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There is an opioid epidemic We all share responsibility
Will we take steps to turn the tide
Jay T Bishoff MD FACSCo-Chairman Provider Education Committee
Intermountain Urological InstituteClinical Professor Surgery
University of Utah School of MedicineSalt Lake City Utah
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
This has recently been a matter of a lot of angst for me Dr Hershel Jick said We have published nearly 400 papers on drug safety but never before have we had one that got into such a bizarre and unhealthy situation
New England Journal of Medicine Letter to the Editor 19803022
How Did We Get Here
bull 1980 NEJM 1 of narcotic patients become dependent
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
bull Unwittingly became a major contributor to todays opioid crisis
bull 608 Citationsbull 722 used the letter as evidence that addiction in opioid-treated patients is rare
bull 808 did not mention that the original letter described inpatient findings
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
Stop The Flow
Gold King Mine
Silverton Colorado
2015 Environmental Restoration LLC
bull Under EPA Contract
bull Tap a Tailings ldquoPondrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
This has recently been a matter of a lot of angst for me Dr Hershel Jick said We have published nearly 400 papers on drug safety but never before have we had one that got into such a bizarre and unhealthy situation
New England Journal of Medicine Letter to the Editor 19803022
How Did We Get Here
bull 1980 NEJM 1 of narcotic patients become dependent
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
bull Unwittingly became a major contributor to todays opioid crisis
bull 608 Citationsbull 722 used the letter as evidence that addiction in opioid-treated patients is rare
bull 808 did not mention that the original letter described inpatient findings
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
Stop The Flow
Gold King Mine
Silverton Colorado
2015 Environmental Restoration LLC
bull Under EPA Contract
bull Tap a Tailings ldquoPondrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
How Did We Get Here
bull 1980 NEJM 1 of narcotic patients become dependent
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
bull Unwittingly became a major contributor to todays opioid crisis
bull 608 Citationsbull 722 used the letter as evidence that addiction in opioid-treated patients is rare
bull 808 did not mention that the original letter described inpatient findings
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
Stop The Flow
Gold King Mine
Silverton Colorado
2015 Environmental Restoration LLC
bull Under EPA Contract
bull Tap a Tailings ldquoPondrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
How Did We Get Here
1980 NEJM 1 of narcotic patients become dependent
bull One-paragraph letter
bull One hundred words long
bull Unwittingly became a major contributor to todays opioid crisis
bull 608 Citationsbull 722 used the letter as evidence that addiction in opioid-treated patients is rare
bull 808 did not mention that the original letter described inpatient findings
New Yorker Nov 2013 Celine GounderHttpwwwgaogovnewitemsd04110pdf
Httpwwwonlinewsjcomnewsarticles
Stop The Flow
Gold King Mine
Silverton Colorado
2015 Environmental Restoration LLC
bull Under EPA Contract
bull Tap a Tailings ldquoPondrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Flow
Gold King Mine
Silverton Colorado
2015 Environmental Restoration LLC
bull Under EPA Contract
bull Tap a Tailings ldquoPondrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Flow
Gold King Mine
ldquoAccidentally Destroyed Plugrdquo
3 Million Gallons Mine Waste
Cadmium
Lead
Arsenic
Beryllium
Zinc
Iron
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Flow
Gold King Mine
EPA Took Full Responsibility
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Bleeding
Gold King Mine
Dead fish
Dead plants
Residents
Farmers
Recreation
Months of Clean Up
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Bleeding
Gold King Mine 2015
Months of Clean Up
Sediment Remains
Unknown Duration
Never the same
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Opioid Deaths
bull For decades US life expectancy rising
bull In 1950 most Americans live to 68 yo
bull In 2014 most Americans live to 78 yo
bull In 2015 life expectancy dipped by a month
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Opioid Deaths
bull Deaths from prescription opioids
bull quadrupled in less than 20 years
bull more than 183000 people have died in the United States from overdoses related to prescription opioids since 1999
bull the CDC reports heroin use has more than doubled in the past decade and with that a huge spike in heroin-related deaths
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
The Bottom Line(data from 2006)
Adolescents do not perceive prescription drug use as ldquodrug abuserdquo
ldquoLeft Overrdquo Narcotics gateway drug for teensFirst time users initial drug of choiceo Marijuana 22 milliono Prescription pain meds 21 million
78 of heroin users started with prescription pain meds
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
JAMA Surg 2017152(6)e170504 doi101001jamasurg20170504 Published online April 12 2017
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
PEDIATRICS Volume 136 number 5 November 2015
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
PEDIATRICS Volume 136 number 5 November 2015
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
J Urology February 2011 Volume 185 Issue 2 Pages 551ndash555
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Narcotic Use In Urology
Hypothesis Urologists over prescribe narcotics
Objective bull Assess prescribing practices consumption and disposal of prescribed narcotics
after urological surgery
bull Determine the prevalence and degree of narcotic over-prescription and surplus medication disposal
bull Make specific reasonable recommendations for number of tablets based upon procedure
J Urol 185551-555 Feb 2011
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Design
Setting 2 private hospitals amp 1 academic hospital
Patients3-month consecutive sample of adult patients
Mail survey
Phone Survey
586 patients contacted
J Urol 185551-555 Feb 2011
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
DesignExcept investigators prescribing physicians and patients
no prior knowledge of the study
Surveys were administered to patients 2-4 weeks post-operatively
Data collected included perception of pain control
type and quantity of medication prescribed
quantity of medication leftover refills needed
disposal instruction given surplus medication disposition
J Urol 185551-555 Feb 2011
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
DesignLevel of Invasiveness Examples
1 1Cystoscopic Endoscopic and ESWL TURP TURBT Ureteroscopy laser lithotripsy ESWL
2 Minor open Suprapubic tube sacral neuromodulation prosthesis
circumcision hydrocele TOT sling
3 Major Lap or endoscopic PCNL lap nephrectomy lap pyeloplasty robotic
prostatectomy
4 Major open Open prostatectomy open nephrectomy open partial
nephrectomy radical cystectomy
J Urol 185551-555 Feb 2011
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Surgery Type Tablets
Prescribed
Tablets Used Unused
CystoEndo 20 (range 11-32) 10 (range 0-30) 50
Minor Open 20 (range 14-30) 8 (range 0-29) 58
Major Lap 20 (range 14-31) 12 (range 2-26) 40
Major Open 30 (range 14-37) 14 (range 4-29) 50
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Pain managementbull 84 of patients were satisfied with pain control
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
J Urol 185551-555 Feb 2011
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Pain managementbull 84 of patients were satisfied with pain control
bull No difference seen in satisfaction based upon
o Level of surgery
o Type of medication
o Amount given taken or refills requested
bull Refill Requests
o 9 one
o 2 2 or more
J Urol 185551-555 Feb 2011
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Narcotic Disposal bull 92 received no instructions
bull 7 given instructions but did not remember
If you have leftover narcotics what did you do with them
bull 91 Kept at home
bull 6 threw in trash
bull 2 flushed down toilet
bull 1 back to pharmacy
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o Unused tablets in the state of Utah from one health care system
o Tanner pelvic fracture 2008 60 vicodin used 12
o Jeremy Nephew lap Chole30 vicodin
ldquoUncle Jay What do I do with the 23 left overrdquo
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care System 22 hospitals
o 2009 Out Patient Surgery 90366
o 2009 In Patient Surgery 33885
J Urol 185551-555 Feb 2011
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = 8900000
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Results
Left Over Narcoticsbull 275 patients had 1600 unused narcotic tablets
bull Intermountain Health Care 22 hospitals
o Out Patient Procedures 90366
o In Patient Procedures 33885
bull Potential Unused Tablets 750000 ndash 890000
o unused tablets in the state of Utah from one health care system
o street value 1$mg if assume 10 mg x 890000 = $8900000
o 2016 Intermountain Health Care
bull Prescribed 19000000 narcotic doses
bull Street Value $430000000
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
A National Crisis
Addiction Affects 16 percent of the US Population
40 million Americans compared to
27 million with heart disease
26 million with diabetes
19 million with cancer
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
A Complex Problem
bull 7000 prescription for opioids are filled daily in Utah
bull 822 ndash 95 opioid prescriptions per 100 adults
bull One in 25 Utah adults receive prescription opioids for treatment of chronic pain
bull 764 percent increase in Morphine Milligram Equivalents dispensed between 2002 and 2015
bull 416 percent of pregnant Medicaid recipients in Utah received a prescription opioid compared to the national average of 23 percent
bull Drug poisoning deaths are the leading cause of accidental deaths in Utah surpassing deaths due to firearms falls and motor vehicle accidents combined
bull Opioid use disorders cost Utah $237756000 in health care costs
bull There were 300 opioid overdose deaths in 2015
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Raising Awareness
Public awareness messaging around the safe use storage and disposal of prescription medications
bull Increase the percentage of people who believe that prescription opioids have ldquodefiniterdquo potential for abuse or addiction
bull Increase the percentage of people exposed to ads on the safe use storage and disposal of prescription medications
bull Increase the volume of medications disposed of in pharmacy drop boxes
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Local Substance Abuse Authorities
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Media Campaign Impact
ldquoYesrdquo Exposed to
Ad Content
Behavior
Impacted
Behavior Not
Impacted
ODDeath Potential 65 35
Addiction Potential 65 35
Safe USD 79 21
Conversation with Dr 65 35
Q33 (If exposed to ANY ads) ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo
ldquoIn what ways have the messages impacted your behavior around your prescription opioid medicationsrdquo 2017
No impact 36
Followed doctorrsquos instructions more closely 24
Took lower doses or stopped taking the Rx opioid 16
Learned more about signssymptoms of addiction or asked doctor about addiction 13
Asked doctor about other ways besides prescription opioid medications to treatmanage pain 17
Disposed of leftover prescription opioid medications more frequently 19
Kept better track of my prescription opioid medications 20
Kept medication locked up or in a less accessible location 25
NA Do not have an opioid medication prescription 9
NA Have not seen a doctor about treating or managing pain 2
Other (SPECIFY) 11
Donrsquot recall (VOL) 4
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Limiting the Supply -Prescription Drop Boxesbull 21 Intermountain community pharmacies have installed
medsafe receptacles
bull Over 11000 pounds of medication disposed (176000 prescriptions)
bull Financial support for eleven new community-based drop boxes in 2017
0
5
10
15
20
25
30
35
40
2011 2016
35 of individuals surveyed in 2016 used drop boxes as compared to 16 in 2011
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staffldquoIf I prescribe less my office staff will be overwhelmed by calls for morerdquo
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
My staff will be swamped with calls for more pain medication
2015-2016 RLAP Lap Renal Ureteroscopy Total
Cases 88 149 71 308
Mean PainCallsMonth 05 10 25 4
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumption
bull Impact on office staff
bull Impact on patient satisfaction ldquoI wont prescribe less because it will drop my on line star ratingsrdquo
JAMA May 2431 2016 vol 315Number 20
JAMA May 16 2017 vol 317 Number 19
Annals of Emer Med645 Nov 2014
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Limiting the Supply ndash Prescribing Practices
bull Lack of disease specific consumptionldquoHow do you know the 60 tablets I prescribe is not the right amountrdquo
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Narcotic Information Initiative
2017 Goal ndash Learn How Much Patients Use
Surgical Services Clinical Program
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
How many doses do patients take
Factors
bull Procedure
bull Gender
bull Age
bull Previous exposure
bull Type of Narcotic
bull Other pain medication
bull Genetics
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
SSCP Plan
1 Find out how many patients take
2 Provide physicians with this information
3 Work to resolve the causes of the unintended consequences
4 Improve access to the DOPL database in iCentra
5 Provide physicians feedback
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
SSCP Narcotics Survey Goals
1 Find out how many patients take
2 Give patients timely specific information on how to dispose of the narcotics
3 Identify Naiumlve vs Exposed state
4 Identify different outcomes based upon types of prescription narcotics
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intermountain Pain MedicationPatient Survey
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Initiated at Logan Regional HospitalJan 9 2017
Process ndashbull Patient provides email address (iCentra sites) bull Education to patients 2 weeks prior to survey
send outbull Patient Education ndash Mention in Pre-admission phone call Rack-card distribution in SDS OR Waiting Rooms Print out at discharge (MAWDS Teaching)
bull First survey send outs Jan 24 2017 resulted in a 58 response rate
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Rack-card distribution
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Rack-Card
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
I see the need for Change
But How and Is there Data to Help Direct Me
Preoperative
Tylenol Oral Rectal $$$IV
Gabapentin 300 to 600 mg
Decadron 8 mg
Magnesium Sulfate 30-50 mgkg
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Preoperative Gabapentin for Post Analgesia
bullGabapentins role in the treatment of chronic neuropathic pain is well known
bull What is its role for managing postoperative pain
bullMeta-analysis of all randomized trials
bullEffect onbull pain scores
bull analgesia consumption
bull analgesia-related side effects in the first 24 hr following surgery
Can J Anaesth 2006 May53(5)461-9Preoperative gabapentin for postoperative analgesia a meta-analysis Seib RK1 Paul JE
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Preoperative Gabapentin for Post AnalgesiaEight placebo-controlled randomized controlled trials
PRINCIPLE FINDINGS
Patients who received gabapentin preoperativelybull Significantly lower pain scores (-119 at rest and -110
with movement on a 100-point visual analogue scale)
bull Significantly lower opioid consumption (-147 mg of morphine in 24 hr)
bull No difference in the incidence of side effects
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Introperative Magnesium
Twenty Randomized Clinical Trials N=1257PRINCIPLE FINDINGS
bull Combined effects favored magnesium over control for pain at rest (le4 h minus074 [minus108 to minus048]
bull Post Op 24 h minus036 [minus063 to minus009]) bull With movement at 24 h minus073 (minus137 to minus01)bull Opioid consumption was largely decreased in the
systemic magnesium group compared with control weighted mean difference (99 CI) of minus1052 (minus1350 to minus754) mg morphine IV equivalents
Can J Anaesth 2006 May53(5)461-9 Preoperative gabapentin for postoperative analgesia a meta-analysis SeibRK1 Paul JE
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative Magnesiumlt 4 hours at rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative Magnesiumlt 4 hours with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative Magnesium24 Hours Post Op at Rest
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative Magnesium24 Hours Post Op with movement
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative MagnesiumOpioid Consumption
Perioperative Systemic Magnesium to Minimize Postoperative Pain A Meta-analysis of Randomized Controlled Trials Gildasio S De Oliveira Jr MD MSCI Lucas J Castro-Alves MD Jamil H Khan BS Robert J McCarthy PharmD Aesthesiology 07 2013 Vol119 178-190
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Intraoperative Local Anesthesia
October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
To read this article in full please review your options for gaining access at the bottom of the page
INTRAOPERATIVE LOCAL ANESTHESIA DECREASES POSTOPERATIVE PARENTERAL OPIOID REQUIREMENTS FOR TRANSPERITONEAL LAPAROSCOPIC RENAL AND ADRENAL SURGERY A RANDOMIZED DOUBLE-BLIND PLACEBO CONTROLLED INVESTIGATIONHERKANWAL S KHAIRA
J STUART WOLF Jr Correspondence information about the author J STUART WOLF Email the author J STUART WOLF
From the Department of Urology University of Michigan Ann Arbor Michigan
DOI httpdxdoiorg10109701ju000013774769549bd
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
bull Double-blind
bull Placebo controlled study
bull Port sites and hand assist incision were infiltrated with bupivacaine or
placebo prior to surgery
bull A total of 72 patients undergoing transperitoneal laparoscopic renal or
adrenal surgery were randomly assigned to the treatment (05
bupivacaine) or placebo (09 normal saline) arm Port and hand assist
port sites were infiltrated at the outset of the procedure
Intraoperative Local Anesthesia
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
12 hours(plt05)
24 hours (plt05)
Total (plt05)
Placebo 30 mg 50 mg 57 mg
Bupivacanie 20 mg 35 mg 37 mg
Mean Parenteral Morphine Equivalents
Wolf et all J Urology October 2004 October 2004Volume 172 Issue 4 Part 1 Pages 1422ndash1426
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Change
How
Post OpSit down at patients bed side
Tell them how important it is to me that their pain is controlled without giving them dependence or having too many left over for diversion
Use alternatives to narcotics
If you need more call me and I will get another prescription for you
1000 mg Tylenol q 8 hours x 7 days
400 ndash 800 mg Ibuprofen q 8 hours x 7 days
Dilaudid 4 mg frac12 every 4-6 hours as needed Dispense 6
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
Stop The Bleeding
Narcotic Gold Mine
Dead Patients
Dead dreams
Dead aspiration
Devastated Families
Years of Clean Up
Sediment Remains
Unknown Duration
Never the same
We are still here
We Should Be Here
