Implementation of a Novel Johns Hopkins Perioperative Pain Program: An Integrated Care Model

From the 2018 HVPAA National Conference

Traci Speed (Johns Hopkins School of Medicine), Ronen Shechter (Johns Hopkins School of Medicine), Grace Huckenpoehler (Loyola University Maryland), Irini Hanna (University of Maryland), Nikia Smith (Johns Hopkins School of Medicine), Elizabeth Goldberg (Johns Hopkins School of Medicine), Angela Llufrio (Johns Hopkins School of Medicine), Kayode Williams (Johns Hopkins School of Medicine), Marie Hanna (Johns Hopkins School of Medicine)

Background

Increased use of prescription opioids for chronic pain has led to alarming rates of addiction and opioid related deaths in the United States. Opioid prescriptions in the post-operative period contribute to this epidemic.

Objectives

The Perioperative Pain Program (PPP) utilizes multimodal pain approaches within an integrated healthcare model to improve patient-centered pain outcomes and decrease opioid utilization along a continuum of three defined stages: 1.preoperative, 2.postoperative hospitalization and 3.post-discharge. PPP clinic consists of anesthesiologists who specialize in acute and chronic pain, psychiatrists and addiction medicine specialists with referrals to physical medicine and rehabilitation, integrative medicine specialists and intensive outpatient substance use programs, if needed. This pilot study aims to investigate the feasibility of implementing a novel perioperative clinical care pathway within a quaternary academic center.

Methods

PPP evaluates perioperative patients who are chronic opioid users, on opioid maintenance therapy, or are at high risk of developing persistent opioid use postoperatively. Primary outcomes include morphine milligram equivalent doses (MME), pain severity, physical and mental health functioning, and symptoms of insomnia using the Brief Pain Inventory (BPI), Short Form Health Survey (SF-12), and Insomnia Severity Index (ISI), respectively.

Results

From November 2017 through February 2018, PPP has collected patient-reported outcomes on N = 65 new patients (42% Caucasian, 56% female, 46% unemployed/disabled).  Specialists in orthopedics, general surgery, colorectal surgery, plastic surgery, otolaryngology, oncology, in addition to primary care and anesthesia have made referrals.  The majority of patients are referred post-operatively, however one-third (N = 21) had an initial PPP consult pre-operatively.  The majority of initial consults (88%) used opioids in the month prior to initial visit and 10% are on opioid maintenance therapy (e.g., methadone or buprenorphine).  Twenty-six percent of initial consults are current smokers. At initial visit, PPP patients report using MME of 190.5mg + 456mg.  They also report moderate-to-severe pain severity (6.5 + 2.4) and pain interference (6.4 + 2.3), poor physical health (29.2 + 8.1) and mental health (44.7 + 12.7) and clinically meaningful symptoms of insomnia (14.0 + 7.4).  All patients who continue in PPP sign an opioid agreement and receive random urine toxicology screens.  The psychiatrist located in the PPP clinic evaluates approximately 25% of initial consults.

Conclusion

We have successfully implemented a novel integrated pain management program for chronic opioid users or opioid-naïve patients at risk of developing opioid misuse that provides multimodal pain approaches and delivers continuity of care throughout the perioperative period.

Implications for the Patient

Opioid prescriptions in the perioperative period have contributed to the opioid epidemic. Patients are willing to receive treatment throughout the perioperative period in a pain management program that aims to improve patients’ functional status while safely and effectively weaning opioids.