Published 11/1/2015
Mary Ann Porucznik

Curbing Opioid Consumption: No Easy Task

Comprehensive plan needed to combat growing opioid epidemic

A comprehensive effort is necessary to help address the growing opioid epidemic in the United States, according to the AAOS Information Statement on Opioid Use, Misuse, and Abuse in Orthopaedic Practice. The statement, which was developed by the AAOS Patient Safety Committee and adopted by the AAOS Board of Directors at their October meeting, calls on orthopaedic surgeons to be accountable for their direct or indirect contributions to the epidemic and to responsibly develop solutions to effectively treat this epidemic.

The AAOS is also among the 27 physician organization members of the American Medical Association Task Force to Reduce Opioid Abuse, committed to identifying the best practices to combat this public health crisis and moving swiftly to implement those practices across the country.

"Although minimizing patient discomfort remains an important goal of orthopaedic care, great caution should be used in prescribing opioids," said David Ring MD, PhD, a member of the AAOS Patient Safety Committee. "The new information statement outlines specific strategies, considerations and collaborations for advancing safer and more effective pain management."

The statement calls for a comprehensive opioid program to decrease opioid use, misuse, and abuse in the United States. Such a program would include the following:

  • 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
  • support for more effective opioid abuse treatment programs

Strategies for success
The information outlines the following strategies for safer and more effective pain management and treatment:

Establish standardized opioid prescription protocols/policies: To depersonalize discussions about opioids, standardized opioid protocols should be used in all settings (inpatient, outpatient, office). Surgeons and team members should explain to patients that opioid protocols/policies benefit patients and extended families and cannot be violated.

Limit use of extended-release opioids: Because acute pain following injury or surgery typically improves over hours to days, extended-release opioids should not be used to treat acute pain. The effectiveness, risks, and role of long-term opioids for nonmalignant pain are unclear. Orthopaedic surgeons should consider using alternative nonopioid treatments or referring patients to multidisciplinary pain centers for treatment of chronic nonmalignant pain.

Restrict 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.

Use predictive opioid use/misuse/abuse tools: Patients at risk for greater opioid use should be identified. 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.

Communication strategies: Surgeons should script and practice empathetic and effective communication strategies, appropriate for all levels of health literacy.

Professional, 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 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 during recovery.

Improved 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, or practice, especially when dealing with patients who have ongoing or chronic pain issues.

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.

Continuing 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.

Quality 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.

Maintenance 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.

Opioid 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 death.

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. Physicians, patients, and caregivers in the United States need to learn how to treat pain with less dependency on opioid medications.

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

Additional Information:
Opioid information statement