From the 2022 HVPA National Conference
Olivia Sutton MD (Johns Hopkins), Ronen Shechter MD, Traci Speed MD/PhD, Ariana Prinzbach MD, Marie Hanna MD, MEHP
The use of prescription opioids for pain management has created a nationwide public health crisis, and many of the prescriptions leading to opioid use disorder and death were initiated in the perioperative period.
The authors hypothesized that a multidisciplinary approach to perioperative pain management would lead to a decrease in postoperative opioid consumption while reducing postoperative pain scores and improving functional outcomes.
A Personalized Pain Program (PPP) was implemented at Johns Hopkins, aiming to care for surgical patients across the perioperative period. Patients on chronic opioids were invited to participate in the program starting 4 weeks prior to surgery or immediately after surgery, and were seen both inpatient postoperatively as well was outpatient in the ensuing months. Patients were educated on multimodal therapy for pain and the risks of escalating opioid consumption post-operatively. Providers involved in the multidisciplinary pain management team included acute and chronic pain specialists, psychiatry, addiction medicine, physical medicine and rehabilitation, and integrative medicine. Baseline measures were collected at the first pre-surgical or post-surgical PPP clinic visit, as well as at subsequent postoperative follow-up visits. Data collected included opioid consumption (via milligram morphine equivalents (MMEs)), pain scores (via Brief Pain Inventory (BPI)), and functioning scores (via Short Form-12 (SF-12)).
Over the first 9 months since the inception of the PPP, 145 patients had an initial visit. Of those, 61 were seen peri-operatively for more than 1 clinic visit. Relative to the first postoperative visit, linear mixed model analysis adjusted for age, sex, surgery severity, drug intake before surgery, and chronic pain, showed a significant reduction (-4.98 MME per week) in opioid use over time relative to each PPP visit (P < 0.001) without increase in pain scores on BPI pain severity score. Physical and mental functioning improved (P = 0.005 and P = 0.02, respectively) as measured by the SF-12. Hospital length of stay was decreased from 6.5 days to 5.8 days for all surgeries, and from 7.6 days to 5.2 days for spine surgery.
Conclusions and Clinical Implications
A multidisciplinary, comprehensive, and coordinated approach to perioperative pain management in chronic opioid users can decrease opioid requirements, decrease pain scores, improve functional scores, and decrease hospital length of stay. The PPP, designed to address perioperative pain in an unprecedented manner, adds value for patients, the hospital, and the health system at large. Additional research is needed to compare MME usage with current standards of care, establish best timing of first consult in relation to surgery, and define factors that lead to improved pain outcomes.