female, 64” 192# BMI=33

▪S/P (R) Hip Fx due to fall at home while doing housework

▪Pain 8-9/10 dull, achy, throbbing, stabbing, 10/10 with movement

▪PMHx: osteoporosis hypercholesterolemia, DM (type 2, diet) FMS, IBS

▪PSHx: breast Bx(-), TAH, Appy

▪Allergies/ S/E’s 6-keto opioids = CNS, neuro, CV hyportension, GU, GI events

▪PΨHX: denies; aside DIMS, tearful about this fall, feels hopeless, helpless, loss of self esteem.

▪SOCHx: Solitary living, EtoH (6 oz. wine/noc) nicotine: Ø, cannabis: Ø, SRDU: Ø, has one cat

▪PPMP: reviewed=WNL

Case 2 (Cont)

▪Routine: arise 6am, asleep 10pm, nocturie once

▪RxHx: Stating (use every other day), oral hypoglycemic (less than compliant)

▪OTC: D3, APAP, NSAIDS (not sure of doses or names of drugs)

▪Herbals: garlic, ginger, ginseng (to stop), turmeric, melatonin

▪Labs: CMP-WNL

▪Tests: EKG=NSR, QTc=410

▪Note: Resistance to medication “use reflects weakness” Has teenage grandchildren who visit

Case 2 (Cont)

▪Plan: 1) Stop all home use OTC/Rx for pain

2) Stop herbals-rationale given

3) Opioids LA Q 8 to 12 hrs (abuse deterrent)

4) APAP 500mg Q 8 hr PRN pain

5) Small dose short acting opioids Q 8hr PRN for BTP

6) Inpt small dose IV opioids for pain which is unresponsive to above Tx

7) SNRI for pain, FMS, tearfulness (have social worker see pt)

8) Low dose gabapentinoids, or topiramate

10) scheduled NSAID IV of 6 hours when appropriate

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Case 2 (Cont)

▪Choices: 1) PRN doses only

2) Timed doses of Rx plan, stop herbal/OTC at home

3) Scheduled Tx plan with PRN (for BTP)

4) Refer back to PCP within 15 days of outpatient post OP pain meds

Pharmacotherapeutic Rapid Evaluation (per RLB)▪Efficacy v. Efficiency

▪2. Iatrogenic Effects v. Toxic Effects

▪3. Compliance/Adherence v. Nonadherence

▪4. Economics (Payor, Self, Copay, PBM)

▪5. Monitoring; who, what, why, where

▪6. Outcomes

▪7. “Communicate before you medicate” (RLB)

▪8. Noncompliances or Noncomplainers (J. Clin Psychiatry 1988, Barkin, Stein)

Proposal for Opioid Free Anesthesia (Intraoperative Pain)• Perioperative: APAP, NSAID (w/o C/I), scopolamine patch.

• Intraoperative: Multimodal Opioid sparing systemic analgesia, regional anesthesia evaluation, epidural anesthesia, intrathecal route.

• Ketorolac, clonidine, lidocaine/bupivacaine, gabapentinoids, ketamine. MgSO4, methylprednisolone (Can J. Anesth 2003 50:336-41)

• Dexmedetomidine (Br J Anesth 2014 112:906-11) or N20, propofol, SMR.

• Postoperative: Monitor for analgesic needs, medication side effects, medication therapeutic effects or a potential iatrogenic ADRs.

• CPM above, anti-hyperalgesic if perceived prominent nocicption persists-consider anesthesiologists fellowship trained pain specialist with a multidisciplinary pain management team inpatient and outpatient.

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1. In the process of designing a patient specific treatment for postoperative pain which process below is/are most important?a) Transmissionb) Conductionc) Perceptiond) Modulatione) All of the above


1. In the process of designing a patient specific treatment for postoperative pain which process below is/are most important?a) Transmissionb) Conductionc) Perceptiond) Modulatione) All of the above


2. During the process of synthesizing a comprehensive

treatment which of the following is/are most important?a) Incorporating a patient specific treatment planb) Encourage involvement of direct family care-givers

facilitating therapeutic benefitsc) Engage the collateral health care providers insightsd) All of the above

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2. During the process of synthesizing a comprehensive

treatment which of the following is/are most important?a) Incorporating a patient specific treatment planb) Encourage involvement of direct family care-givers

facilitating therapeutic benefitsc) Engage the collateral health care providers insightsd) All of the above


3. During an evaluation of the following receiving

phenomena, identify the most significant to utilizea) Medical diagnosis confirmed in the recordb) Patient/family testimonialsc) Catastrophizingd) Patient medication demandse) All of the above


3. During an evaluation of the following receiving

phenomena, identify the most significant to utilizea) Medical diagnosis confirmed in the recordb) Patient/family testimonialsc) Catastrophizingd) Patient medication demandse) All of the above

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Creating and Implementing Enhanced Recovery After Surgery (ERAS) Programs

Rebecca N. Blumenthal, MD

Vice Chair of Innovation

Department of Anesthesiology, Cri tica l Care and Pain Medicine

NorthShore University HealthSystem

Cl inical Assistant Professor

Univers ity of Chicago, Pri tzker School of Medicine

Disclosures

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• Describe the most common components of ERAS protocols, and discuss the history and evidence-based practice of enhanced recovery

• Demonstrate that ERAS protocols provide transformative plans for minimizing pain, reducing perioperative opioid usage, expediting patient recovery, and decreasing perioperative complications

• Outline the process for creation of ERAS programs for hospital systems, and identify some limitations and challenges for successful ERAS design and implementation

Learning Objectives

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Creating and Implementing Enhanced Recovery Programs

Increase Awareness and “Buy-In”

Increase Awareness and “Buy-In”

Develop PlanDevelop PlanAssemble Multi-

disciplinary TeamAssemble Multi-

disciplinary TeamPrepare and

Execute RolloutPrepare and

Execute RolloutEnsure Sustainable

ModelEnsure Sustainable

Model

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Increase

Awareness and

“Buy-In”

Increase

Awareness and

“Buy-In”

Develop PlanDevelop Plan

Assemble Multi-

disciplinary

Team

Assemble Multi-

disciplinary

Team

Prepare and

Execute Rollout

Prepare and

Execute Rollout

Ensure

Sustainable

Model

Ensure

Sustainable

Model

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• Enhanced Recovery After Surgery

• Proven multidisciplinary, collaborative approach

• Scientific principles used to optimize pre-, intra-, and post-operative care

• ERAS protocols have been shown to:

oDecrease length of stay (LOS)

oDecrease perioperative complicationso Improve outcomes

oLower cost

ERAS: Definition

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• Average LOS for elective colorectal surgery was 6-12 days.

• Advances in laparoscopic surgery decreased LOS to 4-6 days.

1990s

• Kehlet et al (Denmark) did multi-modal rehab and decreased LOS to 2 days.

• 3 Interventions.

2000• “ERAS was born.”

• Intent: Develop evidence-based perioperative care pathways to facilitate patient recovery.

2001

History of ERAS

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• ERAS pathways proliferated nationally and internationally, initially for colorectal, but then developed for other surgical sub-specialties

• Multiple conclusive studies proved the efficacy of each step of the protocols

• Preponderance of clinical outcomes literature for ERAS versus conventional care supports:

oReduced surgical stress

o Improved recovery of GI function

oFewer complications

oDecreased LOS with no increase in readmissions

ERAS in the 21st Century

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Goals of an ERAS Protocol

Deliver Comprehensive Perioperative Care that is

Patient-Centered and Reduces Variation in

Outcomes

Optimize Patients for Surgery, Minimize Stress,

and Restore Normal Physiology Expeditiously

Encourage Clinician Teamw ork and

Communication to Achieve Process Measure

Compliance and Success

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PREOPERATIVE

-Preoperative Education and Optimization (Prehabilitation)

-Preoperative Fasting Guidelines and Carbohydrate Loading

-El imination of Mechanical Bowel Preps

-Thromboembolism and Antimicrobial Prophylaxis

INTRAOPERATIVE

-Multimodal Non-Opioid Analgesics and Antiemetics

-Regional Anesthesia

-Normothermia and Euvolemia

-Minimize and Early Removal of Dra ins/Foleys/NGs

POSTOPERATIVE

-Early Mobi l ization/Ambulation

-Early Nutri tion

-Multimodal Non-Opioid Analgesics

Components of an Enhanced Recovery Program

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• Preoperative Period thru Post Discharge/Recovery

• Use Combinations of Non-Opioid Analgesics

• Improve Pain Scores

• Decrease Opioid Related Side Effects and LOS

oNausea/Vomiting and Pruritus

o Sedation and Respiratory Depression

o Ileus and Urinary Retention

o Post-op Delirium and Addiction

• Greater Patient Satisfaction

Multimodal Non-Opioid Analgesics

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DECREASE OPIOID USE DECREASE PAIN DECREASE PONV OTHER

TYLENOL Yes Yes Yes Synergy with NSAIDS

NSAIDS Yes Yes YesSide Effects: COX-1 versus COX-2

GABAPENTIN Yes Yes Yes Sedation

LIDOCAINE Yes Yes NoQuick Return of GI Function

KETAMINE Yes Yes Yes Bolus vs. Infusion

Common ERAS Multimodal Non-Opioid Analgesics

Other Analgesics: Alpha-2 Agonists, Steroids, B-Blockers, Magnesium, Non-Pharmacologic

Sources: Beverly et al. (2017), Helander et al., (2017), Khan et al. (2016), Wang et al. (2016), DeOliveria et al. (2015),Tan et al., (2015), Apfel et al. (2013), Schmidt et al. (2013), McNicol et al. (2011), Ong et al. (2010), Hurley et al. (2006), and Straube et al. (2005)

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1 Multimodal Analgesic

2 Multimodal Analgesics

>2 Multimodal Analgesics

“Stepwise” Positive Effects of Multimodals

Additions of Non-Opioid Analgesics Associated with Additive Positive Effects in Total Joints.

>2 Multimodals:1. 19% Decreased Resp. Compl.

2. 26% Decreased GI Compl.3. 18.5% Decreased Opioid Usage4. 12.1% Decreased LOS

NSAIDS and Cox-2 Inhibitors were the MOST EFFECTIVE Multimodal Non-Opioid Analgesics

Source: Memtsoudis et al. (2018)

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Peripheral Neural Blockade (e.g. TAP, Upper and Lower Extremity

Blocks)

Decrease Opioid Consumption

Decrease LOS (about 1 day)

Decrease PONV and Post-Op Ileus

Excellent for Laparoscopic Abdominal and Ortho Procedures

Central Neural Blockade (e.g. Epidural and SAB)

Decrease Time to Return of Gut Function (by 17 hours)

Decrease Opioids and Post-op Morbidity (CV, Pulm, GI)

Decrease LOS (about 1 day)

Decrease Protein Catabolism and Endocrine Metabolic Response

Excellent in Open Abdominal Procedures

Use Low Concentration of Local Anesthetic to Prevent Motor Block and Hypotension

Regional Anesthesia

Sources: Pirrera et al. (2018), Helander et al. (2017), Kim et al. (2017), Guay et al. (2016), Popping et al. (2014), Favuzza et al. (2013), Johns et al. (2012), Charlton et al. (2010), and Holte et al. (2002)

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Rogers et al. (2018) Braga et al. (2018) Aarts et al. (2018) Pecorelli et al. (2017)

VATS; 422 pts Colorectal; 722 pts Colorectal; 2876 pts Colorectal; 347 pts

Protocol Compliance Protocol Compliance Protocol Compliance

Early Mobilization Early Mobilization Early Mobilization

Early Nutrition Early Nutrition Early Nutrition

Early Removal of Drains/Tubes Early Removal of Drains/Tubes

Preop Carbohydrate Drinks Delete Mechanical Bowel Prep, Normothermia

Laparoscopy

ERAS Elements with Greatest Impact on Recovery

ERAS elements with the greatest impact

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Improve Patient Education and Participation

Optimize Perioperative Nutrition

Standardize Perioperative Anesthetic Regimens

Minimize Pain/Opioid Usage/Stress Response

Encourage Early Mobilization and Oral Intake

ERAS Protocols are Evidence-Based

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Nicholson et al., 2014, BJSLau et al., 2017,

World J SurgVisioni et al., 2017, Annals of

Surg

# Randomized Controlled Studies 38 42 39

# Patients 5,099 5,241 6,500

Surgical Sub-SpecialtiesCR, GU, Ortho, Upper GI,

ThoracicCR, GU, Ortho, Upper GI, Thoracic CR, GU, Upper GI

Decreased LOS 1.14 days 2.35 days 2.50 days

Decreased Complications 30% 38% Odds Ratio=0.7

Decreased Cost N/A $830-$3100/day $5109

No changes in…Mortality, Readmissions, Major

ComplMortality, Readmissions (except

upper GI)Readmissions

Meta-Analysis of ERAS Programs in Surgical Patients

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Cost

• Reduced Cost

• Increased Revenue

Infection

• Reduced Post-op Infections

• Decreased Inflammatory Mediators

Opioids

• Reduced Opioid Usage

• Decreased Addiction Risk

Cancer

• Rapid Recovery and Return to Oncologic Therapy

• Decreased Cancer Recurrence and Improved QOL

Additional ERAS Benefits

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• Health Economics in ERAS Programs

(Stowers et al., Can J Anesth 2015)

o 17 Studies

o Colorectal, Bariatric, Gyne, Gastric, Pancreatic, Esophageal, Vascular

o All Studies Report Cost Savings (Related to Quick Recovery, Decreased Morbidity and Complications)

o All Costs are In-Hospital Costs

o Few Studies Account for Readmissions and Follow-Up

• ERAS protocols need initial investments by institutions, but rapidly result in important gains financially and clinically

• Once implemented, financial gains continue to result in considerable savings proportional to the number of patients in the protocols

Cost Benefits

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36 Abdominal and Pelvic Surgical

Studies, 4142 pts (2070 ERAS, 2072

non-ERAS)

ERAS Decreases

LOS

ERASReduces Post-op SSI, UTI,

Pulm. Compl.

ERAS Decreases

PeriopInflamm. (CRP,IL-6)

ERAS Improves Post-op Immune Function

ERAS Protocols Reduce Post-op Infections

Rational For ERAS Benefit:1. Preincision Abx, Surg. Site Antiseptic Prep2. Nutrition (Pre-op Carbs, Early Enteral PO)3. Laparoscopy4. Normothermia5. GDFT6. Early Removal of Drains, Tubes, Catheters

Source: Grant et al. (2017)

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• US Opioid Epidemic

o 2 million Americans dependent on opioids for chronic medical conditions

o >4 million Americans use prescription opioids non-medically

o 1/3 of people addicted to opioids took their first opioid

post-operatively

o 2018-DEA mandated a 20% decrease in opioid manufacturing

• ERAS Solution-Decrease Perioperative Opioid Usage

o Patient Education and Expectation Management

o Multimodal Non-Opioid Analgesia

o Regional Anesthesia

• Challenge: Define Appropriate Quantity of Post-op Discharge Meds

ERAS Protocols Combat the Opioid Crisis

78

Sources: Brandal et al. (2017), Warren et al. (2017), Wick et al. (2017)

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ERAS Impacts Cancer Survival

79

Sources: Asklid et al. (2017), Kim et al. (2016), Juneja et al. (2014), Gustafsson et al. (2013)


Increase Awareness

and “Buy-In”

Increase Awareness

and “Buy-In”Develop PlanDevelop Plan

Assemble Multi-

disciplinary Team

Assemble Multi-

disciplinary Team

Prepare and

Execute Rollout

Prepare and

Execute Rollout

Ensure Sustainable

Model

Ensure Sustainable

Model

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How Do We Implement ERAS Pathways???

• There is No Formula!

• ERAS Must be Tailored to an Institution and Practice.

• Coordination, Integration, and Standardization are Keys for Successful ERAS Programs.

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First Steps of ERAS Implementation

Review Quality Data

Quantifiable Data Describing the Current State for a Specific SurgicalSpecialty, i.e. Volume, Growth, Adverse Event Risk

Define Metrics to Improve

Realistic Goals Identified to Achieve eg. LOS, opioid usage, complication rate, readmission rate etc.

Identify ERAS “Champion”

Typically a Physician (Anesthesiologist or Surgeon) Willing to LeadERAS Design and Implementation with a Multidisciplinary Team

82

Appoint a Clinical “Champion”

83

Champion’s Initial Responsibilites

Administrative

Support

1. Awarenessand “Buy-In”2. Financial Backing3. Resource Availability

Literature

Review

1. Evidence Based Practice2. Current Literature Review-ERAS Society Recs3. Reputable/Comparable Institution Model

Goals and

Outline

1. Use Quality Data2. Identify First Surgical Service3. Define InitialTimeline

Recruit Motivated

Leaders

1. Surgery/Anesthesiology2. Quality3. Nursing etc.

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Increase Awareness

and ”Buy-In”

Increase Awareness

and ”Buy-In”Develop PlanDevelop Plan

Assemble Multi-

disciplinary Team

Assemble Multi-

disciplinary Team

Prepare and

Execute Rollout

Prepare and

Execute Rollout

Ensure Sustainable

Model

Ensure Sustainable

Model

85

Anesthesiology

Surgery

Quality Managers

Nursing

Pharmacy

Phys ical Therapy

Pain Clinic

Nutri tion

Information Technology-EMR

Home Care

Multidisciplinary Team of Stakeholders

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ERAS Steering Group Meetings

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ERAS Steering Group Meetings

• Start with Core Group

• Present Quality Data• Build Consensus

• Use Evidence-Based/Best Practice • Develop Timetable• Identify Potential Barriers to Success

o Cost Restraintso Resource Availability

o Time Commitmento Enthusiastic/Committed Championso Administrative and Dept. Support

o “Buy-In” from All Providerso IT and Quality Involvement

o Pharmaceutical Approval/Availability

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Increase Awareness

and “Buy-In”

Increase Awareness


Assemble Multi-

disciplinary Team

Assemble Multi-

disciplinary Team

Prepare and

Execute Rollout

Prepare and

Execute Rollout

Ensure Sustainable

Model

Ensure Sustainable

Model

88

Getting to the Finish Line!

89

Preparation

Execution

Create a Preoperative Education Manual

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1. Develop Evidence-Based ERAS Protocola) Define Pre-, Intra-, and Post-op

Interventionsb) Consider Resources, Patients, Local

Experience etc.c) Obtain Input, Support, and Consensus

of Multidisciplinary Teamd) Pre-emptively Recognize Areas of

Contention

2. Create New ERAS Pre-op and Post-op Order Sets and Eliminate Old

3. Define New Nursing Care Plans

4. Commitment that All Patients having Procedure, All Providers, Will Participate

Design ERAS Pathway and New ERAS Order Sets

91

Involvement of Multidisciplinary Team Members

• Pain Clinico ERAS Spinal Fusion Patients (or any ERAS patient on chronic opioids)

o Pre-op Consult for Patients on >50 MMEs of Opioids, Extended Release Opioids, with Substance Abuse History, Difficult to Control Pain Issues etc.

o Help Adjust ERAS Spine Protocol and Meds to Assist with Perioperative Pa in Management

o Acute Pain Consults Post-op

o Patients Return Post-op to Primary Pain MD

• Pharmacyo Review Order Sets

o Approve, Order, Stock ERAS Meds

• Physical Therapyo Spinal Fusion ERAS

o Total Joint/Ortho ERAS

• Home Care-Discharge Planning

• Informational Technologyo Input New Order Sets

o Design Program to Track Metrics

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Education of All Personnel Involved in Care (Anesthesiologists, Surgeons, RNs, PAs)

Design Icon in EMR to Notify All Caregivers that Patient is an ERAS Patient (IT)

Continuous Refinement of Protocol, Manual, Order Sets with Input by Team

IMPLEMENT!!!!

Final Steps Prior to Rollout

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Increase Awareness

and “Buy-In”

Increase Awareness


Assemble Multi-

disciplinary Team

Assemble Multi-

disciplinary Team

Prepare and

Execute Rollout

Prepare and

Execute Rollout

Ensure Sustainable

Model

Ensure Sustainable

Model

94

Keys to Creating a Sustainable Model

Ensure Compliance

Maintain Accountability

Track Metrics

Establish Governance

95

• Clinical Leadership is Key

• Each Protocol Should be Championed by Physicians and Nurses on the “Front Lines” and in the Quality Department

• ERAS Champions Need to be Willing to Build ERAS Pathways with a Multidisciplinary Team and Support the Protocol Pre- and Post-Implementation

• Leaders Need to Devote Significant Non-Clinical Time to the ERAS Effort

• If Few Protocols exist in the Literature, Champions Need to be Willing to Build, Evaluate, and Pioneer a New Pathway

• The Leadership Team must continue to meet Post Rollout to Evaluate Metrics and Outcomes and Revise the Pathway

Establish Successful Governance

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-Institution Specific

-Simplified with Help of EMR and Hospital IT Department

-Quality Managers Invaluable

Define and Track Metrics

Re

adm

issi

onRa

te

Opioid Usage

SSI

and

DVT

Rat

e

Length of Stay

Pro

toco

lCom

plia

nce

Cost Savings

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Compliance and Accountability Will Ensure Future Continued Success of ERAS

98

Maintain Accountability and Set Goals of Participation

Ensure Maximum Compliance with Entire ERAS Protocol

ERAS Process Review- Criteria for Future ERAS Protocol Development

99

Current Volume of Procedure

Anticipated Growth of Procedure

Procedure Risk for Adverse

Events

Clinical Leadership &

Support, Desire to

Collaborate Towards a Goal

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Future ERAS Directions

Hospital Recovery:Metrics: LOS, Readmision Rate, Cost, etc

Clinical Recovery:Return to Baseline Physiologic Parameters: Ambulate, Void etc

Biological RecoveryBiomarkers: CRP, Neutrophil-Lymphocyte Ratio

Patient Reported OutcomesTools: QoR-9,15,40, PQRS

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• ERAS Protocols are Evidence-Based, Multidisciplinary, and Collaborative Approaches to Perioperative Care Based on Scientific Principles that Optimize Preoperative, Intraoperative, and Postoperative Care

• ERAS Care Maps and Standardization Result in Significant Decreases in Complications, Opioid Use, LOS, and Cost, and Improved Patient Rehabilitation and Recovery

• ERAS Strategies are Increasingly Being Utilized In the Era of Value-Based Care

Enhanced Recovery After Surgery (ERAS)-Summary

101

• Development of Enhanced Recovery Programs Requires “Clinical Champions” and Broad Multidisciplinary Support and Participation

• A Number of Roadblocks for Successful ERAS Implementation may Need to be Overcome Including Cost Restraints, Resource Availability, Time, Administrative and Departmental Support, “Buy-In” from All Providers, Reliable Ancillary Support Services, and Involved Quality Managers

• After Implementation of ERAS Pathways, it is Imperative that a Plan Exists to Ensure the Program Remains a Successful and Sustainable Model

Creating and Implementing Enhanced Recovery Programs- Conclusion

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1. ERAS Protocolsa. Depend only on input from the anesthesia and surgery teams.b. Are evidence-based pathways that encompass all aspects of perioperative care.c. Cons ist of preoperative, intraoperative, and postoperative elements; in recent studies, the preoperative elements are associa ted with the greatest

impact on recovery.

d. Are proportionally successful based on the number of ERAS interventions in a protocol (increased numbers of interventions lea d to increased success of ERAS).

2. Several systematic review and meta-analysis reports of ERAS programs in multiple surgical subspecialties (colorectal, upper abdominal, genitourinary, orthopedic, and thoracic) have demonstrated that ERAS care is associated with all of the following excepta. Decreased hospital length of s tay.b. Reduced perioperative complications.c. Increased readmission rate.

d. Reduced pain score, opioid usage, and opioid-related s ide effects .

3. All of the following factors may limit successful implementation of ERAS programs in hospital systems excepta. Resource availability and cost.

b. Administrative support.c. “Buy-in” from a l l providers.

d. Private versus academic hospital system.

e. Committed ERAS champions.


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Answers: 1. b 2. c 3. d

Appendix: References

Aarts M, et al. Postoperative ERAS Interventions Have the Greatest Impact on Optimal Recovery. Experience with Implementation of ERAS across Multiple Hospitals. Ann Surg2018; 267(6):992-997.

Apf el CC, et al. Intravenous Acetaminophen Reduces Postoperative Nausea and Vomiting: A Systematic Review and Meta-Analysis. Pain 2013; 154:677-689.

Asklid D, et al. The Impact of Perioperative Fluid Therapy on Short-Term Outcomes and 5-Year Survival among Patients Undergoing Colorectal Cancer Surgery – A Prospective Cohort Study within an ERAS Protocol. European Journal of Surgical Oncology 2017; 43:1433-1439.

Bev erly A, et al. Essential Elements of Multimodal Analgesia in Enhanced Recovery after Surgery (ERAS) Guidelines. Anesthesiology 2017; 35:e115-e143.

Braga M, et al. Identification of Core Items in the Enhanced Recovery Pathway. Clinical Nutrition ESPEN 2018; 25:139-144.

Brandal D, et al. Impact of Enhanced Recovery after Surgery and Opioid Prescriptions at Discharge from the Hospital: A Historical-Prospective Study. Anesth Analg2017; 125(5):1784-1792.

Charlton, S, Cyna AM, Middleton P, Griffiths JD. Perioperative Transversus Abdominis Plane (TAP) Blocks for Analgesia After Abdominal Surgery. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD007705.

De Oliv eira GS, et al. Single-Dose Systemic Acetaminophen to Prevent Postoperative Pain. Clinical Journal of Pain 2015; 31:86-93.

De Oliv eira GS, et al. Perioperative Single Dose Ketorolac to Prevent Postoperative Pain: A Meta-Analysis of Randomized Trials. Anesthesia Analgesia 2012; 114:424-430.

Fav uzza J et al. Outcomes of Discharge after Elective Laparoscopic Colorectal Surgery with Transversus Abdominis Plane Blocks and Enhanced Recovery Pathway. Journal of the American College of Surgeons 2013; 217:503-506.

References

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Grant, et al. Impact of Enhanced Recovery after Surgery and Fast Track Surgery Pathways on Healthcare-Associated Infections: Results from a Systematic Review and Meta-Analysis. Annals of Surgery 2017; 265:68-79.

Guay J, Nishimori M, Kopp S. Epidural Local Anaestheticsversus Opioid-Based Analgesic Regimens for Postoperative Gastrointestinal Paralysis, Vomiting and Pain After Abdominal Surgery.Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD001893.

Gustafsson U, et al. Guidelines for Perioperative Care in Elective Colonic Surgery: Enhanced Recovery After Surgery (ERAS) Society Recommendations. World Journal of Surgery 2013; 37:259-284.

Gustafsson U, et al. Adherence to the Enhanced Recovery after Surgery Protocol and Outcomes after Colorectal Cancer Surgery. Archives of Surgery 2011; 146:571-577.

Helander EM, et al. Use of Regional Anesthesia Techniques: Analysis of Institutional Enhanced Recovery after Surgery Protocols for Colorectal Surgery. Journal of Laparoendoscopic & Advanced Surgical Techniques 2017; 27:898-902.

Holte K, et al. Epidural Anaesthesia and Analgesia – Effects on Surgical Stress Responses and Implications for Postoperative Nutrition. Clinical Nutrition 2002; 21:199-206.

Hurley RW, et al. The Analgesic Effects of Perioperative Gabapentin on Postoperative Pain: A Meta-Analysis. Regional Anesthesia and Pain Medicine 2006; 31:237-247.

Johns N, et al. Clinical Effectiveness of Transversus Abdominis Plane (TAP) Block in Abdominal Surgery: A Systematic Review and Meta-Analysis. Colorectal Disease 2012; 14:e635-e642.

Juneja R. Opioids and Cancer Recurrence. Curr Opin Support PalliatCare 2014; 8(2):91-101.

References (cont.)

106

Kehlet H, et al. Enhanced Recovery After Surgery: Current Controversies and Concerns. Anesth Analg 2017; 125(6):2154-2155.

Kehlet H. ERAS Implementation- Time to Move Forward. Ann Surg 2018; 267(6):998-999.

Kehlet H. Multimodal Approach to Control Postoperative Pathophysiology and Rehabilitation. Br J Anaesth 1997; 78:608-617.

Khan JS, et al. An Estimation for an Appropriate End Time for an Intraoperative Intravenous Lidocaine Infusion in Bowel Surgery:A Comparative Meta-Analysis. Journal of Clinical Anesthesia 2016; 28:95-104.

Kim AJ, et al. The Role of Transversus Abdominis Plane Blocks in Enhanced Recovery After Surgery Pathways for Open and Laparoscopic Colorectal Surgery. Journal of Laparoendoscopic& Advanced Surgical Techniques 2017; 27:909-914.

Kim B, et al. The Impact of Postoperative Complications on a Timely Return to Intended Oncologic Therapy (RIOT): the Role of Enhanced Recovery in the Cancer Journey. International Anesthesiology Clinics, 2016; 54(4):e33-e46.

Lau C, et al. Enhanced Recovery After Surgery Programs Improve Patient Outcomes and Recovery: A Meta-Analysis. World Journal of Surgery 2017; 41:899-913.

McNicol ED, et al. Single-Dose Intravenous Paracetamol Or Propacetamol for Prevention Or Treatment of Postoperative Pain: A Systematic Review and Meta-Analysis. British Journal of Anaesthesia 2011; 106:764-775.

MemtsoudisSG, et al. Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resources Utilization. Anesthesiology 2018; 128(5):891-902.

Nicholson A, et al. Systematic Review and Meta-Analysis of Enhanced Recovery Programmesin Surgical Patients. British Journal of Surgery 2014; 101:172-188.

References (cont.)

107

Ong CKS, et al. Combining Paracetamol (Acetaminophen) with Nonsteroidal Antiinflammatory Drugs: A Qualitative Systematic Review of Analgesic Efficacy for Acute Postoperative Pain. Anesthesia Analgesia 2010; 110:1170-1179.

Pecorell i N, et al. Impact of Adherence to Care Pathway Interventions on Recovery Following Bowel Resection within an Established Enhanced Recovery Program. Surg Endosc 2017; 31(4):1760-1771.

Pirrera B, et al. Transversus Abdominis Plane (TAP) Block Versus Thoracic Epidural Analgesia (TEA) in Laparoscopic Colon Surgery in the ERAS Program. Surgical Endoscopy 2018; 32:376-382.

Pöpping D, et al. Impact of Epidural Analgesia on Mortality and Morbidity after Surgery. Annals of Surgery 2014; 259:1056-1067.

Rogers L, et al. The Impact of Enhanced Recovery after Surgery (ERAS) Protocol Compliance on Morbidity from Resection for Pri mary Lung Cancer. Journal of Thoracic and Cardiovascular Surg 2018; 155(4):1843-1852.

Schmidt P, et al. Perioperative Gabapentoids. Anesthesiology 2013; 119:1215-1221.

StowersM, et al. Health Economics in Enhanced Recovery after Surgery Programs. Canadian Journal of Anesthesia 2015; 62:219-230.

Straube S, et al. Effect of Preoperative Cox-II-Selective NSAIDs (Coxibs) on Postoperative Outcomes: A Systematic Review of Randomized Studies. Acta Anaesthesiologica Scandanavica 2005; 49:601-613.

Tan M, et al. Optimizing Pain Management to Facilitate Enhanced Recovery After Surgery Pathways. Canadian Journal of Anesthesia 2015; 62:203-218.

Visioni A, et al. Enhanced Recovery after Surgery for Noncolorectal Surgery? A Systemic Review and Meta-Analysis of Major Abdominal Surgery. Annals of Surgery 2018; 267:57-65.

Wang L, et al. Ketamine Added to Morphine Or Hydromorphone Patient- Controlled Analgesia for Acute Postoperative Pain in Adults: A Systematic Review and Meta-Analysis of Randomized Trials. Canadian Journal of Anesthesia 2016; 63:311-325. 108

References (cont.)

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Warren J, et al. Effect of Multimodal Analgesia on Opioid Use after Open ventral Hernia Repair. Journal of Gastrointesinal Surgery 2017; 21(10):1692-1699.

Wick E, et al. Postoperative Multimodal Analgesia Pain Management with Nonopioid Analgesics and Techniques – A Review. JAMA Surg 2017; 152(7):691-697.

References (cont.)

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Modulating Chronic Pain with Physical Therapy: Key Considerations for

Appropriate Management

Carol A. Courtney PT, PhD

ProfessorDepartment of Physical Therapy

and Human Movement Science


Chicago, Illinois

October 4-5, 2019

Disclaimer

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• I have nothing to disclose.

Objectives

•Appreciate the effect of physical therapy interventions on aberrant nociceptive processing.

•Understand the use of quantitative sensory testing in physical therapy management of chronic pain.

•Recognize the importance of a collaborative approach in health care for management of chronic pain.

Chronic Pain: An Epidemic

• Prevalence of chronic pain in US adults > 18 yo• estimated at 30.7 and 43%

• Similar statistics in UK

• Social and financial ramifications staggering • Disability; reduced quality of life

• Increased risk of hospitalization, institutionalization, mortality

Johannes 2010 J Pain; Institute of Medicine 2010; Fayaz 2016 BMJ

Schafer 2014 BMC Public Health; Morales-Espinoza 2016 Pain

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Another US Epidemic:•Opioid-related abuse and addiction

# O

pio

idP

resc

rip

tio

ns

Dis

pe

nse

d

Musculoskeletal pain

May present with myriad of symptoms

Confusing to clinician

Leads to non-specific diagnoses (eg: Low Back Pain)

What is sensitization?

Old view: pain was hard-wired

Stimulus Response

The central nervous system can learn…

Neuroplasticity

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Peripheral Sensitization‘stimulus evoked plasticity of the nociceptor’ Woolf 2007 Anesthesiology

Inflammatory mediators bind to receptor - cause:

↓ threshold

↑ excitability

Primary hyperalgesiarestricted to site of tissue injury

Requires ongoing stimulus for maintenance

Woolf 2004 Ann Int Med

Sensitization of Nociceptive Pathways

Central nociplasticity

• occurs following repetitive or intense noxious stimulus Latremoliere and Woolf 2009 J Pain

Characterized by:

Increased excitability of nociceptive pathways

Decrease in descending inhibitionCourtney 2010 J Pain, 2016 JOSPT

Adapted from Costigan 2009 Ann Rev Neurosci

Peripheral Sensitization

Central Sensitization

Inflammatory mediators

How do we identify the patient with centrally mediated pain?

•Laboratory Methods

•Clinical Presentation

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Found:

• Hyperexcitable FWR (nociceptive reflex) in knee OA vs. healthy age/gender matched control subjects

• ↓ threshold to elicit reflex

Facilitated nociceptive reflex as a biomarker for central sensitization

Other Musculoskeletal Conditions

Whiplash, Fibromyalgia Banic 2004

Cervical Spine Dysfunction

Sterling 2010Lateral Epicondylalgia

Lim 2012

Anterior Cruciate Ligament RuptureCourtney 2011

Clinical Features of Central Nociplasticity

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Clinical features of centrally-mediated pain

•Heightened intensity of pain

•Spreading of Pain (Altered pain threshold outside of injured area = Secondary hyperalgesia)

•Pain ramps up easily (temporal summation)

• Impaired ability to inhibit pain

•Latent pain

•Hypoesthesia

Courtney 2010 JOSPTAllodyniaOften in region of most pain‘Feels like sunburn’

Greater Intensity and Distribution of Symptoms/Hyperalgesia

• increased size of peripheral receptive field

Clinical Implication:

Input from a wider region can induce pain

Bajaj 2001, Pain; Lluch-Girbes 2016, Phys Ther

In Knee OA:Enlarged areas of pain associated with • higher knee pain severity, stiffness and • higher scores Central Sensitivity Inventory

How? HeterosynapticFacilitation

Courtney 2017 JMMT

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Regional vs Widespread Hyperalgesia

Skou 2013; Scan J Pain

Dynamic Measures of Central Sensitization

•Conditioned Pain Modulation• Detects impaired descending inhibition

•Temporal Summation• Detects hyperexcitability of nociceptive pathways

Dynamic Measures of Central Nociplasticity•Temporal summation of second pain is the perceptual correlate of wind-up

Price 1977, Pain

•Homosynaptic facilitation

•Repetitive stimuli applied (1 Hz)

With central nociplasticity:• Steeper response curve

Temporal Summation

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Dynamic Measures of Central Sensitization

Courtney 2017 JMMT

Impaired Pain Inhibition Lewis 2012 J Pain

•Found in many chronic pain populations

• Knee OA: Arendt-Nielson 2010 Pain, Courtney 2016 JOSPT

• Hip OA: Kosek and Ordeberg 2000 Pain

• Chronic patellofemoral pain Rathleff 2016 Pain Med

• Fibromyalgia: Kosek & Hansson 1997 Pain, O’Brien 2018 J Pain

Management

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TENStranscutaneous electrical nerve stimulation

How does it work? (both central and peripheral effects)

• “Re-boots” descending inhibition

• Repetitive use results in a cumulative and longer-lasting TENS effect

Vance 2014

• Local Effects:

• In animal model, reduces Substance P

Rokugo 2002

Dosing:• Stimulation amplitude must be of sufficient strength to produce an analgesic

effect• Repeated use dampens central excitability and enhances descending

inhibition

• Use mixed-frequency. Modulating between low and high frequencies delays opioid tolerance

Interpretation:

1. Turn it up

2. Use it often

3. Use Modulating Frequencies

Why does it work?

Sluka 2013*Use High Frequency TENS in patients using opioid medications

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Manual therapy

• RCT demonstrated independent contribution of manual therapy for knee OA treatment outcomes Abbott 2015 JOSPT

Applied Grade III oscillatory mobilization at the tibiofemoral joint 2 X 3 minutes

Result: ↓ flexor withdrawal response

= Decreased Central Sensitization

Courtney 2016 JOSPT

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EXERCISE

Physical Activity Guidelines

• For Overall Cardiovascular Health:

• At least 30 minutes of moderate-intensity aerobic activity at least 5 days per week for a total of 150 minutes.

OR

• At least 25 minutes of vigorous exercise 3 days per week

AND

• Moderate- to high-intensity muscle-strengthening activity 2 days per week

Exercise in Physical Therapy

•Strength

•Endurance

•Motor Control

•Function

•Power

But, what about for pain?

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Inoculation for chronic pain?

• Regular physical activity prevents development of chronic muscle pain and exercise-induced muscle pain Lima 2017 Pain

• How?

• Reducing phosphorylation of NR1 subunit of NMDA receptor in CNS (a component of central sensitization)

• Regular physical activity = no effect on development of acute pain

• But prevents development of central sensitization

• **Physical inactivity is a risk factor for development of chronic pain

Exercise induced Analgesia:

• Peripheral Effects• Muscle contraction disperses

inflammation

• Restores joint normal movement • removes mechanical driver of

pain

Also• Increases expression of endogenous

analgesic substances in exercising muscle Lima 2017 Pain

• Central Effects• Opioid Mechanisms• β-endorphin release activates descending

inhibitory pathways Stagg 2011

• Positive effects on mental health• Mood elevation • Reduction of stress and depression

Janal 1984Non-Opioid Mechanisms• Serotonergic Inhibition

Bobinski 2015• Exercise increases serum concentrations of

endocannabinoids Dietrich & McDaniel 2004

Aerobic Exercise: Dose Response

• Recommend intensity >50% VO2max and duration >10 min to elicit exercise analgesia

Hoffman 2004

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©2008The American College of Sports Medicine. Published by Lippincott Williams & Wilkins, Inc.

2

ISOMETRIC CONTRACTION: Dose Response

HOEGER BEMENT, MARIE; DICAPO, JOHN; RASIARMOS, REBECCA; HUNTER, SANDRA

Medicine & Science in Sports & Exercise. 40(11):1880-1889, November 2008.

DOI: 10.1249/MSS.0b013e31817eeecc

**low level contraction (elbow flexion) for long

duration = greatest decrease in pain

Hoeger-Bement 2008

“hypoalgesic effect larger for contractions at a low to moderate intensity held for longer durations.”

Naugle 2012

Confrontational therapy (Graded Exposure)

• exposure of patient to the feared stimuli (activity) without any danger

• graded or hierarchical approach

• the most mildly feared activities are targeted first

• Gradual exposure to more intense anxiety provoking stimuli

• therapist and client collaboratively develop an exposure hierarchy in which feared stimuli are ranked accordingly

López-de-Uralde-Villanueva 2016 Pain Med

Conclusion

• Increasing evidence that various therapies can down modulate pain processing such as:

• TENS

• Manual therapy

• Exercise

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ReferencesJohannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain. 2010 Nov;11(11):1230-9. Dart RC et al. N Engl J Med 2015;372:241-248Costigan M, Woolf CJ (2000) Pain: molecular mechanisms. J Pain. 2000 Sep;1(3 Suppl):35-44.Woolf CJ. Central sensitization: uncovering the relation between pain and plasticity. Anesthesiology. 2007 Apr;106(4):864-7.Latremoliere A, Woolf CJ. Central sensitization: a generator of pain hypersensitivity by central neural plasticity. J Pain. 2009 Sep;10(9):895-926.Courtney CA, Fernández-de-Las-Peñas C, Bond S. Mechanisms of chronic pain - key considerations for appropriate physical therapy management. J Man Manip Ther. 2017 Jul;25(3):118-127.Courtney CA, Steffen AD, Fernández-de-Las-Peñas C, Kim J, Chmell SJ. Joint Mobilization Enhances Mechanisms of Conditioned Pain Modulation in Individuals With Osteoarthritis of the Knee. J Orthop Sports Phys Ther. 2016 Mar;46(3):168-76. Courtney CA, Kavchak AE, Lowry CD, O'Hearn MA. Interpreting joint pain: quantitative sensory testing in musculoskeletal management. J Orthop Sports Phys Ther. 2010 Dec;40(12):818-25. doi: 10.2519/jospt.2010.3314. Epub 2010 Oct 22. Review.Courtney CA, Durr RK, Emerson-Kavchak AJ, Witte EO, Santos MJ. Heightened flexor withdrawal responses following ACL rupture are enhanced by passive tibial translation. Clin Neurophysiol. 2011 May;122(5):1005-10. doi: 10.1016/j.clinph.2010.07.029. Epub 2010 Sep 26.Courtney CA, Witte PO, Chmell SJ, Hornby TG Heightened flexor withdrawal response in individuals with knee osteoarthritis is modulated by joint compression and joint mobilization. J Pain. 2010 Feb;11(2):179-85. doi: 10.1016/j.jpain.2009.07.005. Epub 2009 Nov 27.Courtney CA, Lewek MD, Witte PO, Chmell SJ, Hornby TG. Heightened flexor withdrawal responses in subjects with knee osteoarthritis. J Pain. 2009 Dec;10(12):1242-9. Bajaj P, Bajaj P, Graven-Nielsen T, Arendt-Nielsen L. Osteoarthritis and its association with muscle hyperalgesia: an experimental controlled study. Pain. 2001 Aug;93(2):107-14.Arendt-Nielsen L1, Nie H, Laursen MB, Laursen BS, Madeleine P, Simonsen OH, Graven-Nielsen T. Sensitization in patients with painful knee osteoarthritis. Pain. 2010 Jun;149(3):573-81.Kosek E, Ordeberg G.. Lack of pressure pain modulation by heterotopic noxious conditioning stimulation in patients with painful osteoarthritis before, but not following, surgical pain relief.Pain. 2000 Oct;88(1):69-78.Rathleff MS, Petersen KK, Arendt-Nielsen L, ThorborgK, Graven-Nielsen T.. Impaired Conditioned Pain Modulation in Young Female Adults with Long-Standing Patellofemoral Pain: A Single Blinded Cross-Sectional Study. Pain Med. 2016 May;17(5):980-8.Kosek E, Hansson P. Modulatory influence on somatosensory perception from vibration and heterotopic noxious conditioning stimulation (HNCS) in fibromyalgia patients and healthy subjects.. Pain. 1997 Mar;70(1):41-51.

O'Brien AT, Deitos A, Triñanes PegoY, Fregni F, Carrillo-de-la-Peña MT. Defective Endogenous Pain Modulation in Fibromyalgia: A Meta-Analysis of Temporal Summation and Conditioned Pain Modulation Paradigms. J Pain. 2018 Aug;19(8):819-836

Sluka KA, Walsh D. Transcutaneous electrical nerve stimulation: basic science mechanisms and clinical effectivenessJ Pain. 2003 Apr;4(3):109-21.

Vance CG, Dailey DL, Rakel BA, Sluka KA. Using TENS for pain control: the state of the evidence. Pain Manag. 2014 May;4(3):197-209.

Hoeger Bement, M, Dicapo, J, Rasiarmos, R, Hunter, S. Medicine & Science in Sports & Exercise. 40(11):1880-1889, 2008.

Lee KH, Chung JM, Willis WD Jr. Inhibition of primate spinothalamic tract cells by TENS. J Neurosurg. 1985 Feb;62(2):276-87.

Questions

1. Your patient is a 27 year old female with chronic low back pain, with intermittent radiation into the Left gluteal region and lower extremity. On the PainDetect Questionnaire, she answers that “light touching (i.e. clothing) is moderately painful” in the lumbar region. Regarding her response to light touch, you hypothesize that the patient:

a. is catastrophizing her symptoms

b. is reporting allodynia to light touch

c. may have neuropathic pain

d. B and C

Questions

1. Your patient is a 27 year old female with chronic low back pain, with intermittent radiation into the Left gluteal region and lower extremity. On the PainDetect Questionnaire, she answers that “light touching (i.e. clothing) is moderately painful” in the lumbar region. Regarding her response to light touch, you hypothesize that the patient:

a. is catastrophizing her symptoms

b. is reporting allodynia to light touch

c. may have neuropathic pain

d. B and C

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Question

2. Which of the following regarding descending pain inhibition is true?a. Physical therapy interventions such as exercise, manual therapy and TENS facilitate pain inhibitionb. The amygdala is a key relay for pain modulationc. Because the effect of TENS is long lasting, recommended dosage is once/weekd. Opioid and serotonergic mechanisms may interact to promote analgesia with exercisee. A and D

Question

2. Which of the following regarding descending pain inhibition is true?a. Physical therapy interventions such as exercise, manual therapy and TENS facilitate pain inhibitionb. The amygdala is a key relay for pain modulationc. Because the effect of TENS is long lasting, recommended dosage is once/weekd. Opioid and serotonergic mechanisms may interact to promote analgesia with exercisee. A and D

Question

3. Regarding graded exposure for management of the client with chronic musculoskeletal pain:

a. involves gradual exposure in terms of time or intensity to a painful activity

b. pain is always disregarded during these therapies

c. it is best to start with the most irritating activity

d. all of the above

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Question

3. Regarding graded exposure for management of the client with chronic musculoskeletal pain:

a. involves gradual exposure in terms of time or intensity to a painful activity

b. pain is always disregarded during these therapies

c. it is best to start with the most irritating activity

d. all of the above

Thank you!

Department of Physical Therapy and Human Movement Science

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Preventing Persistent Post- Surgical Pain & Opioid Use in ...€¦ · The development of an integrated treatment for veterans with comorbid chronic pain and posttraumatic stress disorder.

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