This Information Statement was
developed as an educational tool based on the opinion of the authors. It is not
a product of a systematic review. Readers are encouraged to consider the
information presented and reach their own conclusions.
The United States is in the midst of an epidemic of opioid drug
(narcotic drug) use, misuse, and abuse.1 To address this critical
public health issue, all physicians and orthopaedic surgeons must be
accountable for their direct or indirect contributions to the epidemic and should
responsibly develop solutions to effectively treat this epidemic.
It is estimated that the United States consumes 80 percent of the
global opioid supply.2 According to the U.S. Food and Drug Administration
(FDA), more than 50 million Americans were prescribed some type of narcotic
pain medication in 2011, which represents a nearly 100 percent increase in
narcotic pain medication prescriptions since 2008.2 This increase in
opioid prescription medication corresponds to an increase in opioid diversion to
nonmedical users as well as a resurgence in heroin use.3-5 Opioid
overdose is now the leading cause of accidental death in young adults.6
Opioids are associated with a higher risk of postoperative death.7 Opioids
also increase the risk of fall and fracture in the elderly.8, 9
The AAOS believes that a comprehensive opioid program is necessary to
decrease opioid use, misuse, and abuse in the United States. New, effective
education programs for physicians, caregivers, and patients; improvements in
physician monitoring of opioid prescription use; increased research funding for effective alternative pain
management and coping strategies; and support for more effective opioid abuse
treatment programs are needed.
The American Academy of Orthopaedic Surgeons supports the following strategies
for safer and more effective pain management and treatment:
Prescription Protocols/Policies: Orthopaedic surgeons and their
team members can more effectively depersonalize discussions about opioids by
using standardized opioid protocols in all settings (inpatient, outpatient,
office) to control opioid use. Orthopaedic practices should establish protocols/policies
to better control and limit opioid prescription dosages as well as appropriate/inappropriate
opioid uses for acute musculoskeletal injuries, postsurgical pain, and chronic
pain. Surgeons and team members should explain to patients that opioid protocols/policies
benefit patients and extended families and cannot be violated. Such opioid
protocols/policies should include:
Opioid Use Consensus: Each practice should set ranges for acceptable
amounts and durations of opioids for various musculoskeletal conditions
treated, both surgically and nonsurgically.
Limit on Opioid Prescription Size: A prescription should only include the
amount of pain medication that is expected to be used/appropriate, based on the
protocol established. For patients who live longer distances from their surgeons,
two prescriptions for smaller amounts of opioids with specific refill dates should
be considered rather than a single large prescription. Most patients do not
fill the second prescription, so this strategy limits potential opioid misuse.
Extended-Release Opioids: Orthopaedic surgeons most often treat acute pain following
injury or surgery. Such acute pain typically improves over hours to days,
rather than days to weeks. With one exception, extended-release opioids are not
FDA-approved for the treatment of acute pain.
of Opioid Use for Preoperative and Nonsurgical Patients: Pain from acute
trauma or chronic degenerative diseases can usually be managed without opioids
prior to surgery. Surgical patients using opioids preoperatively have higher
complications rates, require more narcotics postoperatively, and have lower
satisfaction rates with poorer outcomes following surgery.11 The
effectiveness of opioid use for the treatment of chronic pain other than cancer
is debatable. Policies/protocols that limit use of opioids in patients with
non-acute conditions can help limit patients’ soliciting opioid prescriptions
from more than one physician. Policies/protocols that restrict opioids for
preoperative, nonsurgical, and chronic pain patients should be considered.
Predictive Opioid Use/Misuse/Abuse Tools: Patients at risk for greater opioid use should be identified (eg, using the opioid risk tool http://www.mdcalc.com/opioid-risk-tool-ort-for-narcotic-abuse/). Patients with symptomatic depression and ineffective coping strategies should be identified and treated prior to elective surgery. Physicians, the public, and policy makers should value interventions to lessen stress, improve coping strategies, and enhance support for patients recovering from injury or surgery.
Surgeons should script and practice empathetic and effective communication
strategies, appropriate for all levels of health literacy. Patients are more
comfortable and use fewer opioids when they know their doctor cares about them
Interpersonal, and Organizational Collaborations: Partnerships need to
be established among hospitals, employers, patient groups, state medical and
pharmacy boards, law enforcement, pharmacy benefit managers, insurers, and
others. Patients need to understand that opioid medications should be used only
as directed and to practice safe storage and disposal. The patient’s family and
friends should also be educated to help with physical activities that are
difficult and to provide emotional support for recovery. Prior to elective
surgeries, physicians should encourage (or should work with) patients to
establish a social network—including visiting nurses and home health aides, as
well as neighborhood volunteers—to provide emotional and physical support
Care Coordination and Opioid Use Tracking: It should be possible
for a surgeon and pharmacist to see all prescriptions filled in all states by a
single patient. Opioid use is best coordinated through a single prescribing physician/surgeon/practice,
especially when dealing patients have ongoing/chronic pain issues. Doctors in
emergency departments or other consulting physicians can then contact that prescribing
physician/surgeon/practice to determine if an exception is warranted. Referral
for alternative pain management strategies should be considered for atraumatic
musculoskeletal pain. Evidence is available that ongoing pain after injury or
surgery is most often associated with symptoms of depression, posttraumatic
stress disorder, and ineffective coping strategies—all of which are responsive
to cognitive behavioral therapy.
Medical Education (CME) for Physicians: Physician and caregiver awareness
of the risks and appropriate uses of opioid medications is important. Requiring
periodic CME on opioid safety and optimal pain management strategies will help physicians
reduce opioid use and misuse.
Improvement: Physicians and caregivers should integrate
performance improvement in pain management, stricter opioid prescribing, and screening
and treatment for substance use disorders into new delivery model quality
metrics. Questions about satisfaction with pain relief and pain medication may
not be optimal quality measures.
of Proper Opioid Access: Even as healthcare providers and
regulators take steps to address the problem of opioid abuse, they must
recognize that, in certain settings and for certain conditions, patients with
terminal conditions and other appropriate indications should have access to
opioid analgesics to manage their pain.
Culture Change: Making opioids the focus of pain management has created
many unintended consequences that often put both patients and their families at
increased risk of addiction and death. A new approach to pain management is
needed to effectively change the cultural expectations of patients with pain.
Patients with similar injuries and surgeries experience varying amounts of
pain. The differences in pain for a given injury or surgery are largely
explained by individual patient circumstances, characteristics, and mindset.
Stress, distress, and ineffective coping strategies create greater pain. Peace
of mind is the strongest pain reliever. Studies have found that opioids are
associated with more pain and lower satisfaction with pain relief. Opioids are potentially
dangerous medications for all patients; they are highly addictive and can cause
In the United States, the current cultural expectation of opioid use as
the primary treatment for acute and chronic pain has created an opioid
epidemic. Only a culture change led by physicians dedicated to limiting
inappropriate opioid use will solve this epidemic.12 Physicians,
patients, and caregivers in the United States need to learn how to treat pain
with less dependency on opioid medications.11
Executive Office of the President of the United
States. Epidemic: Responding to America’s Prescription Drug Abuse Crisis. https://www.whitehouse.gov/sites/default/files/ondcp/issues-content/prescription-drugs/rx_abuse_plan_0.pdf
Manchikanti L, Singh A: Therapeutic opioids: A
ten-year perspective on the complexities and complications of the escalating
use, abuse, and nonmedical use of opioids. Pain
Physician 2008;11(2 suppl):S63-S88. MedlineWeb of Science http://www.ncbi.nlm.nih.gov/pubmed/18443641
Sohn DH. Pain Meds Present Problems. AAOS Now, July 2013. http://www.aaos.org/AAOSNow/2013/Jul/managing/managing8/
Okie S. A flood of opioids, a rising tide of
deaths. N Engl J Med. 2010 Nov
18;363(21):1981-5. doi: 10.1056/NEJMp1011512. http://www.nejm.org/doi/full/10.1056/NEJMp1011512
Erratum in: N Engl J Med. 2011 Jan
20;364(3):290. PubMed PMID: 21083382. http://www.nejm.org/doi/full/10.1056/NEJMx100106
Carey B. Prescription Painkillers Seen as a
Gateway to Heroin. The New York Times, Feb.
11, 2014. http://www.nytimes.com/2014/02/11/health/prescription-painkillers-seen-as-a-gateway-to-heroin.html
Manchikanti L, Helm S II., Fellows B, et al:
Opioid epidemic in the United States. Pain
Physician 2012;15(3 suppl):ES9-ES38. Medline http://www.ncbi.nlm.nih.gov/pubmed/22786464
Fouladpour N, Jesudoss R, Bolden N, Shaman Z, Auckley
D. Perioperative Complications in Obstructive Sleep Apnea Patients Undergoing
Surgery: A Review of the Legal Literature. Anesth
Analg. 2015 Jun 23. [Epub ahead of print] PubMed PMID: 26111263. http://www.ncbi.nlm.nih.gov/pubmed/26111263
Aparasu RR, Chatterjee S. Use of narcotic
analgesics associated with increased falls and fractures in elderly patients
with osteoarthritis. Evid Based Med.
2014 Feb;19(1):37-8. doi: 10.1136/eb 2013-101401. Epub 2013 Aug 13. PubMed
Rolita L, Spegman A, Tang X, Cronstein
BN. Greater number of narcotic analgesic prescriptions for osteoarthritis is
associated with falls and fractures in elderly adults. J Am Geriatr Soc. 2013 Mar;61(3):335-40. doi:10.1111/jgs.12148.
Epub 2013 Mar 1. PubMed PMID: 23452054; PubMed Central PMCID: PMC3719174. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719174/
FDA announces safety labeling
changes and postmarket study requirements for extended-release and long-acting
Lee D, Armaghani S, Archer KR, et al. Preoperative
Opioid Use as a Predictor of Adverse Postoperative Self-Reported Outcomes in
Patients Undergoing Spine Surgery. J Bone
Joint Surg Am. 2014 Jun 4;96(11):e89 http://www.ncbi.nlm.nih.gov/pubmed/24897746
Ring DC. Pain Relief: What Can We Do? AAOS Now, January 2015. http://www.aaos.org/AAOSNow/2015/Jan/research/research2/
©October 2015 American Academy of Orthopaedic Surgeons.
This material may not be modified without the express
written permission of the American Academy of Orthopaedic Surgeons.
Information Statement 1045
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