Efforts of state governments, orthopaedic societies, and the AAOS
Although many patients may benefit from opioid medications, abuse of prescription opioids is a serious problem responsible for nearly 50 deaths a day and thousands of emergency department visits a year. For example, the number of emergencies related to nonmedical use of opioids increased 183 percent between 2004 and 2011. In response, state governments passed nearly 60 laws in 2015 aimed at curbing the opioid epidemic. However, according to a study published in Practical Pain Management, many of these laws have left "an increasing proportion of legitimate chronic pain patients unable to fill their prescriptions."

State laws with specific mandates that impact orthopaedic surgeons are generally related to continuing medical education (CME) requirements, querying prescription drug monitoring programs (PDMPs), and quantitative limits to prescriptions. Currently, 15 states have CME requirements for opioid prescribers. Although these laws vary, with some impacting only pain management clinics, many affect AAOS members.

For example, the New York law requires prescribers who hold a Drug Enforcement Administration license to complete a 3-hour course on pain management, palliative care, and addiction. To help orthopaedic surgeons comply with the mandate, the New York State Orthopaedic Society created an information webpage (http://www.nyssos.org/education/pmc.html). The page includes information on online modules from the Boston University School of Medicine Safe and Competent Opioid Prescribing Education course and the New York Chapter of the American College of Physicians.

PDMPs are state electronic databases that track prescriptions of controlled substances, including opioids. Currently, at least 26 states require prescribers to query the PDMP before prescribing an opioid medication (Fig. 1). However, these requirements significantly vary by state. While some states require prescribers to check the PDMP before writing the majority of opioid prescriptions, others mandate checking the PDMP only for certain providers or under certain circumstances, such as when a provider has a reasonable belief of inappropriate use or if the prescription is for chronic pain.

The Texas Orthopaedic Association (TOA) recently created a webpage (http://www.stateortho.com/txpdmp/) designed to enable orthopaedic surgeons to advocate for proven, patient-centered solutions. According to the grassroots page, "TOA has indicated to lawmakers that the PDMP is an appropriate tool that physicians will utilize when it is necessary.  However, as TOA has pointed out to lawmakers in a recent hearing, 'doctor shoppers' are not going to have a knee replacement surgery or purposely break their arm to access prescription drugs." The TOA is advocating for policies that utilize data from PDMPs to flag patients who attempt to obtain opioid prescriptions from several physicians.

Setting limits
A popular solution to the opioid epidemic among many politicians is setting quantitative limits on opioid prescriptions. With little scientific research supporting the solution, however, state medical societies have sought to mediate its impact on the patient-physician relationship. The Ohio State Medical Association, for example, worked with Gov. John Kasich in March of this year to announce new rules that will create prescription limits of painkillers for up to 7 days for adults and 5 days for kids and teens, with limits only applying to acute pain patients. Exceptions include patients with cancer, those in hospice care, and medication-assisted addiction patients. Prescribers in Ohio can override the limits if they provide a specific reason in the patient's medical record.

In February 2017, Gov. Chris Christie of New Jersey signed a bill into law that sets a 5-day limit on initial prescriptions for pain-killing opioids, with few exemptions. He declared the law, "the toughest in the country in the fight against heroin and opioid addiction." Although Gov. Christie said, "we are taking action to save lives," his administration gave little proof of the efficacy of the law while patient groups decried the potentially dangerous approach. New Jersey physicians opposed the law's "one size fits all" approach and declared it "cruel" to patients.

In 2016, during a meeting of the National Governors Association (NGA), 46 governors signed the Compact to Fight Opioid Addiction. The compact aims to reduce inappropriate prescribing, changing the public's understanding of opioids and addiction, and creating pathways to recovery for individuals with addictions. The NGA Center for Best Practices developed a road map to help states prevent, respond, and treat opioid misuse as well as strengthen law enforcement efforts to address illegal supply chain activity. According to the NGA, "It is designed as a policy development tool, allowing a state to use all or portions of the road map as it applies to their unique situation."

AAOS efforts
In November 2015, the AAOS released an information statement titled "Opioid Use, Misuse, and Abuse in Orthopaedic Practice." The document says, in part, "The AAOS believes that a comprehensive opioid program is necessary to decrease opioid use, misuse, and abuse in the United States. 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; and support for more effective opioid abuse treatment programs are needed."

During the 2017 Annual Meeting, the AAOS introduced a multimedia public service campaign to highlight the potential dangers of opioids. The campaign includes display and radio ads, urging doctors and patients to exercise caution in prescribing and taking opioids (Fig. 2). For more information, visit http://orthoInfo.org/PrescriptionSafety

Despite legislative and other efforts to stem the tide of opioid abuse, the crisis still affects many Americans. The National Safety Council provides toolkits and resources for addressing substance abuse in the home and workplace. To learn more, visit: http://safety.nsc.org/rxemployerkit

Manthan Bhatt is the state government affairs manager in the AAOS office of government relations. He can be reached at Bhatt@aaos.org

AAOS Pain Relief Toolkit
For more resources from the AAOS regarding opioids, access the AAOS Pain Relief Toolkit at https://www.aaos.org/Quality/PainReliefToolkit/

Additional Information:
AAOS information statement "Opioid Use, Misuse, and Abuse in Orthopaedic Practice"