Opioid Crisis: The Numbers

Cornelius A. ThielsComplex General Surgical Oncology FellowMemorial Sloan Kettering Cancer Center

ERAS Conference

November 16th, 2019

Disclosures

• No financial conflicts

• Work performed while at Mayo Clinic, Rochester MN

Poppy FlowerPapaver somniferum

“Somnus”

Roman God of Sleep

Opium 3,400 BC

CDC National Vital Statistics Reports

Morphine 1803 Opioid Crises

“Doctors should keep

patients as pain-free as

possible”

Opioid are the cornerstone

postoperative pain management…

“Use morphine first”

“Several good studies indicate the risk of

addiction is <0.04%”

Recommends against treating

pain as-needed

American Pain Society

©1983 Wong-Baker FACES Pain Rating Scale

1CDC WONDER Database, 201622009 National Survey on Drug Use and Health

The US consumes 80% of the World’s Opioids

1CDC, 20132Bates et. al, 2011

Aggregate economic burden of >$78.5 billion/year2

1CDC WONDER Database, 20162Florence et al, Medical Care, 2013

“Doctors should keep

patients as pain-free as

possible”

Opioid are the cornerstone

postoperative pain management…

“Use morphine first”

Recommends against treating

pain as-needed

“Several good studies indicate the risk of

addiction is <0.04%”

N Engl J Med, January 10, 1980

Actual Addiction Risk

6% progressed to a chronic

opioid use6% progressed to chronic opioid

use regardless of type

30% progressed to a chronic opioid

use after spine fusion

(Jiang et al., Ann Surg , 2017 & Lee et al., J Clin Oncol, 2017 show similar rates)

One out of every three opioid prescriptions are abused1

1CDC Vital Signs, 20152Gaither et al., JAMA Pediatrics, 2016

3Finkelstein et al., Pediatrics, 2017

PEDIATRICS | Original Investigation

https://doseofreality.mn.gov

Surgeon Contribution

1. We prescribe about 10% of all opioids in the US1

2. X% of our patients go on to long-term opioid use2

3. 1 in 3 pills we prescribe get misused or abused3

1Levy et al, Am J Prev Med. 20152Hooten et al Mayo Clin Proc. 2015 & Brummett et al, JAMA Surg 2017 & Thiels et al. BMJ, 2019

3CDC Vital Signs 1999–2008

If that still wasn’t enough evidence…

1. Insurance companies• Various dosing based limits

2. Legislative bodies • The CARA 2.0 Act of 2018, US Senate 3 days*

• The Commonwealth of Massachusetts Act of 2016 7 days*

• Florida 2017 Statute 7 days max, RQ in person visit*

• … every state in US!1

*no exception for surgical patientshttps://www.affirmhealth.com/blog/opioid-prescribing-guidelines-a-state-by-state-overview

???

Prospective Initiative to Develop Evidence-based Guidelines

↓ Opioid Rx

=/↑ Pt Experience

= Refill Rates

Background Research:

1. Overprescriptionof opioids

2. Wide variation in amount prescribed

Thiels et al., Annals of Surgery 2017

Hill et al., Annals of Surgery, 2017

Bicket et al., JAMA Surgery, 2017

<2016 2016 2017

Adults undergoing 25 common elective procedures

• Retrospective Review

• Institutional ACS-NSQIP data + prescription data

• 2013-2015

Procedure GroupsGENERAL SURGERY

1. Lap Cholecystectomy

2. Lap Initial Inguinal Hernia Repair

3. Initial Inguinal Hernia Repair

4. Ventral Hernia Repair

GENERAL SURGICAL ONCOLOGY

5. Simple Mastectomy

6. Breast Lumpectomy

7. Ileocecectomy

8. Laparoscopic LAR

9. VATS Wedge Resection

ORTHOPEDIC

10. Total Shoulder

11. Total Hip

12. Knee Arthroscopic Meniscectomy

13. Total Knee

14. Rotator Cuff Repair

SPINE

15. Lumbar Laminotomy

16. Lumbar Laminectomy

UROLOGY/GYNECOLOGY

17. Lap Hysterectomy

18. Vaginal Hysterectomy,

19. Lap Nephrectomy

20. Lap Prostatectomy

HEAD & NECK

21. Thyroid Lobectomy

22. Parathyroidectomy

23. Carotid Thromboendarterectomy

24. Parotid Gland Excision

25. Tonsillectomy

7,651 elective procedures

•Discharge Prescriptions: No Opioids Prescribed

6%

Opioids94%

Median 375 MME Prescribed!

~50 tabs 5 mg Oxycodone

Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gray RJ, Gazelka HM, Cima

RR, Habermann EB. Wide Variation and Overprescription of Opioids After Elective Surgery.

Annals of Surgery. 2017 Oct;266(4):564-573.

Conclusion

1. >80% of surgical patients were over-prescribed at discharge.

2. Significant unexplained variation within practices.

Thiels CA, Anderson SS, Ubl DS, Hanson KT, Bergquist WJ, Gray RJ, Gazelka HM, Cima

RR, Habermann EB. Wide Variation and Overprescription of Opioids After Elective Surgery.

Annals of Surgery. 2017 Oct;266(4):564-573.

Incremental

Improvement

How do we do better?

Prospective survey 25 common elective procedures:

• 03/13/17 to 01/19/18

• 28 question survey

• 2566 Surveyed Patients

• 75% Response Rate with 3% Refusal Rate

ProcedureGENERAL SURGERY

1. MIS Cholecystectomy

2. MIS Inguinal Hernia Repair

3. Open Inguinal Hernia Repair

SURGICAL ONCOLOGY

4. Open Pancreaticoduodenectomy

5. Simple Mastectomy ± Sentinel Node

6. Breast Lumpectomy ± Sentinel Node

COLORECTAL

7. MIS Partial Colectomy with Anastomosis

8. MIS Low Anterior Resection ± DLI Ileostomy

THORACIC

9. MIS Lung Wedge Resection

10. Open Lung Lobectomy

ORTHOPEDIC

11. Carpal Tunnel Release

12. Total Hip

13. Total Knee

14. Knee Arthroscopic Meniscectomy

15. Rotator Cuff Repair

SPINE

16. Lumbar Laminotomy/Laminectomy

17. Lumbar Fusion

UROLOGY/GYNECOLOGY

18. MIS Hysterectomy

19. Ovarian Cancer Cytoreduction

20. MIS Nephrectomy

21. MIS Prostatectomy

HEAD & NECK

22. Parathyroidectomy

23. Tonsillectomy

VASCULAR/TRANSPLANT

24. Arteriovenous Fistula Creation

25. Carotid Endarterectomy

Opioid Utilization

62% of Opioids Went Unused

77% of Patients had Leftover Opioids

>1 million pills remained unused per institution/year

Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann

EB. Results of a Prospective Multicenter Initiative Aimed at Developing Opioid Prescribing

Guidelines after Surgery. Annals of Surgery. 2018 Sep;268(3):457-468.

*Only includes patients with leftover opioids and not

still taking opioids (n=1485)

Still Possessed

Remaining Opioids

(89.4%)Disposed of

Them

(9.6%)

Other (1.0%)

What did patients do with extra opioids?

Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann

EB. Results of a Prospective Multicenter Initiative Aimed at Developing Opioid Prescribing

Guidelines after Surgery. Annals of Surgery. 2018 Sep;268(3):457-468.

Amount Opioids Prescribed vs ConsumedNaïve

Only

0 100 200 300 400 500 600 700

Carotid Endarterectomy

Parathyroidectomy

Arteriovenous Fistula Creation

MIS Partial Colectomy with Anastomosis

Carpel Tunnel Release

Breast Lumpectomy ± Sentinel Node

MIS Cholecystectomy

MIS Inguinal Hernia Repair

Ovarian Cancer Cytoreduction

Open Inguinal Hernia Repair

Simple Mastectomy ± Sentinel Node

MIS Hysterectomy

MIS Low Anterior Resection ± Diverting Ileostomy

MIS Prostatectomy

MIS Nephrectomy

Knee Arthroscopic Meniscectomy

Open Pancreaticoduodenectomy

MIS Lung Wedge Resection

Tonsillectomy

Rotator Cuff Surgery

Lumbar Laminotomy/Laminectomy

Open Lung Lobectomy

Lumbar Fusion

Total Hip

Total Knee

Median Amount Consumed (in MME) Median Amount Remaining (in MME)

a

Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann

EB. Results of a Prospective Multicenter Initiative Aimed at Developing Opioid Prescribing

Guidelines after Surgery. Annals of Surgery. 2018 Sep;268(3):457-468.

Prescribing Guidelines Must

be Procedure Specific!

Opioid Utilization

Consumed <50 MME

(66% non-orthopedic)

Consumed Zero

(40% non-orthopedic)

Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann

EB. Results of a Prospective Multicenter Initiative Aimed at Developing Opioid Prescribing

Guidelines after Surgery. Annals of Surgery. 2018 Sep;268(3):457-468.

Significant # of Patients

Require No Opioids at

Discharge!

16% Difficult to Obtain

9%Too Few Opioids

7% Not

Satisfied

0% 20% 40% 60% 80% 100%

Ease of Refill*

Amount Prescribed

Post-Discharge Pain Control 91% Very or Somewhat Satisfied

63% Right Amount of Opioids28% Too Many

Opioids

80% Very or Somewhat Easy to Obtain

*Includes only 321 (12%) patients who required a refill

Patient Experience with Pain Control?

Thiels CA, Ubl DS, Yost KJ, Dowdy SC, Mabry TM, Gazelka HM, Cima RR, Habermann

EB. Results of a Prospective Multicenter Initiative Aimed at Developing Opioid Prescribing

Guidelines after Surgery. Annals of Surgery. 2018 Sep;268(3):457-468.

Pre/Post Roll Out DataDepartment of SurgeryRochester, MN Only

Unpublished QI Data

Guidelines LaunchedPre Cohortn=620

3/2017 1/2018 2/2018

Post Cohortn=1189

7/2018 12/2018

Procedure

Median Opiods

Prescribed (in MME)

Median Opiods

Prescribed (in MME) p-value

All 150 75 225 60 38 113 <0.001

Ateriovenous Fistula Creation 0 0 75 0 0 0 0.046

Breast Lumpectomy ± Sentinel Node 118.75 60 150 50 50 75 <0.001

Carotid Endarterectomy 0 0 150 0 0 100 0.52

MIS Cholecystectomy 150 75 187.5 60 50 75 <0.001

MIS Inguinal Hernia Repair 115 75 150 75 60 100 <0.001

MIS Low Anterior Resection ± Diverting Ileostomy 187.5 75 225 37.5 0 112.5 <0.001

MIS Lung Wedge Resection 337.5 225 450 200 75 225 <0.001

MIS Partial Colectomy with Anastomosis 112.5 75 187.5 45 0 100 <0.001

Open Inguinal Hernia Repair 150 112.5 200 60 50 90 <0.001

Open Lung Lobectomy 543.75 250 600 210 75 320 0.006

Open Pancreaticoduodenectomy 180 75 375 75 0 125 0.009

Parathyroidectomy 75 50 112.5 50 0 60 <0.001

Simple Mastectomy ± Sentinel Node 175 112.5 225 137.5 75 212.5 0.039

Pre Rollout Post Rollout

IQR IQR

Median Amount Opioids Prescribed (in MME)

>50% Reduction

in # of Opioids Prescribed(=hundreds of thousands of fewer unused pills in the community)

Unpublished QI Data

(Naïve Only)

20 Tabs Oxy 8 Tabs Oxy

0

100

200

300

400

500

Amount of Opioids Prescribed after Discharge (in MME)

Pre Rollout Post Rollout

Unpublished QI Data

(Naïve Only)

*

**

* **

*

**

*

*

*

*

*p<0.05

Bar = IQR

Less Variation in Opioid Prescribing!

↓ Variation

Unpublished QI Data

(Naïve Only)

No significant increase in refill rates within

most* procedure!

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

Refill Rates

Pre Rollout Post Rollout

*

*p<0.05 (n=20

patents only)

Tramadol?

Half of post-discharge opioids in our institution got Tramadol1

• 3rd most common opioid nationally2

1Unpublished QI Data2Thiels et al., British Medical Journal. 2019.

3Justin Morgenstern, "Don’t prescribe tramadol", First10EM blog, May 13, 2019.

British Medical Journal. 2019; 365: I1849.

Annals of Surgery 2017 Apr;265(4):715-721

Try to get patients off opioids before surgery…

Under Review J. Surgery

Questions/Discussion

Cornelius A. Thiels, DO, MBAthiels.cornelius@gmail.com

thielsc@mskcc.org

ERAS Conference

November 16th, 2019