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If you’ve taken opiates for more than 5 days, your body is already dependent on them quitting them requires a medical detox, not just a taper protocol.

INFORMATION FOR SURGEONS

Your patient must be on a reduced dose before surgery

Surgical providers often need to reduce a patient's opioid use prior to surgery. Many surgeries are postponed indefinitely because the patient cannot reduce use prior to surgery on their own. This leaves the patient in a place where they are unable to take the next steps in their treatment and leaving them on perpetual opioid pain management.

 

RMD can partner and work closely with the surgical team.

By coordinating care RMD can detox the patient down to zero or very low dose opioids up to 1-2 days prior to surgery, depending on the treatment goals.

 

Your patient is nervous to take opioids after surgery OR  Your patient is having trouble stopping opioids after injury or surgery

Providers create treatment plans to assist patients with chronic pain and recovery from injury or surgery, but how much attention is placed on the taper or detox from opioids in the treatment plan?

Offering a detox service to patients who are having difficulty tapering off opioids is not only a way to expand your treatment plan, but it also can reduce your liability as well.

 

 

Detoxification: Usually used to refer to a process of
withdrawing a person from a specific psychoactive substance in
a safe and effective manner. The term actually encompasses safe management of intoxication states (more literally, ‘‘detoxification’’) and of withdrawal states. Source

 

DETOX PRE-SURGERY

Frequently when a patient is in chronic pain, their MME is too high for surgery and/or to handle breakthrough pain. Detoxing the patient off opioids or to a lower dose can sometimes be medically necessary and beneficial to improve outcomes.

Effect of Preoperative Opioid Use on Adverse Outcomes, Medical Spending, and Persistent Opioid Use Following Elective Total Joint Arthroplasty in the United States

Between 17% and 40% of patients undergoing elective arthroplasty are preoperative opioid users.

Among 34,792 patients (38% hip, 58% knee, 4% shoulder), 6,043 (17.4%) were preoperative opioid users with a median morphine equivalent daily dose of 32 mg. Preoperative opioid users had increased length of stay (IRR = 1.03, 95% CI = 1.02 to 1.05), nonhome discharge (OR = 1.10, 95% CI = 1.00 to 1.21), and 30-day unplanned readmission (OR = 1.43, 95% CI = 1.17 to 1.74); experienced 35% higher surgical site infection (HR = 1.35, 95% CI = 1.14 to 1.59) and 44% higher surgical revision (HR = 1.44, 95% CI = 1.21 to 1.71); had a median $1,084 (95% CI = $833 to $1334) increase in medical spend during the 365 days after discharge; and had a 64% lower rate of opioid cessation (HR = 0.34, 95% CI = 0.33 to 0.35) compared with patients not filling two or more prescriptions across periods.

Preoperative opioid users had longer length of stay, increased revision rates, higher spend, and persistent opioid use, which worsened with dose. Adverse outcomes after elective joint replacement may be reduced if preoperative opioid risk is managed through increased monitoring or opioid cessation. Source

Preoperative Chronic Opioid Therapy
A Risk Factor for Complications, Readmission, Continued Opioid Use and Increased Costs After One- and Two-Level Posterior Lumbar Fusion -  Source

 

DETOX POST-SURGERY

Chronic postoperative opioid use is a growing problem. It is up to surgeons and doctors to help recommend safe protocols to encourage patients to taper or stop in a timely manner.

A recent review found that 67%–92% of surgical patients reported having unused opioids in their possession. Source

84% of opioid users report obtaining their drug supply from a friend or relative who was prescribed opioids by their physician. Source

In light of the opioid epidemic in the United States, anesthesiologists are uniquely positioned to play a role in reducing opioid use for surgical patients, for whom opioids continue to be first-line analgesic agents and nonopioid medications are inconsistently prescribed.1,2 Crucially, several studies suggest that surgery is associated with an increased risk of long-term opioid use, a phenomenon known as persistent postoperative opioid use.3,4 As such, efforts to reduce the risk of persistent postoperative opioid use can have a direct effect on opioid use at the population level. In addition, decreasing the risk of persistent postoperative opioid use could also have indirect benefits in reducing population level opioid use by reducing the incidence of diversion, particularly in light of studies suggesting a substantial amount of opioid overprescription and large amounts of unused pills among patients undergoing surgery.5–7

CONCLUSIONS
• For opioid-naïve patients, persistent postoperative opioid use should be defined as having filled a 60 days’ supply of opioid during postoperative days 90–365. For patients who used opioids before surgery, persistent postoperative opioid use should be defined as any increase in opioid use above baseline during this time period.
• The incidence of persistent postoperative opioid use ranges from 0.6% to 26% for opioid-naïve patients and from 35% to 77% for patients with previous opioid exposure.
• Patient characteristics associated with an increased risk of persistent postoperative opioid use included preoperative opioid use, depression, substance use disorder, preoperative pain conditions, and smoking. Source

Persistent postoperative opioid use contributes to the opioid use epidemic, and it is critical for anesthesiologists and surgeons to recognize our contribution to this ongoing public health issue. Source

Persistent Opioid Use Following Total Knee Arthroplasty: A Signal for Close Surveillance: A total of 24,105 patients were studied. After the initial 90-day postoperative period, 41.5% (N = 9914) continued to use opioids. Also, 155 (0.6%) revisions occurred within 1 year and 377 (1.6%) within 5 years. Compared to patients not taking any opioids, patients using medium-low to high OME after the initial 90-day period had a higher adjusted risk of 1-year revision, ranging from HR = 2.4 (95% confidence interval, 1.3-4.5) to HR = 33 (95% confidence interval, 10-110) depending on the OME and time period. Source

An Opioid Prescription for Men Undergoing Minor Urologic Surgery Is Associated with an Increased Risk of New Persistent Opioid Use: Prescription of opioids after low acuity urology procedures is significantly associated with increased opioid use at 1 yr after surgery; efforts should be made to reduce postoperative opioids, especially for urologic procedures that do not typically require opioids. Source

Risk factors for postoperative opioid use after elective shoulder arthroplasty: Included were 4243 SAs from 3996 patients, and 75% used opioids in the 1-year preoperative period. The factors associated with increased opioid use in all postoperative quarters (Q4 incident rate ratio [IRR] shown) were age <60 years (IRR, 1.40; 95% confidence interval [CI], 1.29-1.51), preoperative opioid use (1-4 Rxs: IRR, 2.15; 95% CI, 1.85-2.51; ≥5 Rxs: IRR, 9.83; 95% CI , 8.53-11.32), anxiety (IRR, 1.11; 95% CI, 1.03-1.20), opioid dependence (IRR, 1.23; 95% CI, 1.05-1.43), substance abuse (IRR, 1.17; 95% CI, 1.07-1.28), and general chronic pain (IRR, 1.38; 95% CI, 1.28-1.50). Opioid usage in patients undergoing SA is widespread at 1 year, with three-fourths of patients having been dispensed at least one Rx. These findings emphasize the need for surgeon and patient awareness as well as education in the management of postoperative opioid usage associated with the indicated conditions. Surgeons may consider these risk factors for preoperative risk stratification and targeted deployment of preventative strategies. Source

Patient Factors Associated With Prolonged Postoperative Opioid Use After Total Knee Arthroplasty: Avoidance or weaning of preoperative opioids should be considered. Source

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