The clinician's perspective
Although a flurry of legislative and regulatory activity in response to the opioid crisis has reduced the volume of opioid medications being dispensed, the epidemic of addiction continues to be a serious issue.
Orthopaedic surgeons, who account for 7.7 percent of the total opioid prescriptions dispensed in the United States, often find themselves among the physicians most scrutinized in regard to prescribing patterns—all the while, responding to competing mandates both to curtail the dispensing of drugs to which some people become addicted and to provide optimal and appropriate care to their patients.
At the 2016 AAOS Fall Meeting—which included the convening of the Board of Councilors, whose 90-plus members are elected by state and regional orthopaedic societies to keep an eye on the front lines of medicine—a symposium was dedicated to issues surrounding opioid abuse and the corresponding regulatory and legislative activity. A view of that activity from the perspective of the American Medical Association (AMA) was previously presented in the January issue of AAOS Now, in an interview with AMA President Andrew Gurman, MD.
Providing a surgeon's perspective on the opioid issue was David S. Jevsevar, MD, MBA, chair of the AAOS Council on Research and Quality.
A surgeon's view
Dr. Jevsevar prefaced his remarks by saying, "I'm cynical about how we got here, but optimistic about the future."
He noted that before the 1990s, opioids were not routinely used in orthopaedic care.
"All that changed in the 1990s, when we took a very different view of what pain is," he said. "We became okay with the idea that painkillers were used after surgery and that they were not addictive. We said pain has no purpose, though we know from an inflammatory standpoint, there is a purpose for pain. We said that subjective reports should be accepted, as in the smiley-face forms that our nurses call us on when a patient in the hospital has pain."
Much of this mindset is "based on a fallacy," he said.
"The whole concept that when we give pain medicine after surgery it is not addictive is from a letter to the editor in the New England Journal of Medicine based on one person's experience. There is no scientific article that says that pain medication is not addictive when given for postoperative pain. There never was such a paper, and this letter is what is cited.
"Our own government called the first decade of the 2000s the 'Decade of Pain Control and Research,'" he continued. "We increased our pain control without as much research as we would have liked to have.
"The opportunity for our patients to become addicted when we prescribe opioids postoperatively has been reported to be anywhere from 1 percent to 40 percent," he continued. "So, the opportunity for addiction definitely exists in postoperative pain relief."
Conflicts of interest
In addition to vast spending by manufacturers to market their drugs, there is evidence that pharmaceutical companies promoted misleading information about pain medication, and investigations have revealed extensive ties between drug companies and nonprofit organizations.
"I have no problems with conflicts of interest, but we have to identify when conflicts occur," said Dr. Jevsevar. "The literature shows that there were significant conflicts of interest that changed not only the medical and healthcare agenda, but also the national and legislative agenda."
According to Dr. Jevsevar, the government contributed to increased use of opioids through various quality of care initiatives to measure patient satisfaction.
"The intent was good in measuring patient experience," he said. "The problem was that the item most correlated with our patient experience was good pain control. So if we gave good pain control, we were likely to get a good Hospital Consumer Assessment of Healthcare Providers and Systems score. Anyone practicing would look at this and take the path of least resistance, which was to do our best to control pain and get those scores of 10 down to 2s and 3s."
The Centers for Medicare & Medicaid Services created "pay-for-performance" incentives, and penalties increased dramatically under the Affordable Care Act, noted Dr. Jevsevar.
"So those of us who are more likely to write a lot of pain medication prescriptions are more likely to get good reviews from our patients," he stated. "People are happy when they get lots of drugs. That may be a cynic's view of how we got to where we are, but I think that is a reality."
Prior use of pain medication is significant, asserted Dr. Jevsevar.
"Thirty-four percent of patients who come to my total joint practice are already on some form of narcotic pain medication," he said. "What to do with those patients is challenging. We know that there is also a risk in the postoperative period."
In the trauma population, patients may face psychological problems stemming from their experiences, noted Dr. Jevsevar.
"We have to remember that every procedure we do is a controlled traumatic event for these patients," he said.
When physicians do prescribe pain medication, how the patient uses is it is uncontrolled. A survey found that of the actual number of pills prescribed, 28 percent were used for pain relief.
"We don't really know what happened to the other 72 percent of those pain medications," said Dr. Jevsevar. "We can estimate that at least some of those meds ended up on the street."
Piecemeal legislation by states can simply shift where patients go to seek prescriptions.
"When Maine restricts pain medications, those patients are going to end up in New Hampshire (where Dr. Jevsevar practices, at Dartmouth) and Massachusetts," he said.
Tools for the clinician
Perioperative counseling is significantly beneficial, said Dr. Jevsevar.
"The ability to sit with patients and go through with them what their pain needs and concerns are can be helpful," he noted.
"There are validated assessment tools such as the Brief Risk Questionnaire and the Patient-Reported Outcomes Measurement Information System (PROMIS) Pain Interference (and Depression) score," he said. "Studies show that even in patients with cancer, there aren't so many with pain in the extreme of between 8 and 10. So when our patients are talking about the 8 to 10 range, they may be patients with other issues going on in their lives that are stimulating pain generators. It takes time for us to figure those out. These are important discussions to have."
Prescribing protocols are also useful.
"They're not evidence-based, but that's okay—we don't have a lot of evidence in this area," he said. "Use your best judgement in trying to decrease the variation in use of pain medications. It's important to turn the pain management issue over to the primary care physician (PCP) and have that ongoing dialogue with them. There is a big disconnect between us giving the prescription, and the PCP giving the prescription.
"The one thing that few of us do, probably because of reasons related to time, resources, and insurance, is refer these patients to those who can actually treat these underlying problems," he continued. "Unfortunately, our health system doesn't pay for that, but hopefully this crisis will lead us in that direction."
Dr. Jevsevar offered some practical recommendations.
"Patients taking suboxone or opioids for chronic pain are patients who most of us as orthopaedic surgeons should not treat with medication postoperatively," he said, noting that these patients can be referred to others, such as pain specialists or PCPs.
He recommended that new patients who do not have acute conditions should not be given opioids.
"I think orthopaedic surgeons are pretty good at this, but it is important that we don't start the problem," he said. "We need to check statewide databases before prescribing."
Dr. Jevsevar said his practice provides a set amount of opioids for pain after surgery or injury, and "we find that patients are pretty good with that."
In his view, it is beneficial to explain to patients "that pain is normal and part of the healing response, and the pain they have is not abnormal. So many think that any pain they get is abnormal and can be controlled by medication. The discussion should be, 'Look, after surgery you are going to have some pain. We want to get an 8 down to a 3 or 4, and it might take a while to get down further.'"
Orthopaedic surgeons should not prescribe pain medication for chronic pain, he said.
"That is not in the purview of our specialty," he noted, adding that orthopaedists should avoid prescribing extended-release pills, as "they are not intended for acute postoperative pain."
He urged surgeons to use the resources on the Patient Safety section of the AAOS website— specifically, the Pain Relief Toolkit (http://www.aaos.org/Quality/PainReliefToolkit), which includes clinical vignettes that contain practical information.
Overall, Dr. Jevsevar said, "We're heading in the right direction. We want to get to pain relief that is not based on opioids, and we have a ways to go."
Also speaking at the symposium were Daniel M. Frohwein, MD, an anesthesiologist, and Adrianna Simonelli, a professional staff member for the House Energy and Commerce Committee.
Terry Stanton is the senior science writer for AAOS Now. He can be reached at firstname.lastname@example.org