Orthopedic surgeons are some of the biggest opioid medication prescribers — comprising the third highest in the United States.
A webinar sponsored by the Hospital for Special Surgery Ambulatory Surgery Center of Manhattan (HSS) underscored how patient expectations, poor pain control, strattera dosi and social determinants of health all influence opioid use among orthopedic surgery patients.
Dr Kanupriya Kumar
Opioids have long been used as the first-line agents for pain. Historically, no plan exists for discontinuing or tapering these prescriptions. The United States consumes 80% of the world’s opioids. “Prescribers and nurses want a quick way to ease patients’ pain, and patients often expect and desire an easy solution to any discomfort. There are many reasons for this, but culturally we are primed to not tolerate any pain, and we are bombarded with advertisements telling us we can treat everything,” said Kanupriya Kumar, MD, anesthesiology site director at HSS. Kumar co-presented the webinar with Uchenna Umeh, MD, assistant attending anesthesiologist at HSS, and Alex McIntyre, MD, an orthopedic surgery resident at Tufts Medical Center in Boston, Massachusetts.
Overtreating pain with opioids has led to opioid misuse and eventually the opioid epidemic, Umeh said.
Dr Uchenna Umeh
Educating patients about postoperative medication use (dose and frequency) is paramount to a successful pain management plan. “Physicians should develop and discuss the pain management plan with the patient preoperatively,” Umeh told Medscape Medical News.
Survey Reveals Unrealistic Expectations
Recent literature has focused on opioid prescribing patterns among orthopedic surgeons, multimodal pain strategies, and risk factors for chronic opioid use.
Less is known about patient expectations regarding postoperative opioid use, McIntyre said.
To find out more, McIntyre and his colleagues surveyed 727 adult patients who had recently undergone elective orthopedic surgery. Most were 60 years or younger. Among these participants, 41.5% had a history of illicit drug use and 57.5% reported taking prescription opioids in the past.
A large majority — 75% — thought opioid use was a moderate or large problem and 84% thought that opioids were overused to treat pain. Overall, 30% worried that they’d have an addiction problem after taking opioids.
Nevertheless, 13% expected to have no pain after surgery and 86% expected an opioid prescription 1 week to 1 month postoperatively. A total of 50% said they’d save their extra pills for potential future pain, and 11% would save them to give to someone else. This highlights the importance of diligent prescribing practices and the need for future research into opioid utilization, McIntyre said.
The survey also revealed that unrealistic public expectations about postoperative opioid prescribing could lead to decreased patient satisfaction and produce conflicts between surgeons and patients.
Two thirds of the respondents reported that their pain control after elective orthopedic surgery would directly impact their opinion of their surgeon. This is important, as 25% of hospital and physician reimbursement from the Centers for Medicare and Medicaid Services is directly tied to patient satisfaction, McIntyre noted.
“Poor pain control has been linked to lower HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) scores” and longer hospital stays, he added.
Addressing Patient-Physician Conflicts
While 60% of the respondents said they expected a weaning period, 30% said they would push back to receive a longer prescription. Another 8.5% said they might give their physician a poor rating. About 63% would understand why their surgeon would try to wean them off opioids, but over one third would have decreased satisfaction with their surgeon as a result.
It’s interesting that survey respondents anticipated some sort of judicious opioid prescribing, weaning, and instructions on disposal — but would also be dissatisfied with certain outcomes, Kumar said.
“Unfortunately, we live in the world of satisfaction-based sticks and carrots for clinicians, though multiple studies have shown that patient satisfaction is correlated with poorer outcomes,” she noted.
It’s important to communicate early and often, to understand the patient’s perspective, and provide appropriate, data-driven information to set reasonable expectations at the outset. Physicians should use as many tools as possible to provide adequate pain relief for recovery with a minimum of side effects, Kumar advised.
Evaluate, Set Expectations, Educate
Orthopedic surgeons can better manage pain needs through three basic steps, Kumar advised during the webinar.
Evaluate your patients thoroughly. Examine the patient’s prior opioid use before the operation. Have they had issues with pain medications previously? If so, treat preexisting opioid use as any other medical issue to optimize postsurgery.
Do a comprehensive history of pain medications and coexisting medical issues. Some patients may need referrals to a pain management specialist for weaning, bridging, and resumption of home medications.
The next step is to set realistic expectations, Kumar continued. “Postoperative pain is normal: They shouldn’t expect no pain at all.” Pain also varies between patients. It’s important for surgeons to explain to patients what to expect, what pain may feel like — that it may wax and wane but will improve over time.
Surgeons should also share data about pain with their patients. If they know that pain is routine in similar patients having the same procedure, but that it’s short lived and treatable with medication, “it helps allay some of that anxiety and opioid-hoarding tendencies,” she told Medscape.
Providers should also be educating their patients on alternative regimens and appropriate opioid use, including weaning protocols.
In the Tufts survey, some respondents said they’d discontinue taking their pain medicine when the prescription ran out rather than controlling pain with non-narcotics.
But options do exist, and patients and physicians should explore them, Kumar said. “Patients should know that not all surgeries require opioids post-op, especially with robust multimodal therapies,” she added.
Multimodal analgesia can start either before, during, or after the operative period. Researchers of one study that examined 1.5 million total hip or knee arthroplasties found a definite benefit of using options such as NSAIDs or acetaminophen.
Gabapentin and IV infusions of lidocaine, ketamine, or alpha-2 agonists are other options. Nonpharmacologic pain management methods may include icing, distraction theory, cognitive behavioral therapy, or transcutaneous electrical nerve stimulation.
Again, the key with these techniques is expectations, Kumar emphasized. They won’t necessarily provide immediate relief following surgery. However, they can influence how much pharmacologic treatment is needed “and also decrease associated perturbations patients experience like sleep disturbances and anxiety,” she said.
When prescribing any drug, providers should start at the lowest dose at the longest interval possible, Kumar said.
Umeh personally advises patients to begin with acetaminophen and NSAIDs every 4-6 hours “around the clock” (if not contraindicated) for the first 72 hours after surgery and that they reserve opioids for severe breakthrough pain.
“I also encourage patients to use ice as much as possible since it has great anti-inflammatory effects and reduces pain and swelling,” she said. Physicians should discuss pain management at discharge and follow-up with a phone call once the patient is home to re-emphasize multimodal analgesia and minimize opioid use, she added.
The Importance of Regional Anesthesia
Sometimes the solution comes during the surgery itself.
Many orthopedic procedures involve the extremities, which are well suited to known and effective regional nerve block techniques. During the webinar, Kumar discussed the role of regional anesthesia in preventing overuse of narcotics following surgery. “It can lead to complete or partial opioid-sparing protocols for surgery and immediately post-operative. It’s an important part of perioperative pain management.”
Regional anesthesia is associated with decreased early dependency on opioids as well as decreased side effects and improved early function, leading to a smoother transition to postacute recovery.
Longer term, it can result in decreased opioid-related morbidity and mortality, reduced narcotics use, and fewer pills in the community.
“What we can do in the OR can make a world of difference to patients and communities. Orthopedic surgeons are especially well suited to maximize opioid-sparing anesthesia techniques, given the amenability to nerve blocks. Resource requirements are high; you need trained experts, ultrasounds and probes, and block needles. But it’s worth it,” Kumar said.
‘A Little Pain Is Good’
Some patients say they don’t need narcotics to manage pain. Elizabeth Bressel, who’s had 18 orthopedic surgeries, would choose acetaminophen over Oxycontin any day.
Many physicians offer Percocet as a first step, but Bressel said she doesn’t need that. “I’ve had some experiences where doctors wouldn’t listen to me,” she said.
A combination of codeine and Tylenol works just fine and helps her sleep. Bressel was offered Oxycontin in more recent surgeries, but she doesn’t use it much.
“A part of me learned that a little pain is good” because you don’t overexert yourself. It makes you aware of your pain, she said.
However, everyone has a different pain level, she acknowledged. The best thing physicians can do for their patients is to start slowly with pain medications and see if the patient really needs it long term. “Listen to patients, understand them, and know where they’re coming from. Educate them on the expectations.”
Unrealistic expectations are always going to cause problems, she said.
Opioid Use Patterns in Communities
Social determinants of health (SDH) may also influence opioid prescribing patterns and use. Umeh described what she found from a literature review during the webinar.
One BMJ Open cross-sectional study used the Area Deprivation Index (which evaluates a region’s socioeconomic conditions) to assess opioid use and drug poisoning mortality in the United States from 2012 to 2017. The study found that opioid prescription rates and drug poisoning mortality were consistently higher with greater levels of deprivation, she said.
Another study looked at the association between sociodemographic characteristics and county-level differences in opioid dispensing in 2881 counties. Higher morphine milligram equivalents were dispensed per capita for counties with a higher percentage of people below the poverty line, with less than a 4-year college degree, and without health insurance. This was also true of counties with higher percentages of families headed by a single parent, divorced families, and those with disabilities.
Other studies revealed that White patients in higher income areas were more likely to receive buprenorphine and methadone treatments than were Black patients.
These findings are important, given that the medical profession has moved to minimizing opioid prescriptions and/or to opioid-sparing techniques that emphasize nonopioid analgesics and other alternative nonmedication therapies like cryotherapy and acupuncture, Umeh said.
Identifying populations that are at higher risk for opioid misuse and eventually opioid poisoning deaths through SDH is important. “Physicians should tailor postoperative pain management plans for high-risk patients accordingly,” she added.
Assess, Examine, Advocate
Health systems should be examining SDH patterns, identifying social risks and assessing specific patient populations to better connect patients with resources, align strategies, and advocate for patients, Umeh said.
Clinicians can begin by identifying social risk factors for poor health outcomes during the first visit with the patient.
HSS’ EPIC electronic medical record system includes a set of questions in every patient’s chart, she told Medscape. “Once risk factors are identified, connecting the patient to local resources is the next step.” If a patient can’t make follow-up appointments because, for example, they take two buses and a train from their home to the hospital, clinicians should arrange for transportation (such as access-a-ride) to ensure that the patient stays connected to their physician and the healthcare system.
“Collecting data on pain management by patients’ social risk factors will give the health system the opportunity to review that data and create methods to address disparities in pain management. Lastly, using clinical guidelines and standardized pain management plans may reduce clinician bias in pain medication prescribing,” Umeh said.
Kumar, Umeh, and McIntyre reported no relevant financial relationships.
Jennifer Lubell is a freelance medical writer in the Greater Washington Area.
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