Presented at 2021 ASA Annual Meeting in San Diego, CA (October 2021)
Background
The narcotic crisis in the United States has claimed nearly 850,000 lives since 1999 with a staggering annual mortality rate of approximately 70,000 lives. An overwhelming majority of overdose-related deaths in 2017 involved an opioid, and of the 10 million Americans that misused opioids in 2018, over 90% misused prescription pain medications.
Opioids have long been the core of perioperative and surgical analgesia and considered low risk for addiction. However, emerging clinical data suggest that patients who receive opioids during and after surgery may develop long-term opioid use.
In 2017 local, state, and federal initiatives to reduce the use and excess supply of narcotics, along with manufacturing issues and federally imposed production limitations, created a profound shortage of injectable narcotic analgesics. While these converging conditions created an urgent need, they also led to an opportunity to introduce a new culture of narcotic avoidance, with multimodal analgesia and narcotic avoidance practices becoming the new core of anesthetic management.
The anesthesia team at a South Bronx Level II Trauma Center, which provides services to a largely underserved community, believed in the potential benefits that perioperative opioid sparing held for the patients, the facility, and the community. Their performance improvement initiative aimed to prove that patients could have surgery with reduced levels of narcotic by substituting non-narcotic analgesic for the traditional perioperative analgesic, without experiencing increased or prolonged postoperative pain.
Study/PI Project Goal: Demonstrate Efficacy of Perioperative Narcotic Avoidance
Though narcotic avoidance as a perioperative practice has not been universally accepted, and its validity remains in question3 , this team aimed to increase acceptance by decreasing the use of perioperative narcotic analgesic by 50% over a six-month period without sacrificing analgesia, thus limiting the exposure to narcotics for operative patients and potentially decreasing the incidence of new addictions. They planned to accomplish this at their hospital through education and implementation of substitute analgesic therapy. To measure success, they would monitor postoperative pain scores and post-anesthetic care unit (PACU) length of stay.
The Study Implementation
While the primary goal of the PI project was to decrease the use of narcotic therapy, clinical decisions were left to the providers, with the request that where possible, narcotic be used as a second- or third-line alternative.
In January of 2018, the Department of Anesthesiology implemented an educational series of literature reviews focused on narcotic avoidance and multimodal analgesia in the perioperative arena. The emphasis of this implementation was to provide an evidence-based backdrop to foster the avoidance of the excessive or unnecessary use of narcotic. The primary initiative saw a reduction in routine narcotic use in 30% of the case volume.
In January of 2019, recognizing the ongoing risk of new addictions related to exposing patients to narcotic analgesics in the operating room and post-anesthesia care unit, the department set out to further reduce the use of narcotic as a primary analgesic by an additional 50%. This second phase of the narcotic avoidance project was accomplished through a substitution program in which nonnarcotic analgesics were substituted as the primary analgesic in the perioperative arena. Low-dose ketamine, lidocaine infusion, or magnesium infusion would be initiated during the operative period and maintained into the PACU. The team did recognize a concern and potential for breakthrough pain under the avoidance protocols. During the study period, clinical practice dictated that patients whose conditions warranted narcotic therapy or those who discretely demonstrated breakthrough pain received narcotic therapy. The choice to employ narcotic therapy was left to clinical judgment and recommended as a second- or third-line solution rather than as the core of the anesthetic.
Ketamine is recognized as a very potent analgesic at anesthetic doses; it can lead to slowed emergence and postoperative hallucinations. To avoid these concerns, ketamine was used at sub-anesthetic doses.
To ensure patients did not experience unnecessary or new postoperative pain as a result of the intervention, PACU admission and PACU discharge pain scores, all interventions, as well as length of stay (LOS) in the PACU were simultaneously tabulated and monitored. All data was stored in the analytics section of the Surgical Information Systems electronic health record (EHR) and extracted for review independent of patient identifier. There were 6,924 charts reviewed, and the total use rate of narcotics in the operating room (OR) and the PACU were tabulated.
Read full study here.