Johns Hopkins Perioperative Pain Program
The Opioid Epidemic: Background
The use of opioid analgesics for pain management has increased drastically over the past two decades. Since 1999, opioid prescribing has quadrupled, and the number of overdoses and deaths has risen in parallel.1,2,3 According to the National Center for Health Statistics, in 2018, approximately 168 million individuals in the United States were prescribed an opioid and more than 46,802 deaths were attributed to an opioid-related overdose.4 Moreover, the economic cost of opioid-related overdose, abuse, and dependence is exorbitant, exceeding $78 billion annually.1,5 This is a nationwide public health crisis and, as such, warrants a coordinated response that encompasses the entire health care sector.
Perioperative Pain Program at The Johns Hopkins Hospital: An Overview
At the Johns Hopkins Hospital, the Perioperative Pain Program (PPP) was developed as an institutional response to the opioid crisis. Historically, the Johns Hopkins Acute Pain Service had been involved only in inpatient care in the immediate postoperative period. The organization recognized an opportunity to provide more thorough and multifaceted care for surgical patients on chronic opioid therapy (COT) by helping with opioid tapering from the preoperative phase, tailoring anesthetic plans to incorporate multimodal nonopioid interventions, and providing long-term postoperative follow-up.
The perioperative period is an ideal time to educate patients and discuss realistic postoperative pain expectations...
We aim to address the growing difficulty of managing the acute surgical pain of patients on COT, which is essential given that preoperative opioid use has been linked with higher immediate opioid requirements, longer postoperative opioid use, and greater disability after various surgeries.6,7 Additionally, we aim to initiate an opioid tapering plan for patients on COT, with the goal of reducing opioid consumption by 10%-25% before surgery, while maintaining effective pain management by incorporating multimodal analgesia.8 The purpose of this design is to minimize opioid use and avoid the over-prescribing of opioids in an effort to effectively address perioperative pain issues and to promote the quality of postoperative recovery.
Perioperative Pain Program Team at The Johns Hopkins Hospital
This program represents a comprehensive transitional care model, where the same group of pain specialists cares for each patient from the preoperative outpatient setting, through the acute pain period and into the postoperative setting. This model provides the framework for preventing opioid overdose and misuse, with the goal of monitoring and addressing prescription opioid-related adverse events for surgical patients. It has a multidisciplinary structure, and can serve as a template that other health care organizations may adopt with local modifications.
Our mission is to provide coordinated perioperative pain management and to mitigate excessive opioid prescribing.8 We find that the perioperative period is an ideal time to educate patients and discuss realistic postoperative pain expectations. This innovative model addresses aspects of pain management and opioid utilization during the preoperative evaluation, acute perioperative hospitalization, and postoperative follow-up for individuals on COT.
We recognize the importance of clinicians in helping patients with chronic pain set realistic goals and expectations about their pain during the perioperative period. Furthermore, it is essential to optimize each patient’s multimodal analgesic regimen to include a combination, if possible, of acetaminophen, nonsteroidal anti-inflammatory agents, anticonvulsants, neuromodulators, ketamine, muscle relaxants, and local anesthetics via topical application, peripheral nerve injections, or catheters to help manage daily opioid requirements while also optimizing functional status.8 In some cases, a multimodal approach may include psychotherapy, physical medicine and rehabilitation, and integrative medicine techniques.
Integration of care using a transitional-care model
Improving the quality of recovery in the perioperative period requires the integration of care from multidisciplinary teams. These teams consist of acute and chronic pain specialists, psychiatrists, integrative medicine specialists, and physical medicine and rehabilitation providers. Acute pain specialists can tailor the particular anesthetic plan for a surgical patient by incorporating regional anesthesia techniques to minimize opioid use and encourage multimodal analgesia, while chronic pain specialists can help manage these patients using nonopioid and opioid analgesics, thus providing a continuum of care.
Chronic postsurgical pain, which contributes to chronic opioid use, is a common complication after surgery and can include psychological, behavioral, and social factors.8,9 In our clinic, we provide physical medicine and rehabilitation consults to patients who would benefit from it, with the goal of improving postoperative functional recovery, which is a key component of perioperative pain management. Integrative medicine is a component of this program as it offers a range of potentially beneficial nonpharmacological therapies such as acupuncture, hypnosis, and music therapy, which may play a role in reducing postsurgical opioid consumption and side effects. 8,10
This pain program also offers psychiatric services. Pain and depression often coexist, and may represent a risk for prolonged postoperative hospitalization.8 Psychiatric conditions such as mood disorders, anxiety disorders, and substance use disorders (SUD) are associated with long-term opioid use. Comprehensive pain management incorporating both pharmacological and psychological therapies may help improve recovery in the postoperative period.
The PPP at Johns Hopkins has developed a novel infrastructure for triage, pain management education, and treatment. We develop individualized patient plans to include preoperative opioid tapering, regional anesthesia techniques perioperatively to minimize opioid use, and a multimodal analgesic regimen to buttress postoperative opioid tapers.8
Postoperative period follow-up
Each patient enrolled in the PPP is evaluated within 1-2 weeks of discharge and is subsequently followed every 3-4 weeks over a 6-month postoperative time period. These follow-up visits focus on a rehabilitative recovery, are tailored to each patient, and use both pharmacologic and nonpharmacologic approaches. Additionally, patients on opioid maintenance therapy may be referred to intensive outpatient SUD programs if indicated.8
To determine the effectiveness of the PPP and to allow for improvements in the necessary areas, we collected and analyzed data on clinical outcomes throughout the postoperative period. Primary endpoints included adverse opioid-related events such as respiratory depression, ileus, vomiting, length of stay, postoperative inpatient opioid utilization, and hospital readmission due to pain.6 Additionally, at each visit, we gather information on patient-reported outcomes in regard to pain severity, daily functioning, pain-related disability, symptoms of depression, anxiety, insomnia, and overall satisfaction via self-report questionnaires.
In an outcome study using patient-reported outcomes from the first 9 months of the PPP, results reflected a significant reduction in morphine milligram equivalent, improved pain scores, and improved function for surgical patients on COT. Collectively, patients in the clinic reduced opioid usage without negatively influencing their physical pain and quality of life.6
This perioperative pain program engages both patients and their families. Patient testimonials from the PPP during recorded interviews are the following: 11
- Patient reports: "I never thought I would be on much less opioids, physically active and enjoying life."
- Patient who had been taking opioids for 7 years reports: “With their help, I now am on no narcotics.”
- Patient who used to be on the fentanyl patch and was told she would not be able to come off of it reports: “My life has changed, my family has noticed it. I cannot believe after 10 years of using narcotics, I am now on no narcotics.”
Perioperative pain management strategies to date have largely been uncoordinated and significantly reliant on opioid escalation.8 The PPP at Johns Hopkins provides comprehensive coordinated care to patients on COT. The multidisciplinary team utilizes multimodal pain approaches to effectively provide thoroughly coordinated perioperative pain management for chronic pain patients throughout the perioperative period.
Marie Hanna, MD, MEHP, is an associate professor of Anesthesiology and Critical Care Medicine and chief of the division of Regional Anesthesia and Acute Pain Management at The Johns Hopkins Hospital in Baltimore, MD.
Mariam Javed, MD, is a Regional Anesthesiology and Acute Pain Medicine fellow at The Johns Hopkins Hospital.
Traci Speed, MD, PhD, is an assistant professor of Psychiatry and Behavioral Sciences at The Johns Hopkins Hospital.
Ronen Shechter, MD, PHD, is an assistant professor of Anesthesiology and Critical Care Medicine at The Johns Hopkins Hospital.
Kayode Williams, MD, MBBS, is an associate professor of Anesthesiology and Critical Care Medicine at The Johns Hopkins Hospital.
- Hanna MN, Chambers C, Punyala A, et al. A model for an institutional response to the opioid crisis. J Opioid Manage. 2020;16:73-83.
- Han B, Compton WM, Blanco C, et al. Prescription opioid use, misuse, and use disorders in U.S. Adults: 2015 national survey on drug use and health. Ann Intern Med. 2017; 167(5): 293-301.
- Bruehl S, Apkarian AV, Ballantyne JC, et al. Personalized medicine and opioid analgesic prescribing for chronic pain: Opportunities and challenges. J Pain. 2013;14(2):103-13.
- Hedegaard H, Miniño AM, Warner M. Drug Overdose Deaths in the United States, 1999–2018. NCHS Data Brief, no 356. Hyattsville, MD: National Center for Health Statistics. 2020. Available at: https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf
- Florence CS, Zhou C, Luo F, et al. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Med Care. 2016;54(10): 901-6.
- Shechter R, Speed TJ, Blume E, et al. Addressing the opioid crisis one surgical patient at a time: outcomes of a novel perioperative pain program. Am J Med Quality. 2020;35(1):5-15.
- Waljee, JF, Zhong, L, Hou, H, Sears, E, Brummett, C, Chung, KC. The use of opioid analgesics following common upper extremity surgical procedures: a national, population-based study. Plast Reconstr Surg. 2016;137:355e-364e.
- Hanna MN, Speed TJ, Shechter R, et al. An innovative perioperative pain program for chronic opioid users: an academic medical center’s response to the opioid crisis. Am J Med Quality. 2018; 34(1):5-13.
- Brummett CM, Waljee JF, Goesling J, et al. New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 2017;152:e170504.
- Franklin GM, Rahman EA, Turner JA, Daniell WE, Fulton- Kehoe D. Opioid use for chronic low back pain: a prospective, population-based study among injured workers in Washington state, 2002-2005. Clin J Pain. 2009;25:743-51.
- Johns Hopkins Medicine. Perioperative Pain Clinic. 12 Feb 2018. Available at: https://youtu.be/azmZ_6setcY.