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

1 Rapid Practice Changes in Response to the Opioid Epidemic Integrating Adjuvant Analgesics into Practice Kuo-Kai Chin, M.D. Candidate Boussard Lab Stanford University School of Medicine

Disclosures 2 This project was supported by grant number R01HS024096 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Agency for Healthcare Research and Quality. This project was also supported by the Stanford University Medical Scholars Research Program No conflicts of interest to declare.

The Opioid Epidemic 3 • Prescription opioid sales have quadrupled since 1999 with no change in the pain Americans report • 91 Americans die each day from opioid overdose • Total Economic Burden of $78.5 billion • Contributors • Greater availability of prescription and illicit opioids • Limitations in understanding of addiction risk • Emphasis on pain management – Initiatives in the mid- 1990’s regarding the under treatment of pain

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Surgery and Opioids 6 • Surgery is seen as a gateway to opioid dependence • Orthopedic surgeons are responsible for the most opioid prescriptions outside of primary care and internal medicine • Total Knee Arthroplasty (TKA) is incredibly common and often painful

One Approach - Adjuvant Analgesics 7 • Adjuvant Analgesics – medications with primary indications other than pain management • Less risk for dependence compared to opioids • Examples • Anticonvulsants – Gabapentin (Neurontin), Pregabalin (Lyrica) • Anesthetics – Ketamine • Does not replace but often reduces opioid consumption

Adjuvant Analgesics in TKA – the literature 8 • There is not a globally recognized and optimized analgesic protocol after TKA • Gabapentin in particular has been described in RCTs for its potential opioid-sparing effects

Research Questions 9 • Has gabapentin been implemented in a real world setting given national initiatives to reduce opioid prescriptions? • How does gabapentin affect opioid consumption in a diverse population? • How does gabapentin fare in management of post-operative pain and readmissions in a diverse population?

Methods – Study Design 10 • Retrospective, observational study using electronic health records (EHR) from tertiary care academic medical institute • Epic Clarity • Patients identified using ICD-9/ICD-10 codes • All patients undergoing TKA from 2009 through 2017 • For patients undergoing multiple TKAs, only the first procedure was used

Methods – Study Variables 11 • Patient Demographics • age, gender, race, insurance, Charlson comorbidity score • Relevant Dates • admission, procedure, discharge, 30-day readmission • Medications • Gabapentin use – prior to admission, during inpatient stay • Opioid analgesic use – inpatient use per day, aggregated using standard Morphine Milligram Equivalents conversion • Pain Scores • Pre-Admission, Discharge, Follow-Up • 0- 10 scale, designated “high” if >=6

Methods - Statistical Analyses 12 • Descriptive statistics • Chi-square, t-test, K-Wallis for demographics • Joinpoint regression for opioid and gabapentin use over time • Multivariate regression models • Controlled for important demographics & clinical factors • Inpatient Opioid use (log-transformed linear) • High Pain Score at Discharge (logistic) • High Pain Score at Follow-Up (logistic) • Unplanned 30-Day Readmission (logistic)

No. (%) 4046 Age Group, No. (%) Patient Demographics 13 <45 62 (2) 45-64 1390 (34) 65+ 2594 (64) Gender, No. (%) Male 1551 (38) • Sample Size – 4046 Female 2495 (62) Race, No. (%) White 2654 (66) Black 160 (4) • Age – 64% over 65 y/o Hispanic/Latino 433 (11) Asian/Pac 435 (11) Other 9 (0) • Gender – 62% female Insurance Type, No. (%) Private 1343 (33) MediCal/Medicaid 72 (2) • Race – 34% non-white Medicare 2571 (64) Other 60 (1) Length of Stay, mean (SD) 3.14 (1.48) Charleston Comorbidity Score 0 1506 (37) 1 1877 (46) 2 663 (16)

Changes in Gabapentin Use, 2009-2017 14 100 80 60 40 20 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 Crude Rate Modeled Rate 2009-2017: 8.72 annual percent change, p<0.001

Average Inpatient Opioid Use in TKA 15 120 Morphine Equivalents Per Day 100 80 60 40 20 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 Year of surgery Crude Rates Modeled Data 2009-2012: 5.42 annual percent change, p=0.1598 2012-2017: -4.21 annual percent change, p=0.0499

Association of Gabapentin Use and Inpatient 16 Morphine Equivalents per Day Characteristic Estimate Confidence Interval Gabapentin 0.59 (0.44, 0.80) Procedure Year 0.94 (0.90, 0.98) Pre-admission High Pain 1.18 (1.09, 1.28) Gabapentin:Procedure Year 1.11 (1.05, 1.17) Dependent Variable: Inpatient Opioid Use (MME/Person/Day) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

Illustrative Example 17 2009 2017 Person A Person B 100 -> 60 MME 50 -> 40 MME Person A 100 -> 60 MME Person C Person D 50 -> 40 MME 50 -> 40 MME -40% -25%

Association of Gabapentin Use and High 18 Discharge Pain Scores Characteristic Estimate Confidence Interval Gabapentin 1.19 (0.82, 1.75) Pre-admission High Pain 1.83 (1.37, 2.45) Dependent Variable: High Discharge Pain (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

Association of Gabapentin Use and High Follow- 19 Up Pain Scores Characteristic Estimate Confidence Interval Gabapentin 1.07 (0.78, 1.50) Pre-admission High Pain 2.10 (1.61, 2.74) Dependent Variable: High Follow-Up Pain (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

Association of Gabapentin Use and Unplanned 30- 20 Day Readmissions Characteristic Estimate Confidence Interval Gabapentin 1.40 (0.77, 2.70) Pre-admission High Pain 1.14 (0.71, 1.79) Dependent Variable: Unplanned 30-Day Readmissions (Yes/No) Models controlled for: Age, Race, Gender, Insurance, Procedure Year, Length of Stay, Comorbidity Score, Previous Adjuvant Use

Conclusion 21 • In our population based study, there was a significant increase in the use of adjuvant analgesics for postoperative pain management in TKA since 2009 • By 2017, 79% of TKA patients are receiving gabapentin • Adjuvant analgesics are associated with a decrease in opioid consumption while providing equivalent management of postoperative pain and risk of unplanned 30-day readmissions

Policy Implications 22 • The implementation of evidence-based guidelines coupled with proactive leadership can ensure the rapid response to initiatives responding to the opioid epidemic by increasing the use of adjuvant analgesics • Adjuvant pain-management therapies can adequately manage post- operative pain while reducing opioid use. • Further federal and society incentives focused on the use of adjuvant therapies for pain management are needed • Future policy should support study of adjuvant analgesic effects and encourage their use as standard of care

Acknowledgements 23 • Tina Hernandez-Boussard • Karishma Desai, Tina Seto • Steven M. Asch, Ian Carroll, Catherine Curtin, Kathryn McDonald • kchin7@stanford.edu

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Ketamine Trends 28

Pain Trends Over Time 29 • (have available figures on pre, post, and follow-up pain over time)