David Ring, MD, PhD, explores strategies for managing pain without overprescribing pan medication.


Published 5/1/2016
Stephanie Hazlett

Risk Evaluation and Management Strategies for Prescribing Opioids

During the AAOS Annual Meeting, experts discussed the epidemic of opioid drug use, misuse, and abuse in the United States, and focused on ways in which orthopaedic surgeons can practice safe and effective pain management for their patients.

"Risk Evaluation and Management Strategies for Prescribing Opioids," a symposium moderated by Thomas Fleeter, MD, began with a presentation by David H. Sohn, MD, JD, who explored the complicated legal landscape that has developed around physicians' prescribing habits. In recent cases in different states, he noted, physicians have been found liable both for underprescribing and overprescribing pain medications.

So what is an orthopaedic surgeon to do? Dr. Sohn recommended that surgeons use standardized practices to document a complete physical exam, do not prescribe over the phone, and prescribe only per protocol. Additionally, he recommended having a standardized practice to document the physician's discussion with the patient about the risks of opioid use and dependency and the importance of not driving or operating heavy machinery while taking opioids.

Dr. Sohn also noted that the Centers for Disease Control and Prevention (CDC) issued guidance that instructs prescribers to avoid opioids for chronic pain, talk about the treatment plan with the patient before starting long-term opioid treatment, discuss risks with the patient, choose short-acting rather than long-acting opioid medications, always prescribe according to the lowest possible dosage, always have the shortest possible intervals of opioid use, continually evaluate patients, provide risk factor forms for patients to add to their medical records, and use urine drug tests randomly, among other things.

David Ring, MD, PhD, chair of the AAOS Patient Safety Committee, discussed how to manage pain without overprescribing pain medications. Dr. Ring noted that there are various pressures on physicians to prescribe opioids, including genuine care about a patient, time pressure on visits, patient satisfaction pressures, and lack of reimbursement for treatment and evaluation of addiction. However, Dr. Ring noted, "pain does not always follow the nociception. More opioids do not always equal more pain relief. Interventions to optimize self-efficacy [ie, a patient's ability to manage his or her own pain via various methods] may be a more effective means of pain control."

Dr. Ring recommended that physicians practice communicating with their patients about their pain. He also noted that practices should develop a clear office policy around prescriptions, and that physicians may want to include a psychosocial screening evaluation for patients choosing elective procedures. In addition, he urged physicians to discuss pain management and expectations with patients before and after surgery.

On a broader level, Dr. Ring noted the need for a national, centralized, and automatic drug monitoring program, well-developed consensus standards, public education, access to data, and funding for studies on safe pain relief, behavioral health, and addiction.

Paul Arnstein PhD, RN, the final speaker, discussed the need to relieve severe postoperative pain to reduce cardiovascular, respiratory, and neuro-endocrine morbidity that may delay rehabilitation and prolong institutional care.

"Opioids have traditionally been first-line therapy, but are not considered second-line for moderate pain," noted Dr. Arnstein. "For severe pain, they are used as part of multimodal therapy in the lowest dose, for the shortest duration possible."

Dr. Arnstein noted that CDC Guidelines and recent legislative initiatives may help curtail opioid overprescribing. "To do so," he stated, "without sacrificing patient satisfaction and quality outcomes, practices will need to focus more on patient education about safe use, storage, and disposal of opioids. Physicians will need to set clear expectations that some pain is a natural part of the healing process, and help patients learn strategies to relieve physical and emotional aspects of pain without over-relying on opioids."

Stephanie Hazlett is a government relations specialist in the AAOS office of government relations. She can be reached at hazlett@aaos.org