Managing Patients in the Opioid Crisis Era: Insights From the Front Lines (Podcast)

As a large health system in a state on the front lines of the opioid crisis, Cleveland Clinic has had plenty of experience managing opiate use disorder. One of the latest episodes of its new “Neuro Pathways” podcast for healthcare professionals taps the expertise of a provider at the heart of that experience — psychiatrist David Streem, MD, who serves as Medical Director of Cleveland Clinic’s Alcohol and Drug Recovery Center.

In the 21-minute episode, podcast host Alex Rae-Grant, MD, explores with Dr. Streem a range of topics relating to opioid prescribing and overdose prevention, including:

• The advantages of recognizing that overcoming opiate use disorder is typically an individualized journey in which patients need to go through treatment five times, on average
• Strategies Cleveland Clinic uses to mitigate opiate misuse among its huge population of surgical patients, including those with prior opiate use disorder
• Non-opiate approaches to managing chronic headache
• How to keep up with the latest state regulations around opioids

Click on the player below to listen to the podcast now; a short sample of the discussion is excerpted in transcript form below. You can check out more “Neuro Pathways” episodes at clevelandclinic.org/neuropodcast or wherever you get your podcasts.

Excerpt from the podcast

Dr. Rae-Grant: Can you share some specific opiate-related recommendations we now give to surgeons at Cleveland Clinic and how they have changed over time?

Dr. Streem: Probably the biggest change is how we handle buprenorphine for surgery patients who have already been diagnosed with opiate use disorder. Buprenorphine is an opiate that’s prescribed for the office-based treatment of opiate dependence. As such, it should be considered as we develop a perioperative management plan. So when buprenorphine first became available for this purpose, the original recommendations from the federal Substance Abuse and Mental Health Services Administration and others were to taper people off buprenorphine before surgery, use full opiate agonists during the surgery and postoperative period, and restart buprenorphine when the need for perioperative opiate analgesia was over.

We have since found that this is not the best approach. In most circumstances we are now continuing buprenorphine throughout the perioperative period. A number of new guidelines have come out showing that the outcomes of doing this are actually excellent. This approach also reduces the risk of relapse before the operation takes place. As a result, patients are safer and more comfortable, they actually get better analgesia, and they have a better patient experience. For us, that’s what it’s all about. It took some time to help the organization understand this change in approach, but now we can expect a very good outcome in this regard for most surgeries.