Prescription painkillers, often opioids, are commonly prescribed in orthopaedics. New data demonstrate an increase in both the amount of narcotics prescribed and the complications associated with prescription painkillers. In fact, deaths from prescription opioid overdoses in the United States exceed the deaths from heroin and cocaine combined.

According to recent (2010) data from the U.S. Centers for Disease Control and Prevention, the death total among women due to prescription medication overdose was 9,292; 6,631 of those deaths were specifically related to opioids. This is a fivefold increase in opioid deaths during a 10-year period.

The scope of the problem is even greater than the mortality statistics suggest. For every death, multiple women seek emergency care for prescription drug misuse or abuse. Women made more than 670,000 visits to emergency departments in 2010 for prescription misuse or abuse; nearly a third of those visits (more than 200,000) were due to opioids alone.

Prescription opioid overdose is not just a problem that affects women. Men and women have nearly the same rate of emergency department visits for opioid and benzodiazepine abuse. Although men are still more likely to die from prescription painkiller overdoses (more than 10,000 deaths in 2010), the gap between men and women is closing.

Increased usage
Not only has the number of opioid prescriptions increased in the United States—so has the amount of drugs prescribed. Between 1997 and 2006, the amount of opioids dispensed as medication increased from 50.7 million grams to 115.3 million grams, an increase of 127 percent.

During that same period, the number of prescriptions issued for controlled substances increased 154 percent. Prescriptions for certain medications, such as oxycodone, have increased more than 700 percent.

These increases may be related to a greater emphasis on pain management. In 2001, the Joint Commission implemented pain management standards. The standards require organizations to recognize the right of patients to appropriate assessment and management of pain, to screen patients for pain during their initial assessment and, when clinically required, during ongoing, periodic re-assessments, and to educate patients suffering from pain and their families about pain management.

It should be noted, however, that the standards do not require that pain medications be used, or that pain be eliminated.

Side effects
The side effects of opioid administration include respiratory depression, nausea, constipation, physical dependence, and addiction. An additional risk affecting orthopaedic patients is lower activity levels, which have been seen in patients who use opioids for pain control. Side effects specific to women are the risks of amenorrhea and infertility.

All risks increase when patients do not take medications as prescribed. The severity of dependence and addiction is well documented, contributing to opioid abuse. Additionally, tolerance due to the loss of analgesic potency commonly develops. This results in ever-increasing dose requirements, which raise the risks for complications and even death.

Opioids and orthopaedics
Opioid medications are commonly prescribed in orthopaedics for a short term after surgery for acute pain control. Studies have examined the risk of chronic opioid use after ambulatory surgeries. In a 2012 retrospective, population-based study, researchers found that patients who had not previously used opioids and received a prescription for opioids within a week after a short-stay surgery were 44 percent more likely to still be using opioids at 1 year from surgery than those who did not receive such prescriptions.

The literature specifically concerning opioid use in orthopaedic surgery is limited. A study of opioid consumption in outpatient upper extremity patients found that an average of 30 opioid pills was prescribed and 19 were reported unused per patient. These unused pills are at theoretical risk for abuse for nonmedical reasons or by someone other than the patient.

The difficulty for physicians is differentiating between those patients with pain who may be undermedicated and patients who are experiencing addiction. In both cases, patients may request refills and larger doses. One step physicians can take is to screen for prior histories of substance abuse or mental health problems.

In the setting of chronic pain, alternatives to opioid treatment should be tried first. Providers should also inform patients on the risks and benefits of opioids for pain control.

Prevention programs
Programs to prevent overdoses have been successful on the state level. The Utah Department of Health began a program in 2008 that combined a media campaign, guidelines for providers, and research. Within the first year after the campaign was initiated, the state had a 14 percent drop in unintentional deaths related to opioids.

To prevent death from prescription painkillers, the integration of the state to increase provider and patient involvement has been proven beneficial. Additionally, awareness of the increasing susceptibility of women to complications related to opioid use is important for all providers in identifying and preventing opioid-related deaths.

Jennifer K. Wozniczka, MD, is the resident member of the AAOS Women’s Health Issues Advisory Board. She can be reached at jennifer.woz@gmail.com

Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.

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