Articles, Blog

The Surgeon’s Role in the Opioid Epidemic: Opportunities to Make a Difference – 3-7-2018

December 17, 2019


[MUSIC PLAYING] DEBORAH MARQUARDT: So good
morning, and welcome to Surgery Grand Rounds. We have a particularly special presentation
this morning. It’s, obviously, very salient, given the ongoing
opioid crisis in our nation and facing our health care system. This presentation, actually, resulted from
the weekly meetings with the residents with our chairman. They brought up the issue of feeling the challenges
of trying to deal with many of the patients that we receive from the WWAMI region with
significant injuries and requiring a significant amount of opioids, given their diagnosis or
condition, and trying to manage that from such a remote distance and the precarious
nature of that. So taking that question, or that concern,
two of our chief residents, Barclay Stewart and Lacey LaGrone, turned this into the presentation
this morning. And I greatly appreciate all the effort that
they’ve put into it. So we have three speakers. Our first speaker is Dr. Debra Gordon. She’s the co-director of the Harborview Integrated
Pain Care Program, and she’s a teaching associate with the Department of Anesthesiology and
Pain Medicine at the University of Washington. She definitely works with both inpatient and
outpatient pain relief services on improving the systems of care and pain management. She’s a co-investigator for the University
of Washington’s NIH-designated Center of Excellence in Pain Education. And she’s been a leader, both nationally and
internationally, in developing quality improvement guidelines with regard to pain management
and as an active leader in the American Pain Association, the International Association
for the Study of Pain, and as a fellow of the American Academy of Nursing. Our next speaker is Dr. Jared Klein. He is an assistant professor at the University
of Washington. He currently serves as an attending physician
in the Adult Medicine Clinic at Harborview Medical Center and is also a specialist in
addictions medicine. He’s director of the aftercare clinic and
is an active member in the hospital’s opioid review committee, a champion for management
of opioid therapy, chronically, and it sounds like he’s actively working on some programs
to engage patients in their own care of addictions via new online portals. And last, Dr. Ivan Lesnik is an associate
clinical professor in anesthesiology at the University of Washington. He is the chief of pain services at Harborview
Medical Center and also co-director of the Harborview Integrated Pain Care Program. Prior to coming to the University of Washington,
he had an illustrious career in my beloved United States Navy and served a number of
very important roles there, including serving as the specialty leader and a variety of other
things. He completed a pain fellowship after much
of his leadership work in the Navy and went on to become the deputy program director for
the Navy’s Comprehensive Pain Management Program and also developed, and served as the director
of, the Navy Medicine’s first operationalized Functional Restoration Pain Program. So we have quite the lineup this morning. I’m going to stop there and give the rest
of the time to our speakers. DEBRA GORDON: We are thrilled to be here. I think this is such an important topic and
important collaborative for us to be talking about this subject. I wanted to just add to my background, one
of the reasons I’m also interested in this area, not only that I’ve been a surgery trauma
nurse my whole life but that I chaired the American Pain Society’s post-op guidelines
that were released in 2015. That’s the most recent evidence-based national
guideline. That was done in collaboration with the American
Society of Anesthesiologists and regional anesthesiologists. So I’ll make some reference to that as we
go along. So my task is, really, to just kind of give
you the bigger picture about what’s happened with the opioid epidemic, where we are, and
a little about what we know about how we’re doing here. So I’ll try and do that. I think you’ve probably all seen this a million
times. I tell you, every time I look at it, I feel
really old. And it’s not just because I know I’m old enough
to be the mother of most of you in this room. But when I was in practice as a staff nurse,
we very much undertreated pain. And I would say we’re still undertreating
pain today. We’re just overusing the opioids. But we’re not really addressing the bigger
issue of how we treat pain. But clearly, it wasn’t that long ago in many
of the people in this room’s career, in surgery, in particular, that we didn’t ask about pain. We didn’t use zero to 10. Everybody got PRN IM injections. And we knew that we needed to do better. And there’s been a lot of finger-pointing
over the last two decades. And that’s not what we’re here to do today. But I think it is important to understand
all of the various forces that came together, including just increasing the visibility of
pain, having the Joint Commission standards that asked us to address those, that kind
of led to this feeling, also, that opioids were safe, and there was no end organ toxicity,
and there was no iatrogenic addiction. And through 20 years of experience of using
opioids, more long-term, in higher doses, and for chronic pain, we now know that there’s
very little benefit, long-term. And, in fact, there are significant neuroendocrine-immune
adverse effects of long-term opioids, as well as addiction. Oh, sorry. I’ll use the right one. If you want a little more information, and
I think this is a fascinating sociological history, I would highly recommend these two
books. The Pursuit of Oblivion was recommended by
John [? Lozier ?] at the beginning of the Decade of Pain Control and Research, the second
only decade declared by Congress about 15 years ago. This takes you from the Opium War all the
way up to the Bush administration and policy and how that’s affected use of opioids globally. It really talks about the fact that sobriety
is not a normal human state. And throughout history, people have sought
to alter their universe. Dream Land. I hope you’ve all seen that or heard about
that. I would highly recommend that. It really talks about what’s happened most
recently and how this very successful marketing of small business operations really led to
the spread of heroin and illicit opioids in this country. And it really has a lot of discussion about
the University of Washington and the role that’s being played. So great book, if you haven’t seen it. Again, I suspect this isn’t new to you. But the numbers are absolutely staggering. 91 people die every day in the United States
from overdose and most of those involving opioids. We have more than 1,000 people that present
emergency departments with opioid-related problems. We know that we have something like 5% of
the US population and yet, we use 80% of the world’s opioids in this country. And we also know that surgeons write 10% of
all opioids in this country, second only to pain specialists. So it’s really amazing. I’m sure every one of you in this room has
been affected, either personally or professionally, by folks that have been troubled by opioids. You’ve probably seen a million of these curves,
too. They all look the same. Even though we’ve seen some bending of the
curve in Washington, we’re still seeing significant increases of death from both prescription
and illicit opioids. This happens to be, I think, the CDC. And they estimated, in 2016, we had 65,000
deaths from opioid in the United States. So one of the things that’s really of interest
now, and the literature is, really, just exploding, is the relationship of acute opioids, acute
pain. This is a recent study that looked at the
new persistent opioid use after minor and major surgeries. And it looks like, across all, people would
say that 3% to 10% of patients that are having either minor or major surgery, a year later
are still using opioids of some kind. And we know that about 80% of opioids given
to people are unused in their room. And it doesn’t seem to make a difference if
you’re looking at minor or major. It’s across all men, women, ages, procedures. This is a slide that really shows, then, the
variability of post-operative opioid prescribing. This is three major medical centers across
25 of the most common surgical elective procedures. If you see this line at the bottom, that was
the ideal threshold, they said, which was a 200 morphine equivalent dose. And you can see how many of the prescribing
practices are way above that. And look at the wide variability. Look at the top and bottom of the whisker
plots. And again, the authors concluded that the
wide variation was not explained by the patient or operative factors. So we know we have a lot of variation that
we can look at improving. And here is, again, part of the– oh, that’s
kind of weird that that didn’t show up. This is just, again, to show that a lot of
the leftover opioids that are in people’s medicine cabinets go on to be problematic,
in terms of diversion. I have to look at this because I have small
faces. So 64% of people using pain relievers non-medically–
just this big, gray bar– said that they obtained the opioid from a friend or a relative. And according to a 2009 survey, it was easier
for teenagers to buy opioids than it was to get beer. So lots of literature to show that leftover
pills are being used inappropriately. So how many pills do you need to prescribe? Again, this is a really interesting area that
we’ve been looking at through the state. Lots of authors are publishing this. This is a very nice study that looked at 642
patients– again, common surgical procedures. Most of these people were sent home with 20
to 120 tablets and took only 28%, 30% of them. So this is the number of pills these patients
used once they went home. Very small. The probability of continued use among opioid-naive
patients spikes, already, at three days. These are modeling, but it looks like the
risk of chronic opioid use increases by 1% after that third day. It looks like the second prescription doubles
the risk of opioid use. And this article by Pratt, which is most recent,
is really fascinating. Because it looks like it’s the total duration
of opioid use as the strongest predictor of misuse. So it wasn’t the amount of opioids so much
as the duration. So again, it’s lining up with what you’re
hearing from CDC and others to use not only the shortest dose but the shortest duration
of opioid therapy. So I think the summary for this is that we
overprescribe in this country for acute pain for opioids. 42% to 71%, or maybe 80%, of opioids go unused,
and they’re not properly disposed. And persistent opioid use, again, is just
as likely after minor surgery as it is after major surgery. So prescribing less really equals good care. There are studies that show patients are just
as satisfied. They don’t report more pain. They don’t call you back like we think they
will and ask for more prescriptions. They use fewer pills. There’s fewer left over. And they’re not, again, more likely to get
refills. So in, of course, the surgical literature–
I’m sure you’ve probably seen this– there’s calls for surgical leadership to look at how
to help the country deal with this opioid epidemic. And I think this is a nice paper that really
talked about, I think, historically, surgeons unintentionally overprescribe because they’re
trying to meet 99% to 100% of patients’ needs. Because we know, in this environment, it’s
very difficult– especially if you’re out on the peninsula or in Alaska, and you’ve
had surgery here– to get a refill, to come back to see a prescriber. But I think the trend is that we have to prescribe
for the majority of people, who probably only need five to 10 tablets. So Barclay and all asked us to really, again,
link this a little to some of the things that are happening locally around this. So one of the things that you’ve probably
heard about is the Agency for Medical Directors’ guideline Group. This is a collaborative of third-party payers
in the state of Washington and stakeholders, including the University of Washington. And they developed opioid guidelines, initially,
in 2007. Dr. Tauben’s been very involved in that. They were updated in 2010. And then, I had the ability to participate
in the update when I got here to Washington in 2015. And that was the first time that we added
a section on perioperative pain. Doctor Terman from the University of Washington
has led that effort. And we are now in the process of updating
those for 2018 as the legislative rules develop. So Dr. Terman is really looking for input
from surgeons on those. So if you haven’t talked to him already, he
asked me to share his email to contact him if you’re interested in providing some update
on what those will look like. There’s two parallel processes going– updating
the AMDG guideline, which is really designed around best practice guidance, and then, the
conceptual rules. Governor Inslee signed a bill last summer
that said that by January of 2019, we needed new legislative rules for opioids in the state
of Washington. And again, very uniquely, this will include
acute pain and perioperative pain. And those rules are drafted in, probably,
their third or fourth version. And you can look at those on the Department
of Health’s website if you want to. And they’re very specific about discharge
prescribing. This is a little busy table, but I just wanted
to help align where all this stuff is coming from. So you probably heard about the CDC opioid
guidelines. Those came out of the National Pain Strategy. So the Institute of Medicine had a blueprint
on transforming pain care in the United States. It led to a national pain strategy. And several programs resulted in that, including
the Centers for Disease Control Opioid Guidelines, which, again, are mainly focused on chronic
pain. But you’ll notice they have, at the bottom,
for acute pain, probably no more than three days, rarely more than seven days. As I mentioned, the 2015 Washington AMDG guidelines,
we added a perioperative section. And at that point, we really said, don’t send
someone home with more than two weeks’ prescription. If people needed opioids beyond two weeks,
they probably needed to be re-evaluated. The 2018 guidelines are lining up a little
more specifically. You’ll find that there’ll be a table that
really specifically looks at the evidence that we have about these procedures and how
many pills people need and recommends things like eight to 12 pills, or up to 42 tablets
for certain patients, when they’re discharged from the hospital. It also has a lot of language about the use
of prescription monitoring programs, which is mandated in many states. And I think it’s going to, certainly, be mandated
at some point here. It’s just highly recommended. And then the Washington rules. So the difference, again, between the rules
on the far right and the guidelines is the guidelines are best practice. The rules are, really, going to be used for
disciplinary action where providers are not following any best guidance. And again, you’ll notice there’s a lot of
specific information about checking PMP and limiting the prescription dose and providing
naloxone for patients at high risk. And a lot of things are happening already,
in front of the finalization of these rules. I think you probably know that, in November
of this year, the Department of Health issued a new payment policy for Medicaid and all
of their managed care and fee-for-service programs. And they really will not pay for more than
42 doses, which is approximately a seven-day supply, for their patients– of adults. Now, you can override this for any patient
by just saying “exempt” on it. But again, you can see that third-party payers
are really driving the amount of prescription that patients can go home with. I wanted to just show you a couple of metrics. I only have metrics for Harborview. This is metrics that we developed in the last
year. This is on the Access to Excellence, which
you can all see on the internet site for Harborview, if you dive into the pain metrics. I know it’s pretty small. But what we’ve tried to look at is the percentage
of patients, within the first 24 hours after surgery, who received opioids only, nothing
else but opioids. And you’ll see, it’s this small line, here. We put the green threshold as 10%. We don’t know exactly what it is. But we assumed that most people should have
multimodal analgesia. And then, we looked at patients that have
an opioid, plus at least one other non-opioid, and those who got two or more opioids. Because multimodal analgesia is really recommended. And that would include Tylenol, NSAIDs, local
anesthetics, et cetera. So we’re just keeping an eye on that. You can look at your surgical specialty and
see how that looks within yours. This is not on Access to Excellence, but we
did build a measure to look at what is going out the door at Harborview for all opioid
discharge prescriptions. And, again, it’s a little busy. But we had, originally, been monitoring for
how many patients had less than two weeks. And we just recently looked at how many patients
were going out with less than 42 tablets. And it looked like it was about 57%. So almost half of the patients are going out
with more than what is recommended. This looks at some of the higher doses and
then, of course, who’s prescribing. And at Harborview, again, it’s going to be
mostly orthopedics and neural spine because of the types of operations that are done. And this just updates the data from 2017 through
the early part of 2018. And again, you’ll see that there is some room
for improvement. So the green are the higher doses, and the
blue is the 42 tablets or less. And you can look by service, again. So these measures are available. I think we can, certainly, export them to
UW. So just a quick summary. What is it that you can do, as a surgeon? I think, again, these best practices are really
to obtain pre-operative evaluation to look at who’s at risk for difficult-to-control
pain, opioid adverse effects, maybe persistent opioid use. And we have some information about how to
do that screening– really, counseling the patient and managing their expectations that
pain is normal. Yes, you’re going to have pain. But it doesn’t mean that opioids is the best
treatment for that, particularly when you go home. Somebody, some time, around the perioperative
section, probably needs to check the PMP. That’s, I think, going to be mandated. So I think we have to figure out how we’re
going to operationalize that. We need to provide balanced, multimodal analgesia. We need to use the lowest effective dose. We need to avoid new prescriptions for CNS
depressants, benzodiazepines, sending people out, raising the risk for overdose. The clinical practice guidelines say as soon
as someone is oral and tolerating oral use, short-acting oral opioids only. You don’t need to use parenteral. There’s no need to use long-acting opioids. And again, consider the use of naloxone rescue. So there is guidance. This is the American Pain Society’s evidence-based
practice guidelines. And there is a table in there that talks a
little about how to manage patients who have chronic pain or chronic opioid dosing. And I won’t go through that, but there are
guidelines out there that are pretty basic. So this is my last slide. And it’s just the take-home message. This is, I think, what we’ve been trying to
do, culturally, across the university. Certainly, we’ve been doing a lot of work
at Harborview to try and move our focus away from opioids as the first and mainstay of
pain management, and avoid chasing numeric pain ratings and having natural conversations
with people about, pain is normal– it’s trying to improve your function and get you to recover
and avoid adverse events– and really having that communication counseling with patients
and using non-pharmacologic strategies. This patient handout, which is two pages,
is given for every opioid discharge prescription filled at any University of Washington pharmacy. So for the last year, patients who fill their
prescription from UWMC will get this handout that talks about, use your non-opioids, non-pharmacologic
strategies first. It talks about safe use and storage of opioids. So it’s something that you might want to take
a look at so you know that you can reinforce that with your patients. [APPLAUSE] JARED KLEIN: Hi, everyone. I’m Jared Klein. And definitely, thank you to Barclay and Lacey
for inviting me. And it’s great to be here this morning. I’m a primary care internist at Harborview. And I have additional training in addiction
medicine. And I work really closely with Deb and Ivan,
both with some of the outpatient folks and also during transitions of care and also seeing
the patients on the pain service that have been identified as having substance use disorder
and trying to help engage those folks in addiction treatment. And so that’s where I come at this, with the
lens of, really, taking care of folks that have already been identified with addiction
or concern for potential addiction. And I wanted to characterize this as thinking
about, this is really– the time when someone’s undergoing surgery or has an acute injury
in the hospital, this is the opportunity to really engage those folks in care and get
them linked in with services, potentially. So I’m really passionate about this topic. I love talking about it. I love seeing patients and working with patients
with this particular diagnosis. I don’t have any financial disclosures, though,
unfortunately. So my outline is, I want to talk a little
bit about, how do we ask about opioid use disorder or addiction in our patients? What things, what concrete things, could you
do, as surgeons? And then, what kind of resources and referrals
are out there in the community? So really, the biggest take-home is just to
ask, I think. This is something that probably doesn’t happen
enough right now. But we really want to ask patients about their
opioid use and their other substance use. This is the current– I think it was recently
updated– Harborview Surgery health history questionnaire that the patient will fill out. And it does have this nice section here on,
do you use a medication treatment for addiction, like methadone or buprenorphine? And have you used any drugs in the last six
months? Really, I think our patients are reluctant
to sometimes offer this up. This is a highly-stigmatized condition, as
you recognize. And even those in recovery have many reasons
not to disclose their diagnosis. They’re coming, looking for care. And they don’t want anything to prevent them
from having that necessary care. There really aren’t validated screening tools
for pre-operative assessment of substance use. I wanted to share this. This is a validated question that’s used in
primary care, which is, how many times in the past year have you used an illegal drug
or a prescription medication for non-medical reasons? And it’s specifically phrased that way for
several reasons. One is to assume use, which will help improve
your pick-up of folks with an issue. And also, it touches both on illegal substance
but also misuse of prescription medications. And when they’ve compared this to a full psychiatric
exam and urine testing, it’s a highly sensitive question. It really gets to the point, though, of how
do you differentiate someone who’s on chronic opioid therapy, someone who’s maybe misusing
chronic opioids, or someone who has an actual addiction issue? And this is really, really challenging, even
for folks that do this all the time. We focus on what’s called the three Cs. So compulsive use of opioids, the loss of
control, and then, negative consequences are all the kind of adversive behavioral manifestations
of substance use. And that’s the way that we really are able
to put someone who had been– if you have an addiction, you have a substance use disorder. But you should definitely reach out to get
help from pain medicine colleagues, psychiatry, or addiction medicine to sort out cases. I am a big proponent of, how you ask about
this really makes a difference. Sometimes opiate use is obvious. It might be all over the chart. The patient might readily offer that up during
the history. But sometimes, it can be quite subtle. So it’s really important to establish that
rapport. Sometimes asking about past use can be less
threatening to patients. Really listen to the story. Assume that there’s going to be, or anticipate
there’s going to be, some guilt and shame involved. And also, it’s incredibly common for folks
to have had negative experiences with a health care system before. And so you can anticipate those stories, also. Don’t avoid the topic of addiction. And try not to make assumptions. Because everyone’s story is different. This is an interesting study from about a
decade ago. These folks randomized 500 mental health professionals
to read one of two clinical vignettes. And one characterizes this patient as a substance
abuser. And he’s attending a treatment program. He’s required to be abstinent. He’s been compliant until a month ago, when
he’s had some positive urine testing. He’s been a substance abuser for the past
few years. So the randomized folks either read this clinical
vignette or this clinical vignette, which was only altered in the phrasing of the diagnosis
here, which was either as a “substance use disorder” or a “substance abuser.” And, potentially not surprisingly, those who
were shown the “substance abuser” term were significantly more likely to judge the person
deserving of blame and punishment versus those that were shown the term “substance use disorder,”
which is the medically accurate terminology, based on the DSM-5, which was updated about
5 or 10 years ago now. And I’m a big believer that patients really
perceive these attitudes, and what we say makes a big difference. So these are my personal recommendations. I try to use– and this can be challenging,
even for me, because some of these terms are really ingrained in our culture. But I try to use the terms like “person with
opioid use disorder” rather than an “addict” or “user,” an “IVDUer”; “opioid use disorder”
as the diagnostic term rather than “opioid abuse or” “opioid dependence.” Again, those terms were thrown out when DSM
was updated. And instead of “clean or dirty UA,” “negative
or positive urine testing.” I would just strike these from your vocabulary,
if at all possible. So why does it matter to treat addiction? This is a helpful graph for me to characterize
what’s actually going on for folks with opioid use disorder. And on the y-axis here, I put what’s termed
“affect”– how people are feeling– and then “time” on the x-axis here. And with acute use of opioids, people get
euphoria. And with repeated uses, they get some tolerance
to that. But as people use opioids from the first few
days to weeks and move into the chronic use range, which is generally felt to be months
to years, what ends up happening is that they start going into withdrawal between episodes
of use. And so, really, a primary driver of their
use is to help them feel normal again. And this has to do a lot with the neurochemical
changes that happen in the brain with chronic opioid use and with physiologic dependence. And so what happens is people’s– all their
other social obligations tend to fall apart because they are so focused on feeling normal
again in order to accomplish everyday tasks. And that’s where treatment comes in. When we treat someone and help them stabilize–
as far as their affect, as far as their neurochemistry goes– it allows them to accomplish all of
the important things in their lives that, often, have fallen by the wayside, so their
work, their family obligations, et cetera. I would throw out an important distinction
that I’ve been hinting at. And I’m calling it primary versus secondary
prevention of addiction. There’s a lot that can be done by surgeons
and all clinicians to prevent somebody from falling into the trap of addiction in the
first place. But there’s also a subset of folks who are
already suffering from an addiction. And those situations, probably, should be
handled distinctly, I think most people would acknowledge. So we see this commonly on the acute pain
service. When a patient already has an opioid use disorder
and then has a traumatic injury or needs some acute surgical intervention and has acute
pain, by withholding opioids, you are not going to cure their addiction. By not giving them oxycodone for a few days,
that’s not going to fix the problem here. At the same time, providing opioids probably
is not going to worsen their addiction. We want to do it in a safe manner and in a
well-coordinated manner. But the person is already using heroin or
snorting oxycodone. Things are already off the rails, here, at
this point in time. So the goal here is, really, to safely complete
necessary medical care, or, I would argue, in your case, necessary surgical care. And I underlined the word “safely” here because
I do want to emphasize that this is not, willy-nilly, pouring on opioids. But we want to do it in, like I said, a well-coordinated,
safe manner. So the medication treatments that I live in
and use regularly are going to be methadone and buprenorphine, primarily, especially for
folks that are having acute surgical issues. I put naltrexone up here. It’s another FDA-approved treatment for opioid
use disorder. But because it’s a full opioid antagonist,
it’s, really, rarely an option when folks have acute pain issues. And in addition to these, most patients do
benefit from additional services like counseling, mutual support groups, and mental health care. So when do we do this? Ideally, pre-operatively, like probably most
things should happen before surgery, if possible, and involve a multi-disciplinary team of the
surgeon, primary care folks, psychiatrists, addiction medicine, pain medicine. That’s not always a reality, as we know, especially
at Harborview. We see so many folks that have unanticipated
acute traumatic injuries. So there is some growing data showing that
when folks come in for acute medical issues or surgical issues, trying to engage them
in care at that point in time– start medication treatment concurrently with their inpatient
hospitalization, and then link them to outpatient care– that can be really helpful in engaging
someone in care and retaining them in treatment, which is a primary outcome that we think about
from an addiction standpoint. Because if folks stop coming, then they generally
aren’t getting better. So really, who you specifically call is totally
dependent on where you practice. So sometimes it’s going to be a social worker,
chemical dependency counselor. Psychiatrists can be incredibly helpful–
there is some variability in their comfort level or their familiarity with addiction
treatment– and then, if you have addiction medicine expertise available. That’s a fairly scarce resource right now,
unfortunately. At Harborview, what we have conceptualized
is we have something called the SBIRT services– Screening, Brief Intervention, and Referral
to Treatment service– which is county-funded dollars to have chemical dependency counselors
available for inpatients. And they are, really, the first point of contact
for folks. And then, they, on an ad hoc basis, will get
addictions specialists involved. Really, right now, we’re in a pilot phase
of this, trying to provide some of those inpatient-based services for folks. And that’s a collaborative effort between
psychiatry and the Department of Medicine. There’s some state and federal resources,
also. The state funds this recovery helpline, which
is available 24/7 and staffed by volunteers, many of whom are, themselves, in recovery. And the phone number’s up there. They have a great, a nice, website, also. And then, at a federal level, the agency–
which probably should change their name, after what I was saying earlier– is the Substance
Abuse and Mental Health Services Administration, or SAMHSA. It has locators both for methadone clinics
and buprenorphine prescribers, which are available at their website. So buprenorphine is a medication we could
prescribe to treat opioid use disorder. And I would argue that if you have interest,
this would be something you would be able to do. It requires a one-time, eight-hour training
that are available online, in person, or a mixed, half and half, program. And even if you don’t do a lot of prescribing,
just the training, I think, can be really helpful to get a better sense of what’s involved
with that particular medication. It’s really the only medication that a clinician
can prescribe for opioid uses, for the treatment of opioid use disorder. Methadone needs to be dispensed at a opioid
treatment program, like a methadone clinic. And then, this is more of an FYI, addiction
medicine was just, two years ago, actually, approved by the American Board of Medical
Specialties as a multi-specialty subspecialty. So there are many folks in an array of specialties,
including surgeons, who have undertaken additional training for this board certification. And there are fellowship programs in development,
including at UW, around this. So in summary, I would argue that surgeons
can and should ask about addiction in a very frank manner, and think about our choice of
language in order to combat that stigma, and then refer to the appropriate resources whenever
possible and as soon– as early– as possible. So I wanted to show this brief– it’s about
three-minute– video. Barclay, actually, asked for us to try to
find a patient, although the hour was prohibitory. And we searched and searched but most of our
patients can’t make it to clinic before noon, so 6:30 was asking too much, I think. But Deb and I had helped do this video for
a separate project. It involves a patient with an opioid use disorder
who was treated at Harborview– gosh, maybe six years ago, maybe– talking about his experience. He had an NSTI, at the time. And he, subsequently, went on to complete
nursing school and is working as a nurse and has an interesting perspective, having been
a patient and, now, a health care provider. So I wanted to share this with you in lieu
of having a patient come and tell. [VIDEO PLAYBACK] – Yeah, so from my perspective as a nurse
and also of being a patient, a long-term patient in Harborview for an acute thing like this,
which was directly related to my drug use, I have this sense of empathy with what it
actually feels like, not only just on the pain level but also on a level of being discriminated
against for your drug use, which is still seen as a moral failing. I really appreciated getting to know people
that even are in worse social situations than I have been, that are living on the street,
that have been for decades, that also have mental health issues. Because, in a way, this issue of drug use
and also coping with drug use is a really intersectional thing which is not just related
to the medical issue and mental health issue of drug use. It also has to do with socioeconomic issues
and how to deal with stressors related to not being able to find a job or to not being
able to have a place that you can afford in the city. Discrimination and racism and all this kind
of stuff definitely contributes to your coping in life. And it’s been really interesting to get this
perspective and really get to know people on the reasons why they might be getting into
this. Within the hospital system, I had a lot of
people that would be willing to sit down with me and sit down on the side of the bed with
me and look at me in the face and treat me like a human. And those were all really good situations,
like my occupational therapist, who helped me learn how to walk again. She was fabulous. And I had other people that, maybe, weren’t
so much. Like there was some really little things that
helped me, both with my comfort in the hospital but also even pain management. Because I could expect what was going to happen
in the future. Like, some people wouldn’t write their names
on the whiteboard, sometimes for the entire day. I wouldn’t know who my nurse is. And I was completely dependent on people. There would be some providers that would come
in and introduce me to people, individually, and talk to me like a person. But there’d be some people that would just
go in there, turn on the lights, turn their back towards me, start talking to each other,
not even ever say one word with me the whole couple minutes they were in there. And I felt like a subject rather than a patient. And it felt, really, kind of demeaning, in
a way. And again, I don’t know if that was my perception
or not. But I was already in a very aggravated state
because of my own pain that I was dealing with. But also, feeling like a ghost didn’t really
help the situation and probably didn’t help my pain management, either. I know other people that I’ve worked with,
too, that are really difficult. Patients are saying they are going to berate
somebody if they tell them to do something they don’t want to do. And that’s another hard thing to deal with
because I remember, also, doing that when I was working in the hospital and back in
the nurses’ office, where there would be gossip or prejudice about a difficult patient, which
definitely sets the nurses up for being ambivalent and negative about a certain situation that
they had to do in their care. But I think just trying to still– that’s
kind of why I go back to dealing with the capacity of health care providers to be able
to deal with things and to not take it personally. And that’s been my mantra in my work. Because every single patient I have is that
difficult patient. [END PLAYBACK] JARED KLEIN: Great. Thanks. [APPLAUSE] IVAN LESNIK: Great. Thank you, again. Appreciate all the work been done and Barclay
and Lacey to bring us here. I’m going to bring this a little bit more
down to the deck plates, to use some of the Navy phrases, of the day-to-day experience
that we have at Harborview. Long history of innovation around pain. And I think that we’ve got significant overlap
with addiction and supporting that patient population. Here at Harborview, we’ve got a integrative
service that Deb Gordon’s involved in, and myself. And we have a perioperative pain service care
line that involves pre-operative management plus inpatient acute pain service, as well
as a transitional service. You know, in large part, we’re a busy service. I think all of you here know how busy the
services are at Harborview. We’ve delivered 7,000 encounters last year
for acute pain. But of note, greater than 70% of the patient
population of those encounters come with a substance use disorder. And 90% of them are opioid use disorders. That’s a lot of management of opioid use disorders
in a population at risk at Harborview. How do we approach this? We have a team. And as mentioned earlier, my emphasis is working
as teams. My background is a focus in teams. We have an integrated multidisciplinary pain
team, really, to meet the needs of this very complex population, to hope, ultimately, to
improve the outcomes. Our emphasis is on interprofessional care,
working on clear, defined pathways and with a significant focus on care transitions. So let’s talk about a case. And I think this might be helpful to kind
of put this in framework. And this case is an extraction from a number
of patients we’ve seen at Harborview over the years. But a trauma rollover, single passenger, who,
ultimately, underwent laparotomy and splenectomy. But what was noted was the epidural was placed
but it was noted in the PACU he had high opioid requirements. Sent to the floor, diet was advanced– a fairly
standard and conservative oxycodone order with acetaminophen, so attempted multimodal
analgesia. Has an epidural running. But despite all that, frequent calls, uncontrolled
pain, many IV boluses. Surgeons came by to evaluate for any post-operative
complications. Everything looked fine. We’re in the process of assessing the epidural. And what we see is a patient who’s anxious,
complaining of a 10 out of 10 pain, non-distended abdomen, but, really, difficulty in localizing
where that pain is, so difficult to get a pain history. We do a more objective evaluation of the epidural. And we’ve got a pretty extensive epidural,
with T4 to T12. And the patient then, begrudgingly, lets us
know that he’s occasionally been using heroin. And part of this hesitancy to reveal this
is he doesn’t really want to be treated like an addict. So from this scenario, I think, over time,
we can see three different things– even more than that– come out of that. And we’ll kind of look at a minimal care integration,
a moderate care integration, and then, ideally, an optimal care integration around their pain,
their substance use disorder, and their surgical management. In this case, much the same, patient’s indicating
that the epidural is working but still insufficient pain management. Patient says he’s not going to move until
you manage his pain. His pain is poorly managed. He’s not going to move. He’s 10 out of 10 pain. IV hydromorphones ordered. PRN, oxycodone doses are significantly elevated
into Q3 dosing. Patient now endorses better pain control but
still really bad. Post-op day three. We’re looking at over 24 hours, 240 milligrams
oxycodone, 12 milligrams of IV hydromorphone, and he’s watching the clock. Agitated if there’s any delay in medicine,
threatening to leave. The team orders Ativan to deal with some of
the anxiety concerns around his management. Post-op day four. Epidural is discontinued. There’s no change in pain. They reduce the IV Q8 hours. Patient starts accusing them of not treating
real pain. Patient is leaving the floor. And nurse, within the brief period of time,
finds needles at the bedside. Post-op day seven. Patient is ready for discharge but he’s just
not going to leave. He really refuses to participate in his therapy,
remains on 10 to 30 fairly high-dose oxycodone, using full doses of 30 at that Q4 intervals. Increased IV hydromorphone dose, Ativan was
continued. Refuses all of the non-opioid adjuncts, says
they don’t work. He has allergies or adverse effects to all. Patient is discharged on post-op day 10. Barely-managed pain. 10 milligrams of oxycodone, 10 to 30 milligrams
Q4, was written for 252 tablets, and Ativan was continued. Post-op day 14. Readmitted following post-op check for a wound
NSTI. Admits to frequently injecting heroin through
the incision site. Indicated it doesn’t hurt as much doing it
that way. So I think this is, sort of, a worst-case. This is rare to see something, I think, this–
it reached this sort of point in management. But we, clearly, have seen circumstances when
this has happened. I think we can inspire to better integration
and a better scenario, too, where there is some availability of a pain service to address
the patient’s needs. In this case, the patient was started out
on a PCA to get a sense, a little bit, of his opioid requirements. Endorses better pain but, again, still really
bad. Post-op day three. We get a much more detailed history. So I think that when you have a service and
individuals who are comfortable asking the questions and doing the right phrase– this
occasional daily habit, daily use of, or occasional use of, heroin turns out to be a $200 a day
habit during the last six months. Lost his job, is divorced recently because
of ongoing use. So it meets the criteria of consequences of
abuse– doesn’t know what to do, anxious, frightened. PRN clonidine is ordered. Post-op day four. Again, similar scenario. We discontinue the epidural. Was converted to oxycodone to be based on
his IV use. Similar sorts of dosing at Q3 intervals. Again, refuses to engage in therapy– other
non-opioids, at least, in particular, non-opioid adjuncts. Accuses, again, team not treating real pain. Again, leaves floor. The nurse finds needles at bedside. Rehabilitation psychology consulted. Post-op day seven. Again, saying he’s not going to leave with
pain as bad as it is. Continue with oxycodone, discontinue the IV. Encouraged mobilization with additional dose
for mobilization. Hydroxyzine for anxiety. And he continued to decline the opioid adjuncts. The rehab psychology was backlogged and, really,
unable to see the patient in a timely fashion. Post-op day 10. Again, discharged home now. Barely-managed pain. Was able to be seen at a transitional pain
clinic, where they started to initiate an opioid taper. In this case, patient was discharged with
52 tablets, 10 milligram tablets. And on post-op day 12, called in asking for
an early refill. Pain is worse than it’s been. But denies fever, chills, or any change in
the wound. Threatens to call paper for pain not being
treated appropriately. Offered NSAIDs, declines. Day 14. Seen in our postoperative pain clinic. Altered mental status. Declines illicit use. Ran out of pills two days earlier. UA ordered, was seen in clinic. Shortly after that visit in the transitional
clinic, was again readmitted for an NSTI– was injecting through his site with heroin. What’s different in this scenario? A little more integration. Attempt to engage mental health. Referral for treatment with a flyer. Avoidance of co-administered benzodiazepines,
a good thing in his population. Early follow-up. The monitor, so the opioid use. And reduction of diversion risk with 52 oxycodone,
10 milligram tablets, versus 252. And with the earlier presentations, you can
see how critical that issue is in regards to community safety. Let’s just look at case three. Again, sort of similar circumstances. Pain services called. A little bit more integration of pain service. It works with all the integrated elements
that we have available. PCA started. Similar sorts of– look at a shift use of
18 milligrams. Right there, that starts to alert us that
we’ve got somebody with some significant opioid tolerance. That’s the benefit of that dose-ranging with
PCAs because it gives us, really, a sense of what the patient, maybe, their history
is. Again, reveals a $200 a day habit and significant
supply. Similar sorts of concerns about not sure what
to do, anxious and frightened. And then, in this case, this is where I think
we start seeing a departure in really thinking about the downrange management decisions that
will help support this patient. Discuss with this patient the need to replace
his heroin while in hospital with an appropriate medical substitute. And again, there are very few medications
that meet that criteria. You saw that graph that Dr. Klein showed with
reduced fluctuations in levels between feeling poor and feeling good. Methadone, we start off, and it allows us
to standardize and really replete that opioid that they’ve been utilizing illicitly. At the same time, we engage the SBIRT providers
to start the process working. We know we’re going to need a lot of care
coordination. Methadone continues. What we notice frequently, after 24 to 48
hours– marked reduction in the hydromorphone use, reduced requests for PCA boluses. What, often, you’ll see is a much more highly-engaged
patient who’s really ready to discuss being engaged in their recovery from surgery but
also about their therapy. Rehab psychologist is able to support the
patient further in engagement. They will, often, express a desire to see
spiritual care. We’ll assure that element’s going to support
them, as well. In this case, epidural is discontinued. Converted over to a much lower dose of oxycodone. IV hydromorphone is available for mobilization. At this point, now, realizing that we are
addressing the opioid needs, often, they will be more inclined to accept the use of the
non-opioid adjunct. And the concern is, you’re not going to stop
my methadone? we often hear. Patient completes release of information. A real critical part– the care continuity
nurse is made aware of the patient’s desire for medication-assisted treatment on discharge. So we’re looking at post-op day four. And we’re having some significant dialogues
about, what are we going to do with this patient on discharge? And let’s start planning for that now. Let’s start planning for that now. They actually reach out to the local medication-assisted
treatment program. Program assures ability to support intake
the following week. Patient working well with the staff and mobilizing
readily. Post-op day seven. Patient discharged to home. Now, can manage the pain, more optimistic
things can work out. Methadone’s consolidated to a 30 Q day dose. Patient returns to the hospital one day, post-op
day eight, to get a bridge dose of methadone from a provider given to the patient. Oxycodone they’re discharged on is 5 to 10
milligrams, 24 tablets. Again, going to be seen in a transitional
pain clinic. And all the range of non-opioid adjuncts are
provided. Post-op day 10. Follows up in the outpatient transitional
program. First methadone dose was given the day before
in the treatment program. And the plan is now to complete the remaining
opioid taper in the transitional clinic by post-op day 21 or sooner. Post-op day 14. Seen at the post-op check. He’s uneventful, healing, thankful for care,
adequately managed pain, never going to endorse perfect but OK. Has been able to remain clean since. Hopeful. And now, making daily visits to treatment
program and Narcotics Anonymous. So what’s different here, I think, we’re looking
at improved patient and provider satisfaction. Initiation of best practice, what they’ve
already outlined around medication-assisted treatment for these individuals. Marked reduction in opiate diversion and risk
for the communities. A reduced length of stay, certainly, in this
particular scenario, as we presented it, possibly. Avoidance of a use-associated readmission. We know the behaviors of many of these individuals
put them at risk of subsequent medical problems and readmission and ED visits. How do we address that? How do we look at that concern? So what we have adopted as our general principles
of care are really optimize pain care, assuring safety. Stabilization of behavioral issues around
substance use– critical to improve efficiency in care delivery for this patient population. Support opportunity to engage appropriate
substance use treatment throughout the clinical service delivery is an important part. And address the community safety concerns
incurred during the inpatient stay and throughout care transition. So in order to do all that we’ve just talked
about, we’ve actually set up and structured a care algorithm that really works well–
brings in some of the points that Deb and Jared both mentioned– concurrently looking
to address their opioid use disorder while optimizing their pain management with a goal
of timing this so that there is a timely discharge from the hospital and reasonable and appropriate
management of the opioid use disorder concurrently while addressing those principles I mentioned
before regarding safe, effective pain care, engagement in treatment and community safety. This one ended up not getting quite as bad,
save the right direction. What I’m pointing out– this is another pathway
that we have for pre-op. So we mentioned the challenges in screening
for these risk factors pre-operatively in your clinic, where, maybe, the workflow, it
isn’t worked into the dialogue and isn’t part of your workflow. We at Harborview– all elective patients are
given this screen in the pack in our pre-anaesthesia clinic. And if they flag positive for a history of
either opioid or benzodiazepine use disorder, that’s an alert that actually reaches us on
the pain service and identifies the patient for either potential pre-operative evaluation–
where they’ll reach out to us and we’ll work towards scheduling– or a clear identification
of the need for an acute pain service after surgery or on the day of surgery. And we’ll, at that point, initiate and move
the patient through this care pathway that’s active, currently, at Harborview. We’ve also worked around some care pathways
around buprenorphine, both for elective surgery– we’re seeing increased frequency of buprenorphine
prescribing. So what do we do with buprenorphine? How do we manage that? How do we address these patients who are clearly
at risk around the surgical period for going back and falling back to prior use patterns. And the absence of addressing their treatment
concerns and also, for the urgent cases, as well. We’ve been looking at this. This is a poster we presented last year, essentially
looking at initiation of methadone in this pain population, a large part of the population’s
trauma. I’ll just call out the reduction in MED that
we see on discharge for this population with opioid use, that’s a low MED number. And I think, again, the group that we started,
44% made it to an intake and dosing appointment. Now, that might seem like a particularly low
number. But in this population, that’s actually a
pretty satisfactory number that actually shows up at treatment and starts the process of
treatment. Why do we want to start treatment? My argument, I think what I would suggest,
is if we look, really, at the longitudinal cost associated with not managing it– this
is out of California, looking at immediate access and what the process we’re doing at
Harborview versus the medical-managed withdrawal in California, which is required, which, essentially,
is no treatment. They look at differences as cost over time
in these populations in this cohort. And there are significant benefits, both for
the medical system and health care expenditures that we see over time but also from a societal
impact in the way of crime, housing, and workforce. So potentially, very large returns on the
time and effort spent in improving that. I think it really does meet the triple aim
in improving the patient experience, health care outcomes, and the opportunity to reduce
costs. We at Harborview are proud. I think that much of what we’re starting to
do is being recognized at a state level with the Community Leadership Award in these processes
that we’re doing. And it’s a great place to work. And it’s a great place to– for me, leaving
the Navy, I still have that same sense of mission at Harborview. And I’m proud to work with this great team
of surgeons that I see every day. And we look forward to continuing to work
and support this population as best we can. I know we’re just pressed to get the time,
the opportunity, for questions. [APPLAUSE] [MUSIC PLAYING]

1 Comment

  • Reply SONIA April 3, 2018 at 4:36 am

    Thank you for all the informational facts. This medically makes sense .. on one side, it helps people, another is that it’s highly addictive and can kill you if taken in short duration as you said …
    The number of patients pain are rising! I think the nation is worried about this problem due to the spectrum of society that it affects (it’s vast these days!)
    Thanks for all the knowledge!

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