Growing Pains: Opportunity Knocks in the 2022 Center for Disease Control Clinical Practice Guidelines for Prescribing Opioids for Pain

Abstract

PERSISTENT POSTOPERATIVE PAIN in cardiac surgery, defined as pain lasting >3 months after surgery, is a significant and potentially devastating complication that impacts the lives of patients and taxes the healthcare system. Pain in this population has been shown to decrease health-related quality of life, and may ultimately lead to functional disability.1Krasowski JC Hallman MJ Smeltz AM Persistent pain after cardiac surgery: Prevention and management.Semin Cardiothorac Vasc Anesth. 2021; 25: 289-300Crossref Scopus (5) Google Scholar Occurring in nearly half of all cardiac surgical patients, the scope and impact of persistent postoperative pain are vastly underappreciated by the majority of cardiac anesthesiologists worldwide.2Guimaraes-Pereira L Farinha F Azevedo L et al.Persistent postoperative pain after cardiac surgery: Incidence, characterization, associated factors and its impact in quality of life.Eur J Pain. 2016; 2: 1433-1442Crossref Scopus (38) Google Scholar The typical anesthesiologist-patient interaction rarely lasts beyond the perioperative time frame, and so it makes perfect sense that chronic pain and outpatient opioid-prescribing habits occupy no more than the most distant back burner in the brains of cardiac anesthesiologists. Given this, the 2022 Centers for Disease Control (CDC) Clinical Practice Guideline for prescribing opioids for pain likely flew way under the radar of our specialty.3Dowell D Ragan KR Jones CM et al.CDC clinical practice guideline for prescribing opioids for pain – United States, 2022.MMWR Recomm Rep. 2022; 71: 1-95Crossref PubMed Scopus (26) Google Scholar However, closer inspection of this hefty tome may still reveal opportunities for improved perioperative cardiac surgical care and more equitable access to effective evidence-based treatments for acute surgical pain. Some areas of specific interest to the cardiac anesthesiologist are highlighted by the notable changes in the 2022 guidelines compared to the previous 2016 iteration.4Dowell D Haegerich TM Chou R CDC guideline for prescribing opioids for chronic pain – United States, 2016.MMWR Recomm Rep. 2016; 65: 1-49Crossref PubMed Scopus (2081) Google Scholar Set against the backdrop of the still-surging opioid epidemic, conservative and rigid interpretation of the 2016 CDC Clinical Practice Guideline reduced overall prescribing of opioids and increased the number of patients experiencing undertreated pain, rapid opioid tapers, acute withdrawal symptoms, and psychological distress.5Dowell D Haegerich TM Chou R No shortcuts to safer opioid prescribing.N Engl J Med. 2019; 380: 2285-2287Crossref PubMed Scopus (234) Google Scholar The 2022 update aimed to swing the pendulum back toward more responsible, flexible, and individualized opioid use for chronic pain. Importantly, the 2022 guidelines continued to encourage maximizing the use of nonopioid therapies, but also noted the important role of opioids in managing moderate-to-severe acute pain, such as that associated with major surgery. Although cardiac anesthesiologists may not be involved directly in prescribing opioids for patients at hospital discharge after cardiac surgery, the CDC guidelines highlight an ever-growing opportunity to examine the impact of our intraoperative pain management practices on long-term pain outcomes. Unsurprisingly, a significant percentage of cardiac surgical patients are prescribed opioids at discharge. A recent retrospective cohort study analyzing 35,817 cardiac surgical patients offered the best assessment of opioid prescribing patterns at discharge.6Brown CR Chen Z Khurshan F et al.Development of persistent opioid use after cardiac surgery.JAMA Cardiol. 2020; 5: 889-896Crossref PubMed Scopus (62) Google Scholar Among opioid-naïve cardiac surgical patients, 60.6% of patients undergoing coronary bypass artery graft surgery, and 53.7% of valve surgery patients, filled an opioid prescription within 14 days after the surgery. In addition, 1 in every 10 cardiac surgical patients developed new persistent opioid use, defined as opioid use 90-to-180 days after surgery. When patients were prescribed >300 oral morphine equivalents, the risk of persistent opioid use was significantly increased compared to lower opioid prescriptions. In addition, the likelihood of persistent opioid use was found to be higher in women; younger patients; and those with a history of congestive heart failure, chronic lung disease, diabetes, kidney failure, chronic pain, and preoperative benzodiazepine use. Though most preexisting characteristics predisposing patients to persistent opioid use are not modifiable, it does help to identify which patients may benefit from opioid-sparing protocols, such as enhanced recovery after cardiac surgery (ERACS). Though ERACS has been shown to reduce perioperative opioid use after cardiac surgery, the effect of ERACS on discharge prescriptions has not been studied.7Loria CM Zborek K Millward JB et al.Enhanced recovery after cardiac surgery protocol reduces perioperative opioid use.JTCVS Open. 2022; 12: 280-296Abstract Full Text Full Text PDF Scopus (2) Google Scholar One study, using enhanced recovery after surgery protocols in patients undergoing colorectal surgery, identified reduced postoperative opioid use but no change in discharge opioid-prescribing practices.8Brandal D Keller MS Lee C et al.Impact of enhanced recovery after surgery and opioid-free anesthesia on opioid prescriptions at discharge from the hospital: A historical-prospective study.Anesth Analg. 2017; 125: 1784-1792Crossref PubMed Scopus (128) Google Scholar Given cardiac surgical patients spend several days in the hospital and tolerate lower opioid doses under ERACS to discharge, it is plausible that lower opioid doses would be tolerated similarly after discharge. Increased adoption of ERACS and changes in discharge prescription practices to include lower doses of opioids and greater use of acetaminophen and nonsteroidal antiinflammatory drugs when appropriate may result in a decrease in persistent opioid use and dependence in cardiac surgical patients.9Desai K Carroll I Asch SM et al.Utilization and effectiveness of multimodal discharge analgesia for postoperative pain management.J Surg Res. 2018; 228: 160-169Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar Following a similar story arc to ERACS, the intraoperative use of methadone in both pediatric and adult cardiac surgical patients has been demonstrated to reduce postoperative pain and decrease short-term morphine and fentanyl consumption, but its impact on opioid prescribing and persistent opioid use remains unknown.10Lobova VA Roll JM Roll MLC Intraoperative methadone use in cardiac surgery: A systematic review.Pain Med. 2021; 22: 2827-2834Crossref Scopus (3) Google Scholar,11Barnett AM Machovec KA Ames WA et al.The effect of intraoperative methadone during pediatric cardiac surgery on postoperative opioid requirement.Pediatr Anaesth. 2020; 30: 773-779Crossref PubMed Scopus (10) Google Scholar In a secondary analysis of a previously completed randomized controlled trial, intraoperative methadone use in cardiac surgery was associated with reduced subjective pain scores at 1 month; however, the number of patients enrolled in the trial was too small to comment on any differences in persistent opioid use.12Murphy GS Avram MJ Greenberg SB et al.Postoperative pain and analgesic requirements in the first year after intraoperative methadone for complex spine and cardiac surgery.Anesthesiology. 2020; 132: 330-342Crossref PubMed Scopus (29) Google Scholar Multimodal opioid-sparing pain management techniques in cardiac surgery that include regional anesthesia are also viable and attractive options that promote enhanced patient recovery and minimize opioid exposure.13Beverly A Kaye AD Ljungqvist O et al.Essential elements of multimodal analgesia in enhanced recovery after surgery (ERAS) guidelines.Anesthesiol Clin. 2017; 35: e115-e143Abstract Full Text Full Text PDF PubMed Scopus (201) Google Scholar Fascial plane blocks offer a safer alternative to neuraxial anesthesia during cardiac surgery, as there is a lower risk of hemodynamic instability and bleeding complications due to systemic anticoagulation.14Devarajan J Balasubramanian S Nazarnia S et al.Regional analgesia for cardiac surgery part 1. Current status of neuraxial and paravertebral blocks for adult cardiac surgery.Semin Cardiothorac Vasc Anesth. 2021; 25: 252-264Crossref PubMed Scopus (8) Google Scholar There are several fascial plane blocks that have been used effectively in cardiac surgery, including parasternal intercostal plane, interpectoral plane, pectoserratus plane, serratus anterior plane, and erector spinae plane blocks.15Hargrave J Grant MC Kolarczyk L et al.An expert review of chest wall fascial plane blocks for cardiac surgery.J Cardiothorac Vasc Anesth. 2023; 37: 279-290Abstract Full Text Full Text PDF Scopus (1) Google Scholar The type and laterality (unilateral versus bilateral) of fascial plane block depends upon the surgical approach (Table 1). Improved pain control can be obtained by combining different types of fascial plane blocks.16Gawęda B Borys M Belina B et al.Postoperative pain treatment with erector spinae plane block and pectoralis nerve blocks in patients undergoing mitral/tricuspid valve repair - a randomized controlled trial.BMC Anesthesiol. 2020; 20: 51Crossref PubMed Scopus (23) Google Scholar,17Torre DE Pirri C Contristano M et al.Ultrasound-guided PECS II + serratus plane fascial blocks are associated with reduced opioid consumption and lengths of stay for minimally invasive cardiac surgery: An observational retrospective study.Life (Basel). 2022; 12: 805PubMed Google Scholar Single-shot or continuous infusions of local anesthetics are both effective delivery methods in cardiac surgical patients. There are no consensus dosing guidelines for the different blocks, and various local anesthetics with and without adjuvants have been employed.Table 1Potential Cardiac Surgical Approaches and Suggested Regional Anesthetic Techniques With Required Laterality.Cardiac Surgical ApproachesFascial Plane BlocksLateralityFull and partial sternotomyPIP, IPP, SAP, ESPB (fascial plane blocks may be combined)BilateralThoracotomy (lateral or anterolateral)SAPB, ESPB (fascial plane blocks may be combined)UnilateralRobotic-assisted minimally invasive via portsIPP, SAP, ESPB (fascial plane blocks may be combined)UnilateralAbbreviations: ESPB, erector spinae plane block; IPP, interpectoral plane; PIP, parasternal intercostal plane; PSP, pectoserratus plane; PVB, paravertebral block; SAP, serratus anterior plane. Open table in a new tab Abbreviations: ESPB, erector spinae plane block; IPP, interpectoral plane; PIP, parasternal intercostal plane; PSP, pectoserratus plane; PVB, paravertebral block; SAP, serratus anterior plane. In multiple studies, patients reported lower postoperative pain scores, and total opioid consumption was reduced in the regional anesthesia group compared to the standard of care.18King M Stambulic T Hassan SMA et al.Median sternotomy pain after cardiac surgery: To block, or not? A systematic review and meta-analysis.J Card Surg. 2022; 37: 3729-3742Crossref PubMed Scopus (4) Google Scholar,19Kelava M Alfirevic A Bustamante S et al.Regional anesthesia in cardiac surgery: An overview of fascial plane chest wall blocks.Anesth Analg. 2020; 131: 127-135Crossref PubMed Scopus (67) Google Scholar Most clinical studies have evaluated postoperative opioid consumption or pain scores within the first 24-to-72 hours, but only have scratched the surface of these metrics after hospital discharge.20Devarajan J Balasubramanian S Shariat AN et al.Regional analgesia for cardiac surgery. Part 2: Peripheral regional analgesia for cardiac surgery.Semin Cardiothorac Vasc Anesth. 2021; 25: 265-279Crossref PubMed Scopus (8) Google Scholar One month after surgery, Macaire et al. did find lower pain at rest in the group of patients receiving continuous erector spinae plane blocks.21Macaire P Ho N Nguyen V et al.Bilateral ultrasound-guided thoracic erector spinae plane blocks using a programmed intermittent bolus improve opioid-sparing postoperative analgesia in pediatric patients after open cardiac surgery: A randomized, double-blind, placebo-controlled trial.Reg Anesth Pain Med. 2020; 45: 805-812Crossref PubMed Scopus (26) Google Scholar In addition to pain score and opioid consumption, fascial plane blocks have been shown to improve other metrics such as shorter time to extubation, earlier first oral intake, faster ambulation, and decreased intensive care unit length of stay.15Hargrave J Grant MC Kolarczyk L et al.An expert review of chest wall fascial plane blocks for cardiac surgery.J Cardiothorac Vasc Anesth. 2023; 37: 279-290Abstract Full Text Full Text PDF Scopus (1) Google Scholar To date, no study has demonstrated that the addition of regional anesthesia to a multimodal analgesic plan has altered opioid-prescribing habits at discharge or persistent opioid use in cardiac surgical patients. One additional inclusion in the 2022 CDC guideline that is highly relevant to cardiac surgery was the emphasis on persistent disparities in pain management according to race or ethnic group, gender, socioeconomic status, and population density.3Dowell D Ragan KR Jones CM et al.CDC clinical practice guideline for prescribing opioids for pain – United States, 2022.MMWR Recomm Rep. 2022; 71: 1-95Crossref PubMed Scopus (26) Google Scholar Black patients are less likely than White patients to receive analgesia for acute pain. A recent study by Morden et al. examined Medicare data for patients receiving opiates in 2016 and 2017. Black patients received a 36% fewer morphine milligram equivalent dose of opiates than White patients.22Morden NE Chyn D Wood A et al.Racial inequality in prescription opioid receipt – role of individual health systems.N Engl J Med. 2021; 385: 342-351Crossref PubMed Scopus (39) Google Scholar This disparity did not result from a difference in underlying comorbid conditions or healthcare systems. A study by Brescia et al. demonstrated that the amount of opiate prescribed and the timing of opiate prescription were strong predictors of persistent opioid use after cardiac surgery.23Brescia AA Waljee JF Hu HM et al.Impact of prescribing on new persistent opioid use after cardiothoracic surgery.Ann Thorac Surg. 2019; 108: 1107-1113Abstract Full Text Full Text PDF PubMed Scopus (56) Google Scholar However, Black race and female sex were also independent predictors of persistent opiate use after cardiac surgery. This must be placed in the context of the overall body of literature that supports that Black patients receive fewer opiates than White patients across a variety of medical and surgical environments. Do Black patients have persistent opiate use due to inadequate pain treatment within the first 3 months after surgery because they are prescribed a smaller amount of opiates? Anesthesiologists have to be able to synthesize these studies to help multidisciplinary teams manage postoperative pain in an equitable and evidence-based fashion. It seems natural to install opiate protocols for postoperative cardiac surgical patients; however, there is much variability in patient opiate needs. When it comes to racial disparities and opiates after cardiac surgery, there is simply not enough data to make informed decisions. Issues related to access to care, geographic disparities, and early restrictive refills might contribute to the disparity in opiate prescribing. One of the guiding principles of the new CDC document is vigilance to monitor healthcare inequalities. Although eliminating healthcare inequalities for opiates is a formidable task, we can use some of the tenets of the guidelines to help start this process. The CDC recommended that opiate-naïve patients should receive the lowest possible dose (5-10 morphine milligram equivalent per dose) in an immediate-release formulation, and opiates should be prescribed as needed instead of scheduled. In addition, they stressed that the timely reassessment of pain in the acute setting is critical to assess the efficacy of prescribed opiates. The CDC guideline reminds us of best practices for opiate prescribing in which specific data regarding healthcare disparities in cardiac surgery are lacking. Hopefully, a reminder of simple prescribing principles and early reevaluation may decrease the disparity in opiate prescriptions and decrease persistent opiate use. The modern approach to the treatment of acute pain looks as different today as modern cardiac surgery does from its beginnings in the midtwentieth century. Continued change is certainly on the horizon as more minimally-invasive approaches to old cardiovascular pathology become the gold standard. The human experience of pain and the life-altering impact of chronic pain, however, remain unchanged. Both ERACS and regional anesthesia are just 2 examples of how a multimodal and multidisciplinary approach to pain management in cardiac surgery has benefitted patients. Subjective pain scores and perioperative opioid consumption can be reduced through these techniques, but there is still a sizeable gap to close to see these benefits carried forward to persistent opioid use and chronic pain. The new CDC guidelines ask us to recognize the magnitude of the problem, both pain and chronic opioid dependence, and to choose equitable, evidence-based, and individualized treatments for our patients whenever possible. These guidelines can either be viewed as an unwieldy document meant for physicians in other specialties or as a golden opportunity to reexamine our role in solving a public health crisis. None.