Rapid Practice Changes in Response to the Opioid Epidemic - - PowerPoint PPT Presentation

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Rapid Practice Changes in Response to the Opioid Epidemic

Integrating Adjuvant Analgesics into Practice

Kuo-Kai Chin, M.D. Candidate Boussard Lab Stanford University School of Medicine

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Disclosures

This project was supported by grant number R01HS024096 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. This project was also supported by the Stanford University Medical Scholars Research Program No conflicts of interest to declare.

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The Opioid Epidemic

• Prescription opioid sales have quadrupled since 1999 with no

change in the pain Americans report

• 91 Americans die each day from opioid overdose
• Total Economic Burden of $78.5 billion
• Contributors
• Greater availability of prescription and illicit opioids
• Limitations in understanding of addiction risk
• Emphasis on pain management

– Initiatives in the mid-1990’s regarding the under treatment of pain

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Surgery and Opioids

• Surgery is seen as a gateway to opioid dependence
• Orthopedic surgeons are responsible for the most opioid

prescriptions outside of primary care and internal medicine

• Total Knee Arthroplasty (TKA) is incredibly common and often

painful

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One Approach - Adjuvant Analgesics

• Adjuvant Analgesics – medications with primary indications
• ther than pain management
• Less risk for dependence compared to opioids
• Examples
• Anticonvulsants – Gabapentin (Neurontin), Pregabalin (Lyrica)
• Anesthetics – Ketamine
• Does not replace but often reduces opioid consumption

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Adjuvant Analgesics in TKA – the literature

• There is not a globally recognized and optimized analgesic

protocol after TKA

• Gabapentin in particular has been described in RCTs for its

potential opioid-sparing effects

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Research Questions

• Has gabapentin been implemented in a real world setting given

national initiatives to reduce opioid prescriptions?

• How does gabapentin affect opioid consumption in a diverse

population?

• How does gabapentin fare in management of post-operative

pain and readmissions in a diverse population?

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Methods – Study Design

• Retrospective, observational study using electronic health

records (EHR) from tertiary care academic medical institute

• Epic Clarity
• Patients identified using ICD-9/ICD-10 codes
• All patients undergoing TKA from 2009 through 2017
• For patients undergoing multiple TKAs, only the first procedure was

used

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Methods – Study Variables

• Patient Demographics
• age, gender, race, insurance, Charlson comorbidity score
• Relevant Dates
• admission, procedure, discharge, 30-day readmission
• Medications
• Gabapentin use – prior to admission, during inpatient stay
• Opioid analgesic use – inpatient use per day, aggregated using

standard Morphine Milligram Equivalents conversion

• Pain Scores
• Pre-Admission, Discharge, Follow-Up
• 0-10 scale, designated “high” if >=6

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Methods - Statistical Analyses

• Descriptive statistics
• Chi-square, t-test, K-Wallis for demographics
• Joinpoint regression for opioid and gabapentin use over time
• Multivariate regression models
• Controlled for important demographics & clinical factors
• Inpatient Opioid use (log-transformed linear)
• High Pain Score at Discharge (logistic)
• High Pain Score at Follow-Up (logistic)
• Unplanned 30-Day Readmission (logistic)

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Patient Demographics

• Sample Size – 4046
• Age – 64% over 65 y/o
• Gender– 62% female
• Race – 34% non-white
• No. (%)

4046 Age Group, No. (%) <45 62 (2) 45-64 1390 (34) 65+ 2594 (64) Gender, No. (%) Male 1551 (38) Female 2495 (62) Race, No. (%) White 2654 (66) Black 160 (4) Hispanic/Latino 433 (11) Asian/Pac 435 (11) Other 9 (0) Insurance Type, No. (%) Private 1343 (33) MediCal/Medicaid 72 (2) Medicare 2571 (64) Other 60 (1) Length of Stay, mean (SD) 3.14 (1.48) Charleston Comorbidity Score 1506 (37) 1 1877 (46) 2 663 (16)

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Changes in Gabapentin Use, 2009-2017

20 40 60 80 100 2009 2010 2011 2012 2013 2014 2015 2016 2017 Crude Rate Modeled Rate

2009-2017: 8.72 annual percent change, p<0.001

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Average Inpatient Opioid Use in TKA

20 40 60 80 100 120 2009 2010 2011 2012 2013 2014 2015 2016 2017

Morphine Equivalents Per Day Year of surgery

Crude Rates Modeled Data

2009-2012: 5.42 annual percent change, p=0.1598 2012-2017: -4.21 annual percent change, p=0.0499

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Association of Gabapentin Use and Inpatient Morphine Equivalents per Day

Characteristic Estimate Confidence Interval Gabapentin 0.59 (0.44, 0.80) Procedure Year 0.94 (0.90, 0.98) Pre-admission High Pain 1.18 (1.09, 1.28) Gabapentin:Procedure Year 1.11 (1.05, 1.17)

Dependent Variable: Inpatient Opioid Use (MME/Person/Day) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

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Illustrative Example

Person A 100 -> 60 MME

2009 2017

Person A 100 -> 60 MME Person B 50 -> 40 MME

• 40%
• 25%

Person C 50 -> 40 MME Person D 50 -> 40 MME

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Association of Gabapentin Use and High Discharge Pain Scores

Characteristic Estimate Confidence Interval Gabapentin 1.19 (0.82, 1.75) Pre-admission High Pain 1.83 (1.37, 2.45)

Dependent Variable: High Discharge Pain (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

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Association of Gabapentin Use and High Follow- Up Pain Scores

Characteristic Estimate Confidence Interval Gabapentin 1.07 (0.78, 1.50) Pre-admission High Pain 2.10 (1.61, 2.74)

Dependent Variable: High Follow-Up Pain (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

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Association of Gabapentin Use and Unplanned 30- Day Readmissions

Characteristic Estimate Confidence Interval Gabapentin 1.40 (0.77, 2.70) Pre-admission High Pain 1.14 (0.71, 1.79)

Dependent Variable: Unplanned 30-Day Readmissions (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

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Conclusion

• In our population based study, there was a significant increase

in the use of adjuvant analgesics for postoperative pain management in TKA since 2009

• By 2017, 79% of TKA patients are receiving gabapentin
• Adjuvant analgesics are associated with a decrease in opioid

consumption while providing equivalent management of postoperative pain and risk of unplanned 30-day readmissions

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Policy Implications

• The implementation of evidence-based guidelines coupled with

proactive leadership can ensure the rapid response to initiatives responding to the opioid epidemic by increasing the use of adjuvant analgesics

• Adjuvant pain-management therapies can adequately manage post-
• perative pain while reducing opioid use.
• Further federal and society incentives focused on the use of adjuvant

therapies for pain management are needed

• Future policy should support study of adjuvant analgesic effects and

encourage their use as standard of care

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Acknowledgements

• Tina Hernandez-Boussard
• Karishma Desai, Tina Seto
• Steven M. Asch, Ian Carroll, Catherine Curtin, Kathryn McDonald
• kchin7@stanford.edu

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Ketamine Trends

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Pain Trends Over Time

• (have available figures on pre, post, and follow-up pain over

time)