Tragedy Impetus for Perioperative Anesthetic Program for Recovering Addicts

Max Baker would have been 24 years old on his next birthday, and likely a budding medical school student with aspirations of helping young people with opioid addiction. But Max never lived to see that day.

Instead, Max was the victim of a long-time opioid addiction that, while under control, proved deadly following preoperative administration of fentanyl after a car accident.

Yet if Max’s father, James L. Baker, MD, MPH, and Joseph Myers, MD, have their way, tragedies like Max’s might never happen again, the result of Dr. Baker’s Maxwell F. Baker Foundation for Addiction Recovery and Dr. Myers’s ComfortCare recovery maintenance program.

Addiction, Recovery and Then a Fateful Accident

Maxwell F. Baker fell into drug addiction at a young age; by 17 he was addicted to heroin. With the help of pharmacotherapy and the support of his family, however, he was sober a few years later, a college student determined to become a physician so he could help people with struggles like his own. “But late one evening over Thanksgiving weekend, a young girl pulled in front of him while he was driving home and he got into a car accident,” said Dr. Baker, who serves as director of the foundation that bears his son’s name.

Although Max was injured, he refused opioids for pain treatment, keenly aware of his addiction history. But when the time came for Max to have hand surgery for an injury secondary to the accident, he was administered IV fentanyl. That’s when everything changed.

“When he came out of the OR, his eyes were glazed over and he was fuzzy, struggling to speak,” Dr. Baker told Anesthesiology News. “And he said to me, ‘Dad, I need drugs.’ Starting that day, he relapsed. And within a month, he was dead.”

Analgesic Choices for Recovering Addicts

Enter ComfortCare, a perioperative recovery maintenance program that takes a proactive approach to providing perioperative anesthetic care to recovering addicts. The program—the brainchild of Dr. Myers, associate professor of anesthesiology at MedStar Georgetown University Hospital, in Washington, D.C.—is built around a pyramid of analgesic choices that considers a patient’s history of addiction and avoids opioids whenever possible (Figure).

Based on risk–benefit ratios, the analgesic choices near the base of the ComfortSafe Pyramid have the fewest side effects and first consider patients who have reduced sensation, who may not require analgesics at all. The pyramid’s next level is wound infiltration with local anesthetics, such as bupivacaine or liposomal bupivacaine (Exparel, Pacira). Nonopioid analgesics, such as acetaminophen and ketorolac, represent the next level of analgesia, followed by IV infusions of such agents as lidocaine or ketamine. Finally, at the top, opioids are the last resort and are given only when the other analgesic levels prove inadequate.

While the pyramid may be at the center of the ComfortCare program, its focus is always on the patient. “We guide the patients through the perioperative surgical home until they are discharged,” Dr. Myers said. “We initiate a multimodal, nonopioid regimen before and during anesthesia, allowing our patients to awaken …, and then we see if they need opioids. That’s one of the key things; we’re not going to leave our patients in pain if they need opioids. Before discharge, we discuss the analgesic plan with the patient and a supportive caregiver who knows the patient’s story. Finally, we follow the patient until they’ve disposed of all opioids and are in an opioid-free environment.”

Indeed, the ComfortCare program views patient care through a holistic lens, considering each of the following steps as equally important in the patient’s care plan:

• preoperative screening;
• patient education;
• options for care;
• anesthetic plan;
• preoperative planning;
• recommendations to surgical service;
• operating room care;
• PACU strategies;
• discharge team meeting; and
• home follow-up.

“When we take a patient through the pathway, we start at the perioperative screening, where we ask them questions about their history with opioid dependence,” said Jung Kim, MD, a resident at MedStar. “Then we put it all together, where we come up with a comprehensive anesthetic care plan that we all agree to.”

For Dr. Myers, this kind of patient-centered approach lies at the heart of both the perioperative surgical home and ComfortCare. “We go through everything with the patient and let them decide what they want, from the music in the operating room to pain relief,” he said.

Although establishing such a program takes time, energy and commitment, all three practitioners believe it is well worth the effort. “Assuring that the principles of the perioperative surgical home are adhered to is a challenge,” Dr. Myers said. “But it’s best orchestrated by an anesthesiologist.”

“Initially, when you have a lot of moving parts, it can be difficult to orchestrate so that it flows smoothly,” Dr. Kim said. “But once we turn it into a habit, it becomes second nature. In the current climate of [the] opioid epidemic, it’s a much broader issue and one with potentially grave consequences. So maybe it takes a little more time, but we’re doing right by the patient.”

Dr. Baker agreed with this assessment. “I really believe that what Dr. Myers and his colleagues are doing will set a new standard for how anesthesia is delivered, while saving lives along the way. Had this program been around and our anesthesiologists known about it not too long ago, my son might still be here today. So I am a powerful believer in how important it is, because I live every day with the consequences of losing my son.”