Welcome, everyone, we're just going to wait just about one minute here and then we will start. Just let everybody get into the presentation here. Okay, while we're getting ready to start, I just want to do a little bit of housekeeping here. One of the things is that after this presentation, if you were present for it, you will be sent an evaluation. Once you complete the evaluation, you will be sent a continuing education certificate. So, but you must complete the evaluation first. You won't get the certificate without the evaluation. And then second of all, we are going to be holding all of the questions until the end. There is a little question and answer button down at the bottom where you can type in your questions during the program. All right, so let's get started here. I have the pleasure of introducing Jean Antolczyk. And her diverse background includes a five-year enlistment in the U.S. Army and experience as a registered respiratory therapist, licensed massage therapist, pediatric ICU, and pediatric cardiac ICU registered nurse before becoming a certified registered nurse anesthetist. And she became that in 2008. And then she became a Ph.D. prepared educator in 2015. In addition to her undergraduate nursing degree at the University of South Florida in 2004, her master of science degree in anesthesiologist in 2008, and doctorate of philosophy in 2015 at Berry University, she completed an academic fellowship in advanced pain management at the University of South Florida in May of 2019. As an associate professor with Berry University's nurse anesthesiology program, Dr. Antolczyk teaches her graduate students the importance of options for non-opioid general anesthesia, multimodal anesthesia and analgesia, and shared decision-making in anesthesia. So again, I would like to welcome Jean Antolczyk. Thank you so much, Dr. Carlson. As Dr. Carlson mentioned, I currently am an associate professor at Berry University in South Florida, and my graduate students include those enrolled in the physician's associates or the PA program, as well as the podiatry program, although my primary focus is on baccalaureate prepared critical care nurses who have entered a three-year graduate doctoral program in preparation to become certified registered nurse anesthetists or CRNAs. I do not have any disclosures to report to you. However, I am going to discuss the off-label use of magnesium as part of a general anesthetic and analgesic during my presentation today. The overarching goal of the provider's clinical support system is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications, as well as for the prevention and treatment of substance use disorders. Today, what we're going to do is talk about the current state of the opioid crisis. I'm going to describe it to you the way I introduce it to my graduate students. I'm also going to share with you how I impart the importance of shared decision-making between healthcare providers and their patients. And then I'm going to close in discussion of two pieces of legislation that address the opioid emergency that I think you may find useful to you, depending on what state you practice in. To effect a change in practice, the first thing I have to do is capture the attention of my graduate healthcare students. One way to do this is to compare opioids and big pharma to big tobacco. Number one, many of us know in 2023 that smoking is bad for you, but that wasn't always the case as those of you who are my age are familiar. Tobacco companies were experts at marketing their poison. Doctors, nurses, dentists, pharmacists, popular celebrities, actors, actresses were paid to extol how healthy smoking tobacco was. The tobacco companies utilized physicians to recommend cigarettes as a way to reduce anxiety or to treat other minor health ailments. Those physicians, especially the ones with financial ties to the tobacco industry, they denied any connection whatsoever with the use of tobacco and cardiovascular disease or cancer or any of the now proven tobacco-caused illnesses. Free cigarettes were distributed to the public in trials, and that included teenagers. Chemists that were employed by the big tobacco companies learned how to ramp up the habituating nicotine content of cigarettes, and taste enhancers like menthol were added so that people found them more palatable. It was said that the filter on the cigarette would protect the user from any of the negative side effects of smoking, and when the evidence accumulated about the many serious health problems that were caused by tobacco use, studies paid for by big tobacco somehow failed to show any causation. And I say that tongue in cheek. Eventually, when the evidence was overwhelming and undeniable, only then were black box warnings placed on tobacco products, and then we saw the lawsuits. And honestly, many of my students did not live through this, so they're not familiar with the history like people my age are. The opioid industry used big tobacco's game plan. They falsely claimed that unfettered health benefits from the product, the opioid and pharmaceutical companies denied the addicting, the habituating, and the unhealthful properties of opioids, and they paid physicians and tricked government agencies into shilling for them on behalf of opioids. We call this the successful commercialization of habituation and addiction, and I'll give you some examples of how that occurred. We know today, you particularly, because you deal with us every single day, that the opioid crisis is one of the preeminent health problems of present day America. So I also have to introduce my graduate healthcare students to the term big pharma, and to the Sackler family, who many of you know, owns Purdue Pharmaceuticals. They're internationally famous in both cultural and academic circles. They are very generous. They donate millions of dollars to some of the world's leading institutions, including universities and museums with big names such as the Guggenheim or Harvard. Much of their wealth comes from one product, as most of us have read in the newspapers, that OxyContin, and known to all of us as that blockbuster prescription painkiller that was first launched in 1996. And it's led in great part to today's opioid crisis here in the U.S. particularly. Today their donations are often described as blood money, and many of the institutions who have generously, you know, we're welcoming their generous donations over the past couple of decades, are now trying to distance themselves. So when we look at how this happened, this is kind of the storyline that I share with my students, who many are in their mid-20s, early 30s, and not have the institutional and historical knowledge that all of us have. We know that there are a lot of variables to include, but we're going to start with big pharma, dating back to the mid-80s and false marketing and undue pressure that was placed on physicians who tended to be a little opioid-phobic, for lack of a better word, because they were really worried about using opioids to treat pain in situations other than cancer-related pain or end-of-life situations. We know that the U.S. government played a huge role. There was an initiative called Pain is the Fifth Vital Sign that was incorporated in over 1,000 Veterans Administration hospitals and clinics across the nation. The Centers for Medicare and Medicaid Services, CMS, along with the Agency for Healthcare Research and Quality, developed this center called the Hospital Consumer Assessment of Healthcare Providers and Systems, which created a survey that would provide a standardized survey instrument and data collection methodology that they used to threaten both hospitals and physicians with reduced payments based on the survey responses from patients that were often full of misleading questions about pain. We know that there were legal or licit physicians who were overprescribing for a number of reasons that ultimately led to abuse and diversion. We're very familiar with a number of illicit physicians who operated pill mills, especially here in Florida. It was the black market, pharmaceutical-grade opioid distribution that I think I-95 became a famous corridor for people who would come to Florida, buy literally thousands of these pills, and then take them back to their hometowns and sell them, ultimately destroying their communities. Drug dealers, of course, the use of counterfeit pills, heroin, fentanyl, hydromorphone, the newspapers are full of those articles. China is a huge source of these illicit drugs, these synthetic and fake opioids through mail and internet orders and delivery. Then most recently, just on April 14th, the Department of Justice made a huge announcement regarding some of the Mexican drug cartels and how the switch and importation from China is now coming down to the Texas-Mexico border, where the Sinaloa cartel, which is one of the most powerful drug cartels in the world, the DOJ has now identified them as probably the largest organization responsible for the manufacturing and importation of fentanyl here in the United States. We now know, as of today, that fentanyl is now the leading cause of death for Americans between the ages of 18 and 49 years of age. Fentanyl has fueled the epidemic that has been ravaging families and communities across the United States. Between 2019 and 2021, fatal overdoses increased by almost 94 percent, and it's estimated that somewhere around 200 Americans are dying every single day secondary to fentanyl abuse. The numbers vary. Some places say 196, I've seen it as high as 236, but to put this in perspective as I share with the students, that's the equivalent of a Boeing 757-200 crashing and killing everyone every single day. Somehow a lot of this escapes the general population. If you're not directly affected by it or directly involved in trying to combat it, you may not be aware of how significant these numbers are. What we're seeing and what you are all involved with is a paradigm shift. As you know, a paradigm shift is a concept that was identified by Dr. Thomas Kuhn to describe a fundamental change in the basic concepts and experimental practices of a scientific discipline. Kuhn first presented this book as one of our required reading textbooks in our program, The Structure of Scientific Revolution. Just like with hand-washing to prevent infection or the shocking relevation that smoking is not healthy, we are seeing this paradigm shift that takes a critical look at the use of opioids. Oftentimes patients are exposed initially, opioid-naive patients are exposed to their very first dose of an opioid during a surgical procedure. Because CRNAs or Certified Registered Nurse Anesthetists deliver approximately 65% of all the anesthetics provided in the United States and in more than 70% of the nation's rural hospitals where the opioid epidemic is most critical, these CRNAs are the sole anesthesia providers in these rural hospitals. It is critical that CRNAs across the nation recognize their responsibility to become part of this vanguard of healthcare providers and policymakers in an attempt to address this opioid crisis. That is where my students come into play. That is how they become part of this vanguard, joining all of you in this fight. I would like to give you a couple of examples of how CRNAs are helping to lead the way. There are now three opportunities for CRNAs to complete fellowships focusing on non-opioid anesthesia and non-opioid analgesia to include the one I attended at the University of South Florida here in Tampa. And then there's also one at the Middle Tennessee School of Anesthesia and Texas Christian University. There are a number of CRNAs across the nation that I would love to call out, we just don't have time. I'm going to bring to your attention a few. One you'll be hearing from later this year, she's accomplished something outstanding. Katie Kornbaker is a CRNA in Colorado, and when she speaks to you, she's going to describe how she established a non-opioid anesthetic protocol at her hospital in Colorado. This is the example of one of the rural hospitals where the only anesthesia providers are CRNAs. And at her hospital, they exclusively provide opioid-free anesthesia to every surgical patient, which is absolutely remarkable. There's some surgical programs such as the one at my local level one trauma hospital, Tampa General. Their colorectal surgical program uses a completely non-opioid anesthesia and non-opioid analgesia approach. Numerous ambulatory surgery centers and office practices avoid opioids in their practice for a variety of reasons that we'll talk about. Another very instrumental CRNA is Tom Baraboe. Tom Baraboe established the Society of Opioid-Free Anesthesia in Hudson, Ohio, one of those communities that I described that has been decimated by the opioid epidemic and the pill mill that I described. This is a nonprofit organization that he formed to research, promote, and educate anesthesia professionals and the general public on opioid-free pain management for patients. And to their credit, they've been awfully successful. They just held their third annual congress at the Florida State University campus in Panama City, where CRNAs from around the country converge to share their medical practices. They usually have about three or four hundred attendees, which is very significant when you consider there's about 55,000 CRNAs in the United States. And so for that many to be able to come to this conference, leave their operating rooms or their classrooms, and then take that information back across the nation is really spectacular. If you've got time this afternoon, I encourage you to just Google Dr. Scott Sigmund. He wrote a piece for Outpatient Surgery Magazine in February of 2019 called Throw Away the Script. If you Google his name, that's one of the first things that come up, this great article called Throw Away the Script. He's an orthopedic surgeon who practices in Massachusetts, and he says when it comes to pain and pain expectations, surgeons have to prep their patients long before they enter the operating room, that they have to manage the expectations and that the preoperative conversation when they're obtaining their consent is going to set the tone for the patient's recovery period. And I agree with him wholeheartedly. I would just expound upon what he says in the article you're going to read, that it's imperative that all the providers involved in the patient's preoperative, intraoperative, and postoperative period work together to include the surgeon, all the anesthesia providers, and the PACU nurses to make sure that we all follow this same script along the way. And it's a really quick, brief read, two to three pages, but it's invaluable. I share it with my students every year just because of his poignant comments. So we know there's an estimated, depending on your sources, let's say 12 million people in the US that are misusing prescription opioids, prescription opioids, not illicit opioids. And we estimate that there's over a trillion dollars in economic costs associated with this misuse of prescription opioids. We look at missed work, medical expenses. This number, however, does not account for crime-related costs that are associated with opioid abuse, such as home invasions and robberies, et cetera. Billions of dollars are allocated by the federal government for the prevention and treatment of opioid. As you all know, today's presentation is a product of that grant, but I'd like to encourage you to think about some of the unseen costs we don't consider. There are towns and counties that are having to determine how many times their citizens are eligible to receive a dose of Narcan by first responders, because these small towns and cities cannot afford to pay both the electrical bill for their local elementary school, as well as the ever-increasing costs associated with the opioid crisis, especially, as you'll recall, when doses of Narcan were exceeding $1,000 a piece. There were some really hard decisions having to be made in these small communities. As I mentioned, there's estimates that over 200 people die every day from opioid overdoses. I described it's the equivalent of a fully loaded Boeing 757-200 crashing and killing everyone on board every single day. We know that during the year 2020, during the pandemic, the number of opioid deaths increased by 30%, and then we saw another increase of an additional 15% in 2021. In the beginning stages of the pandemic, many people attributed this increase to life being disrupted. People were bored. People were under intense pressure and anxiety. Now, as we come into 2023, we're seeing that there's a different explanation that seems even more clear. The primary driver is the presence of fentanyl in the drug supply that people on the street are able to access. First responders today are now being told just to assume that fentanyl is everywhere and that it's lacing everything. Examples are fentanyl added to meth, methamphetamines, to create what they call speed balls, or fentanyl added to heroin to try to increase the high that the users experience. There's a product called Carfentanil, which is a very dangerously potent analog of fentanyl. Fentanyl, as you know, is somewhere between 50 and 100 times more potent than morphine, but Carfentanil is 100 times more potent than fentanyl. Carfentanil originally was used as a tranquilizer by veterinarians to sedate elephants, horses, and other large animals. A teeny tiny amount of this drug is considered to be a lethal dose to a human being. What drug dealers are doing with it is they're mixing it with heroin to create what they call gray death due to the concrete-like appearance of the patient when they're discovered. Carfentanil is why first responders are having to use hazmat suits when facing potential exposure during a visit to an accident, etc. Even multiple doses of Narcan may not be affected in reviving a patient who is ingested or who has been exposed to Carfentanil. Only 2 milligrams of this deadly drug, 2 milligrams is about the equivalent in weight to 35 grains of salt. That's how little it is, can cause death in humans. The human may not even be aware that they ingested it. Opioids are profitable. That's why drug dealers get into this. Using chemicals that are shipped via the mail, costing altogether maybe $800 or so, can produce $800,000 worth of the product of Fentanyl. We know that opioids are deadly. This slide shows you just how little Fentanyl can kill a person. This slide demonstrates the difference in lethal doses between heroin, Fentanyl, and that little tiny dot of Carfentanil that you see pictured on the right side of the slide. Another thing that we're seeing a lot of is synthetic opioids coming into the communities. There's a drug called Iso or Nitizine that was first identified around 2019 in the Midwest, and then it moved into the southern states and along the eastern seaboard. Its potency is approximately equivalent to Fentanyl, and it's being mixed into and marketed with other drugs to make the drugs more potent and even cheaper to produce. In March of 2020, for example, Iso was found in counterfeit hydromorphone tablets that were being sold on the streets, both in the United States and in Canada. There's also reports across the nation that it's being mixed with other street drugs like cocaine. The major concern is that the people who are purchasing these drugs are not aware that it's present, and so it's causing deadly overdoses and unsuspecting victims. To try to make this topic relevant to my graduate students, because by now I've been going on and on in lecture for quite some time, I'm very excited and passionate about it, but they don't necessarily see it in their textbooks. I share a lot of articles from the New York Times, the Washington Post with them. I list these articles as required reading, and then I cite exam and quiz questions to the articles to make sure that they follow through, because anesthesia providers, like all healthcare providers, need to be educated about this. As I mentioned, because anesthesia providers are often the healthcare provider that breaks the naivete of the opioid-naive patient by using Fentanyl in the operating room, we have to be aware of the long-term ramifications of these decisions. There's a couple questions that I always ask my students to consider. I want to work hard to capture their attention prior to the start of their clinical residencies, and particularly for my CRNA students for the following reason. As critical care nurses, they have already been administering opioids to their patients for many years in the ICUs, for example. Before they've even entered our program, they are under the assumption that they're experts or they're familiar with opioid administration. I want to break that. I want them to know that there are things they don't know, just like there were things I didn't know for many years until I became aware that there were options for non-opioid anesthesia and analgesia in, I think it was 2016 is when I became aware of it and started changing my practice. I also know they're going to spend 24 months, six semesters of their nine-month program. I'm sorry, six semesters of their nine-semester program, their 36-month program. They're going to spend two-thirds of that time influenced by other anesthesia providers who administer Fentanyl as part of their routine, part of their anesthetic plan. I want them to really grasp that the decisions they make in the operating room while their patient is unconscious have a significant role to play in their patient's post-operative recovery journey and beyond. Three questions I always pose to them are, can interoperative and post-operative opioid use lead to chronic use and addiction? I demonstrate to them that, yes, it can. I ask them, what are the surgical and anesthesia-related implications associated with a non-opioid anesthetic? We explore that in great detail. I really ask them to hone in on this last question. Should we keep opioid-naive patients naive to opioids by avoiding that initial use of opioids? I give them some case studies. Susan's case study, she's a 55-year-old female coming into the operating room for a ENT procedure. While she's in the hospital recovering from the procedure, her sister alerts the nursing staff that she stopped breathing and she had to be administered Narcan. This story is covered in a book that I require the students to read called Dead in Bed, which describes a syndrome we in the anesthesia community refer to as dead in bed syndrome, which is a deadly hospital secret where you have patients that died post-operatively because of respiratory depression associated with opioids, both in the hospital as well as outpatient surgery cases whose patients are sent home. Maybe they are not diagnosed with obstructive sleep apnea, for example, and they go home and they take these opioids and they're found dead by their family member. Another case study I asked them to consider, which also addresses the question of what are the surgical and anesthesia-related implications of a non-opioid anesthetic, we can look at a patient named Michelle who is scheduled for removal of a malignant mass. The surgeon requests an opioid-free anesthetic because there are a lot of studies that indicate that some of our opioids and some of our volatile anesthetics, for example, can increase the risk of metastasis in patients who have been diagnosed with cancer. In particular, we hone on the opioid component of that and say, is there a better way to provide anesthesia for these surgical patients who are dealing with malignancies? I also asked them to read about Pamela. Pamela has a history of addiction in her family. Her father is an alcoholic and her sister is in rehab for an opioid use disorder, and she's scared to death of becoming addicted. I educate them about the genetic predilection associated with both hyperalgesia as well as addiction to opioids. Then lastly, I share with them a case study involving impaired providers, and this is pretty powerful. It gets their attention. I share the tragic story of Jan Stewart. Jan Stewart was a CRNA who served as the president of our national association, the American Association of Nurse Ambulatists, from 1999 to 2000, and in 2002, 10 years after serving as our president, she died unexpectedly of an accidental self-administered dose of Sufentra. She was found dead in her home with a syringe and needle in her arm. Now, her family could have kept this a secret, but instead they chose to open the door to reveal that the anesthesia community has a very serious wellness and chemical dependency problem. Her story represents that no one is immune to addiction and opioid abuse. It's estimated that as many as 15% of anesthesia providers have a problem with some form of addiction, and it is a huge component of the AANA, the American Association of Nurse Ambulatists, to try to address this problem. For those of us that have been around for a while, we know that dating back to the mid-1980s, early 1990s, opioids were not used as frequently as they are today. There are at least three generations of healthcare providers and patients, I'm going to use the word brainwashed, that have been brainwashed to believe that opioids are necessary, that they're beneficial, that they're safe, and that they effectively manage pain, and that is not true. That is an absolute misconception. There are all kinds of benefits of non-opioid anesthesia. If we avoid opioids, we know there's a terrible dirty side effect profile associated with opioids that include nausea and vomiting, constipation, ileus resulting in extended hospital stays or additional surgeries, urinary retention, somnolence, dysphoria, tolerance, dependence, abuse, addiction, opioid-induced hyperalgesia, respiratory depression, opioid-induced ventilatory impairment, opioid depression leading to death. The list goes on, arthritis in your proturiance. I think it's so cruel to include opioids in your proturiance epidural so that they spend the rest of the time scratching because they're so itchy, secondary to the opioid that was added to their epidural, which was supposed to make the birth process more pleasant. If we can just get rid of the opioids, we see this dramatic improvement in patient outcomes in care. With the absence of all those immune receptor side effects I just talked about, there's a reduced risk of respiratory depression for patients that are diagnosed with obesity or with obstructive sleep disorders that prevent that dead in bed syndrome I described. There's a reduced risk of immunosuppression and metastatic diseases associated with the intraoperative administration of opioids, and I encourage you to look up the Zeta opioid receptor that's associated with that theory. We can avoid opioid-induced hyperalgesia, opioid tolerance and addiction. It's also, if you think about it, an excellent alternative for patients who have a history of opioid addiction or, as I mentioned, a genetic predilection for opioid addiction. It's also an alternative for patients who are on medically-assisted treatment that require surgical procedures. Something we really have to think about as anesthesia providers in particular is persistent opioid abuse. Several studies indicate that one out of five patients exhibit persistent opioid use following their surgical procedure, and in addition, many studies that have been published recently support the idea that opioids are being overprescribed, leading to bottles of unused opioid pills sitting in medicine cabinets with the potential for abuse by family members or friends that are visiting, groundwater contamination, et cetera. We also know that smokers, patients that are diagnosed with depression, bipolar disorder, pulmonary hypertension, they're also at a higher risk for persistent opioid use. This is something we have to take pretty seriously. In 2017, which was six years ago, one study in JAMA found that there were over two million patients who were still using opioids 90 days after elective ambulatory surgeries. That's a significant finding because it's just a small subsection of all the patients that receive opioids postoperatively. These are smaller elective procedures. They're not the big ones that require hospitalization, et cetera. Let's talk about multimodal pain management. I think because of your specialty, you guys are all very familiar with this. We know it refers to the use of multiple non-mu receptor medications that produce a synergistic analgesic effect. When we talk about non-opioid or opioid-free anesthesia, we're referring specifically to a technique where intraoperative opioids are eliminated and replaced with these multimodal agents that can block the nociceptive pathway. We try to incorporate regional anesthesia. We also use non-opioid medications like alpha-2 agonists, like Prestidex, beta blockers like Esmol, NSAIDs, acetaminophen, gabapentin, magnesium. In particular, my own personal recipe for general anesthesia includes the synergistic blockade of the NMDA receptor as opposed to the mu receptor using magnesium and very low dose or sub-anesthetic doses of ketamine as a foundation of the opioid-free anesthetic technique. For example, some providers will add a background infusion of intravenous lidocaine, which adds a very well-established analgesic, anti-hyperalgesic, and anti-inflammatory component to the overall care plan. We have, let's see, probably about 10 minutes left until we start a question and answer period. For the final portion of my presentation, I want to highlight three over-the-counter medications that offer significant analgesia that are truly underappreciated by many healthcare providers as well as patients. Then we'll discuss two examples of legislation that can support non-opioid anesthesia and non-opioid analgesia. When we honor the people such as yourselves that are leading the fight in the opioid crisis, I have to give really special recognition to the members of the American Dental Association, so dentists, orthodontists, et cetera. This is a years-old meta-analysis that was put together. There are several Cochrane reviews that look at the effectiveness of various pain relievers. All you have to do is Google NSAIDs or Stronger Pain Medications and Opioids or Google NSAIDs and a summary of evidence. Once you get a copy of this PDF following today's presentation, this link is established in the PDF. It shows that a combination of 200 milligrams of ibuprofen and 500 milligrams of acetaminophen given at the same time is one of the strongest pain reliever combinations available. It's clearly more efficacious than any of the opioids used alone or in combination with acetaminophen. This is an absolute contradiction to what I was taught when I was a nurse working in the PICU and the Pedicardiac ICU. We would routinely stagger doses of fentanyl and acetaminophen every three hours. So the patient would get Q6 doses of fentanyl, Q6 doses of acetaminophen, but at three hour increments so that they were always getting a little something because we didn't really understand how these medications work together synergistically. And so you know that they hit on something when big pharma got involved and the pharmaceutical companies jumped on board because in December of 2020, I was walking through the grocery store and I saw this combination of acetaminophen and ibuprofen being sold as Advil dual action. And so you know that you've hit on something. You know, before we were trying to instruct our patients how to buy some acetaminophen, buy some ibuprofen and combine them. Now it's just one-stop shop. It makes it easy. They take three doses for a total of 1,500 milligrams of Tylenol per day and only 750 milligrams of Advil per day, which is well below the maximum recommended daily doses of 3,000 milligrams of acetaminophen and 3,200 milligrams of ibuprofen respectively. And then there's also an over-the-counter addition that we incorporate a lot. We use magnesium sulfate intraoperatively, intravenously as part of our OFA recipe, but we also have our patients go home and take a formulation of magnesium PO called super magnesium. And this contains a combination of aspartate, lactate and citrate, which doesn't cause GI distress. As you know, there are multiple formulations of magnesium and it's really important to instruct your patients to use the right one because most patients don't understand this. So if you go to the grocery store and you buy just over-the-counter magnesium oxide, that's gonna cause a lot of GI distress until the patient gets used to it. It takes a couple of weeks to develop that tolerance essentially. Magnesium oxide, as you know, is an osmotic laxative that's used to treat constipation. Magnesium aspartate is also readily bioavailable. It's available by prescription only and it can cause some confusion with regard to the actual dose of magnesium. So we really like the super mag because we haven't had any complaints from our patients. And the way that magnesium works, it doesn't really have a direct analgesic effect, but it inhibits calcium ions from entering the cells by blocking the NMDA receptors, which causes an antinosis effect. And so we use this in combination with NSAIDs, acetaminophen in some patients and gabapentin as part of our postoperative pain management recipe. All right, so in closing, I've got just a few more minutes left. So I wanna talk about the legislation. We're gonna talk about Florida's non-opioid alternatives law, which became effective in June of 2019. And then the No Pain Act, which is a federal initiative that I'm pleased to report was signed into law in December of 2022, but has not yet gone into effect. And I want you to understand how both of these are gonna help all of us in this fight in the opioid crisis. So firstly, let's talk about Florida's law. How did it come into fruition? Four states to include, let me think, it's Massachusetts, Pennsylvania, Connecticut, and Alaska have some form of advanced directive that works similarly to like a DNR or a blood products refusal form where the patient has the right to say, please don't administer opioids to me. And if I change my mind, I'll rescind it. Florida didn't really wanna do an advanced directive. So there was a lot of compromising to make this come to fruition. When I learned about non-opioid anesthesia in January of 2016, and then I saw the profound impact it had on my patients in the ambulatory surgery setting, both intraoperatively and postoperatively, I approached the Florida Association of Nurse Amethysts Board of Directors, of which I was a member at the time to ask their support in helping me, Florida become the fifth state in the nation to address the patient's right to make a decision about their care, i.e. shared decision-making, right? And I'm pleased to report that our efforts were successful and Florida did indeed become the fifth state to require healthcare providers include their patients in decision-making with regard to the administration of opioids. So the non-opioid alternatives law, which was established in 2019, July 1st, 2019, it became effective. We have to inform our patient about available non-opioid alternatives for pain treatment, which may include non-opioid medications or different types of products. We have to talk to them about non-opioid interventions and treatments such as acupuncture, massage, physical therapy, occupational therapy and other appropriate therapies. We have to discuss the advantages and disadvantages of non-opioid alternatives with them. And then we have to discuss with them whether or not they are at high risk or if they have a history of controlled substance abuse or misuse either in their family or for themselves. And we have to discuss the patient's personal preference. Some patients just don't wanna take opioids because they make them throw up. And a lot of patients say, I'd rather be in pain after a surgical procedure than vomiting after a surgical procedure. And so these are all important things that I encourage my students and my CRNA colleagues to talk to their patients about. The problem is there are some pretty real compliance issues that I'm aware of, and it's either due to lack of knowledge or ignorance by the anesthesia providers. Here on the screen, you see an example of a form in Epic that allows the provider to simply check a box without actually having that discussion with the patient. And my graduate CRNA students report this to me frequently. The last thing I wanna talk about is voices for non-opioid choices. So hospitals receive the same payment from Medicare regardless of whether there's an opioid or a non-opioid treatment plan utilized. And so as a result, hospitals rely on opioids, which are typically dispersed by the pharmacy after discharge because it allows the patients, the hospital not to have to pay for this. And so this No Pain Act is a bipartisan piece of federal legislation that addresses how payments are made to hospitals. And as I mentioned earlier, I'm proud to say it was signed into law in December of 2022. And so beginning in 2025, this law is going to expand patient and provider access to approved non-opioid pain management approaches in all outpatient surgical settings. Here's a number of other things it does, but it's gonna kind of level the playing field for us. And so if you wanna learn more about that, please visit nonopioidclinic.org. And you can see that there are a number of organizations that were instrumental in ensuring this legislation passed. And I just like to close that all of us are working hard to mitigate the misuse and potential abuse of prescription opioids. And as I tell my students, that giant oak tree that you're standing under was once just a little tiny nut that stood its ground and stayed in the fight to survive. With that, I thank all of you for your attention. I thank you for your day-to-day commitment to our patient population. You will receive copies of this presentation. And so you can utilize the resources that I've talked about. And there are two resources offered through PCSS that may be of interest to you. First, the mentoring plan. This information is included in the PDF as well as a discussion forum that you're welcome to register and join. They have a mentor call each month and an expert is available to answer your questions through this discussion forum. And then this slide simply notes the consortium of organizations that are part of the PCSS project. And our final slide serves as a reference for contact information, website, Twitter, and Facebook handles to find out more about the resources and educational offerings made by PCSS. Thank you so much for your attention. Thank you, Dr. Antelcheck, that was wonderful. We do have a series of questions here that some people have asked. So the first one, as a general surgeon who routinely offers medical hypnosis for pre and post-operative, and even do some cases now and then using hypnosis exclusively, what is its utilization by current practitioners who want to avoid opioids? Thank you for that question. And I am so thrilled to hear that a general surgeon is utilizing this technique. I am sad to report that I know of only one CRNA in our nation who routinely advertises that they use hypnosis. I'm sure there are many, and I just don't know about it, but I know of one that offers CEU opportunities to learn how to incorporate hypnosis into their practice. I can tell you that when I got out of the military in 1992 and attended a massage therapy program, I met a surgeon in New York who shared with my classmates that he utilized hypnosis to perform gallbladder surgery, which was a testament to how powerful it can be. I think this is a marvelous resource that we really need to make more clinicians aware of. Okay, another person says, literature varies, especially as we learn more in the past 25 years. For an opioid-naive individual, what is the chance of becoming addicted? As you mentioned, the literature varies, but I can tell you that most of my colleagues report a 6% or 7% number. We are learning more and more every day now that the human genome has been completely, or not completely. We think it's been completely identified, right? But as you know, in medicine, we kind of double our knowledge about what every 18 months or so nowadays. So there's a lot of work being done, particularly at Vanderbilt, the University of Alabama, Birmingham, and North Carolina, particularly regarding the genetic predilection to opioid addiction. And most of my colleagues are currently reporting about 6% to 7% in the general population. That's frightening, because we don't know who those people are. I get maybe a six or seven minute interview with my patient in a pre-op holding area, and unless they know they've had a genetic study done, or they have that healthcare information provided to them, it's kind of a shot in the dark, which is one of the reasons that I think it's a smart thing to keep opioid-naive patients if at all possible. Okay, here's a question. Is the risk of metastatic disease only with intra-op administration? Don't know what topic you were talking about. Probably regarding the use of opioids. So obviously, so I'm affiliated with Moffitt Cancer Center here in Tampa. Our students utilize Moffitt as a clinical site, and it's one of the 20 NCIs. Also, the big guy out in Texas, Arthur Anderson, they utilize a lot of opioid-free options because of the research being done at these major facilities that seem to indicate that the use of opioids intraoperatively, and I also mentioned volatile anesthetics. So opioids aren't the only culprit, but there is a body of evidence that seems to support that intraoperative use of opioids can result in the metastases of some cancers. Okay, and on the same topic, is there an increased risk for persons with persistent pain syndrome who find benefit for very low-dose opioids? So I, you know, when I first learned about this topic, and I'll be frank with you, prior to 2016, I was not aware that you could provide anesthesia without an opioid. It was always part of the recipe that I had been taught, both as a graduate student and then what I saw in practice. You know, the pendulum swings really hard both ways, and there is a place for opioids. Now, I personally leave that to the pain specialists, the physicians and nurse practitioners and pharmacists who are truly experts in that field. I tend to consider myself more of an information sharer. I have some experience, some personal experience in my own practice. I try to spread this message as best I can, but I am by no means, you know, the top expert working in it every single day. So I am careful to say that under the proper supervision of those experts, there is absolutely a role for opioids in patient care. I don't mean to exclude it from every single patient, but I think there's a large population of our patients that will benefit from not being exposed or utilizing opioids. I think this might've been, is there any information regarding the metastatic problems with taking it outside of the operative, perioperative time? So most of the research that we have focused on simply because it's a nurse anesthesia program has to do with the intraoperative use. And so if you'll forgive me, I'm not going to pretend to be an expert on postoperative pain management in that arena, but I do believe that all of these NCI facilities have extensive published literature that the public can access. Okay. This one was please review and discuss ketamine shortage. When will this be remedied? Oh gosh. I wish I had the answer to all of the anesthesia medication shortages. We're dealing with lidocaine shortages. I think a lot of it all stems back from 2017 and Hurricane Marie when it wiped out three major factories in Puerto Rico. And so we saw, and we're still dealing with significant shortages of quite frankly very important agents that are used in non-opioid anesthesia. So my students in Florida report to me that some of their formularies are short of lidocaine, some are short of Esmolol, some are short of ketamine, et cetera. And so I wish I knew the answer to that because I promise you we're in the same boat you guys are as trying to make sure this is available for our patient. Okay. I'm going to combine the next two questions. One of them, can you repeat how magnesium assists in pain control and is there research to support the use of this super magnesium? Yes. So I will repeat how magnesium assists in pain control first. Magnesium as you know, binds to the NMDA receptor. So we have all these different receptors in our body and usually we have historically focused on, well over the past 30 years with regard to opioids on the immune receptor. But if we look at the NMDA receptor, which nitrous oxide axon, ketamine axon, magnesium axon, what it does is magnesium in particular is going to inhibit the calcium ions from entering the cell by acting as an NMDA antagonist by blocking the NMDA receptors. And that results in an anti-nociceptive effect. It's a mechanism. I have this great slide that unfortunately I had to delete pretty much half of the slides I wanted to show you because of our very limited 50 minute timeframe. But I have this beautiful slide that shows all the receptors that are involved in nociceptive, nociception or the transmission of pain. And it asks, is focusing on one receptor, the immune receptor really the right thing to do? And clearly the answer is not. With regard to super mag particularly, we recommend it in our practice simply because it's easily available and it doesn't cause GI distress. But I don't know that research on super mag, the brand has been done. There is copious amounts of research with regard to magnesium and pain management. Literally I've been magnesium and pain into your Google search engine. And I think one of the very first articles that come up is an article dated maybe 2011. It's in PubMed that describes how amazing magnesium is. And in my files, I have articles that date back to 1908, literally 1908 talking about magnesium and its use in general anesthesia long before Big Pharma got involved with opioids. So there's copious amount of research to support its use in pain management. Okay, I'm gonna get one more statement here. First of all, you will be sent a link to complete a evaluation form. Once you have completed the evaluation form, we will send you the certificate for the CE, but you must complete the evaluation form. So don't forget to do that. And basically our time's up, we've kind of run out of time. So I wanna thank everybody for being here and thank Dr. Antelcheck for doing this wonderful presentation. Thank you so much. And I hope you guys will come back to hear Katie's story, Katie Hornbecker. I thank you, bye-bye.

non-opioid anesthesia

analgesia

opioid crisis

shared decision-making

healthcare providers

tobacco industry

NSAIDs

acetaminophen

gabapentin

multimodal pain management