A rather doleful theme emerged from the 2014 AAOS Annual Meeting’s well-attended symposium, “Managing Surgical Pain in the Opioid Epidemic Era.” In discussing the role of orthopaedic surgeons in managing their patients’ pain, presenters echoed the pronouncement by Pogo creator Walt Kelly: “We have met the enemy and it is us.”
Although panelists made no effort to sugarcoat the alarming problem of opioid overprescription, abuse, and addiction, they did offer tested strategies for providing humane and effective pain management to patients while blunting the risk of abuse.
Moderator David L. Nelson, MD, of Greenbrae, Calif., opened the session in a somewhat facetious mode, portraying himself as a physician less than fully focused on safety or efficacy. To his fictitious patient, he said, “I am in charge of your pain. I’ve never had training in pain management. I’ve never asked how many pills my patients need. I give them enough so they don’t call me on the weekend.”
Then Dr. Nelson turned serious and pointed out that prescription opioid drugs kill more people than heroin and cocaine. He also noted the difference between a narcotic and an opioid. “A narcotic is a federal regulatory term,” he said. “If it’s prohibited it’s a narcotic. Opioid is a pharmacology term.”
Sounding a theme, he asked, “How many orthopaedic surgeons know how many pills their patients take? How do orthopaedic surgeons decide how many pills to give their patients?”
The pills of the opioid epidemic “aren’t stolen,” he said. “They are physician-prescribed.”
The panelists, who all happened to be hand surgeons, then proceeded to outline ways to provide fewer opiates to patients.
“When I started learning about pain management,” admitted Andrew Gurman, MD, of Altoona, Pa., “I had no idea how many pills my patients were taking. All I knew was that if they were calling me, I hadn’t prescribed them enough.”
Dr. Gurman noted that deaths from opiates now surpass traumatic auto accident fatalities and that hydrocodone is the most widely prescribed drug in the United States. Of the 131 million prescriptions written annually, 12 million are being used nonmedically. “If a patient is given hydrocodone for 90 days,” he said, “there is a two thirds chance that he or she will still be taking it in 5 years.
“We are part of the problem,” he continued, noting that in his home state of Pennsylvania, 55 percent of people using opioids do not have their own prescription.
“They are getting them from friends or relatives,” he said. “This is not a street drug problem. They take them from medicine cabinets. They go to real estate open houses and peek in the bathroom because the agent doesn’t usually go in the bathroom. They take them during parties. Teenagers find them in medicine cabinets.”
In 2000, Dr. Gurman noted, California passed a law requiring providers “to promptly and effectively treat pain for as long as pain persists.” This caused the use of opioids to curve and spike upward. “The patient who wants the drug knows your legal obligation,” he told the audience.
David C. Ring, MD, of Harvard University, advised having a written policy on opioid prescribing and sharing it with patients. He noted that for ankle fractures, an opioid prescription will average 4 weeks.
According to Dr. Ring, the opioid epidemic is both iatrogenic and “advocatogenic,” a term he coined to describe how self-styled patient advocates have created a problem of overprescription. Surveys show that some surgeons will prescribe opioids because they are concerned about patient antagonism or dissatisfaction, Dr. Ring said. Surgeons on average believe that they can identify problematic patients and have effective communication skills to manage them, but 29 percent of surgeons who responded to one survey said they would like to have help with communication strategies and setting limits.
Jeffrey A. Rodgers, MD, described a study in which investigators sought to assess the quality of analgesic effect following outpatient upper extremity surgery. They hoped to quantify “left-over” medications and evaluate factors that could influence opioid analgesic consumption.
The study involved phone interviews with 250 patients, conducted 7 to 14 days after surgery. Researchers confirmed the medication and dose regimen prescribed and asked patients about their satisfaction with analgesic control, the number of tablets remaining, and supplemental analgesic medications. More than half of the patients contacted (51 percent) were taking hydrocodone; about a quarter (24 percent) were taking oxycodone, and 22 percent were taking propoxyphene. Most patients received 30 pills.
Patients undergoing hard-tissue surgery used more pills than those with soft-tissue problems. More than 90 percent of patients reported adequate pain management, regardless of surgery type, with two thirds (68 percent) reporting an analog pain score of 2 or less. However, more than half (56 percent) used supplemental, nonprescribed medication. Ibuprofen was the most commonly used NSAID, followed by acetaminophen. Five patients reported using an opioid analgesic that was not prescribed by their surgeon. Most of these patients reported using “left-over” medications from a spouse or previous prescription.
A majority of patients reported using their prescription for 2 days or less. Medicaid patients consumed significantly more pills, while Medicare patients consumed significantly less pills, than other payer types. Seventy-seven percent of patients reported using 15 pills or less with nearly half using 0 to 5 pills. Based on the patients interviewed, an average of 19 tablets remained unused, leaving 4,639 pills left over.
Dr. Rodgers spoke of the hazard of “opiates in the wild.” These drugs might come from primary care physician opioid prescriptions for pain, pain management patients “on contract,” and pills from “Grandma Smith after a knee scope.”
In conclusion, he recommended prescribing 15 tablets with one refill. By this regimen, 23 percent of the patients in the study would have to request a refill. Patients may face additional copayments or out-of-pocket expenses as a result, but Dr. Rodgers noted that with a 79 percent reduction of leftover medications “the inconvenience is justified.” He advised colleagues to “have the conversation with your patients.”
Wrist fracture protocol
Dr. Nelson described a protocol he developed and studied in 59 consecutive patients who underwent surgery for distal radius fracture. The patients were given preoperative counseling about pain management. Patients were excluded if they had sustained multiple traumas, were already taking opiates, or were unable to remember how many pills they had taken. Patients were offered the following options:
- face-to-face discussion
- webpages with didactic material and patient statements
- long-acting acetaminophen plus NSAID the morning of surgery
- preincision block with lidocaine and epinephrine
- postsurgical block with bupivicaine and epinephrine
- long-acting acetaminophen plus NSAID after surgery
- hydrocodone/acetaminophen for breakthrough pain
- a follow-up telephone call the day after surgery
The average number of hydrocodone pills taken within 10 days was 0.68. “I know you don’t believe me, but I swear it is true,” Dr. Nelson said. He said that his protocol, described at his website, might serve as a model by which other surgeons can design a pain management approach that fits their practice situation.
Distal radius fractures might be used as an index surgery by surgeons to assess the effectiveness of their pain management. “If surgeons assess and improve their effectiveness while at the same time prescribe less opioid medication, we might decrease physician contribution to the opioid epidemic,” he said.
Loree K. Kalliainen, MD, a plastic surgeon in St. Paul, Minn., discussed her efforts to decrease opiate use, including the development of a pain management protocol that effectively controlled pain in a prospective study of patients undergoing moderately painful surgery, with reduced opioid use as measured by the quantity of hydrocodone taken.
She said a number of factors accounts for the rampant and often unnecessary use of opiates, including the following:
- direct-to-consumer marketing
- overmedication for pain
- the adoption of pain as the “fifth vital sign”
- the concept of “if a little is good, more is better”
- increased self-medication
- improper disposal
She compared the opioid excess to that of overprescription of antibiotics and noted that The Joint Commission “has recognized that the current approach to pain—narcotics, narcotics, narcotics—has not been as effective as hoped.” She also speculated that “increased anxiety in the United States may have contributed to altered expectations regarding pain or altered the experience of pain itself.
“Changing practice patterns is difficult,” she continued. “There is a belief that no change is needed, a lack of awareness of risks. There is a fear of change, and of litigation. The wide variation within and among surgeons suggests no good rationale for prescription size.”
Disclosure information: Drs. Gurman, Rodgers, and Kalliainen—no conflicts. Dr. Nelson—AO; Orthofix. Dr. Ring—Wright Medical Technologies; Biomet; Illuminos.
Terry Stanton is a senior science writer for AAOS Now. He can be reached at email@example.com