So I'm going to be speaking about responsible pain management in the outpatient setting. I have no financial disclosures related to this or any of the content of this talk. So the first question is why do we care? I'm going to give you three reasons why this is relevant to your practice. Number one has to do with surgical outcomes, number two with safety, and number three with efficiency. All right, so first off, surgical outcomes. So what do we know about opioids when we think about responsible pain management? Well, what the data tells us is that responsible pain management starts upstream. So if we look at patients in large retrospective cohorts, so this is 35,000 patients undergoing elective knee, hip, and shoulder replacement, and we look at their morphine equivalent daily dose, preoperative opioid users simply do worse in their surgical outcomes when we look at opioid-native patients. There's a dose response curve between preoperative opioid dose, and on the left you see non-home discharge percentage, on the right you see 30-day readmission rate, and then furthermore if we look at surgical site infection rate, again, dose response between pre-op opioid dose and surgical site infection, and then on the right you see surgical revision rate. So then the question becomes, if you taper patients from opioids, preoperatively does it matter? The answer seems to be yes. So if we look at case cohort studies where patients have been tapered 50% from preoperative opioid doses prior to joint replacement, they have the same functional scores and outcomes as patients who are opioid-naive. So the second reason why we care about this is quite simple. Higher opioid doses equals increased risk of adverse events, and so if we look at patients across all different sectors and we look at opioid dose, we see increasing risk with dose, and that includes patients with acute pain from things like surgery. So number three, efficiency, so it's been very well-documented throughout the literature that enhanced recovery after surgery pathways helps patients move along faster, recover sooner. It's probably beyond the scope of this talk, but this is well-documented by consensus statements and meta-analyses. So moving on, then the question is, so what is multimodal analgesia? What is a balanced pain control program? What does it even look like? So I'm going to start by saying that pain is a condition like anything in medicine, so it has signs and symptoms. That points us to a diagnosis. Once we have a diagnosis, we can think about mechanisms. So as a pain management physician, I think about types of pain, those being nociceptive, inflammatory, and pathologic, including neuropathic pain. All of these are present in the setting of surgery. So what does that mean? It means that we select medications that target each of those mechanisms of pain. So we're targeting inflammatory, neuropathic, nociceptive pain, and we want to have medications from each of those categories in the preoperative medications given to patients. There's no one preoperative cocktail that's been shown to be clearly superior to others. I've put an example on the left-hand side, and you can see you've got examples from all those categories. Now the question is, what's the effect size of this? So if you look at a couple of these, so gabapentin, for instance, in mixed surgical populations, you look 24 hours postoperative, seems to reduce opioid dose by about 20 morphine equivalents. Now these need to be, of course, adjusted and selected for patient comorbidities, patients who are older, high fall risk, decreased renal function. All these are things that need to be taken into account. So the evidence around these medications is replayed over in the literature again and again. There are plenty of systematic reviews. There are plenty of randomized controlled trials, including some trials that actually show that continuing gabapentin throughout the perioperative recovery period actually helps with opioid tapering, patients being 25% more likely to taper completely off opioids versus patients who are not started on gabapentin. So next the question is, what about opioids? The question's always been, how much and for how long? In Tennessee, we actually have state legislature that guides some of this. So in Tennessee, you have different categories of opioid prescribing that are allowed without specialty consultation. So for something that's more than a minimally invasive procedure, so most of what would happen in outpatient pain management setting, in outpatient surgery setting, that's about 50 morphine equivalents per day, up to 10 days. So what's that translate into? That's about oxycodone 5 milligrams every six hours as needed for 10 days. Probably the most useful advice that I can give you, and something that I see playing out over and over, is not continuing all of the other adjunctive medications through the time when the patient is completely off opioids. There are lots of ways to do things, but often we see the patient saying, opioids work. I want to be on the opioids. Well, then they need to take all the other medications because those have been proven to help them taper off the opioids. So what does it look like over time? So this is an example of a multimodal paradigm that would be started preoperatively. So, and then continued postoperatively. When I talk to patients about these, I say, yeah, your pain score might be eight, it might be 10, but the focus on function. What are my goals for you? It's to keep moving, it's to participate in physical therapy, and it's to maximize your surgical outcome, and to have the best outcome you can for whatever surgery you had. So we start the things that are adjunctives, we escalate them to opioids, the patient recovers, opioids are the first medications off, and those other medications are continued as the patient continues to recover. So these things can be built into algorithms. I'm going to give an example here. This is work that we did with our plastic surgery group at Vanderbilt, and we created a two-dimensional algorithm. One dimension is the expected pain with the type of surgery, either a minor or major surgery, and then the other part of the algorithm is whether or not the patient is preoperatively on opioids, because they may be at risk for more difficult to treat pain. This then is given to patients, and it becomes part of their preoperative education, and tells them what to expect, and then if they have questions, those are addressed upstream. So last but not least, what happens when things are going badly? So we do have ways to screen patients who are more likely to have difficulties with pain management in the postoperative period. There is a stratification tool called the O-Net classification, so that starts with identifying whether the patient is opioid exposed or opioid tolerant, and then adds in other risk modifiers, things like psychiatric risk factors, depression, anxiety, bipolar disorder, medication or substance misuse in the past, or high-risk surgery that's likely to have prolonged pain afterwards. When things get really bad, the best thing I can say is seek out help. If you can find a pain management physician, especially one with a background in anesthesiology who still spends at least some of their time in the operating room and understands these patients, all the better. So leaving questions till the end, references, and thank you very much for your time.

responsible pain management

outpatient setting

surgical outcomes

multimodal analgesia

opioid prescribing