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Pain management will be driven by shared risks to provide the best value for care
Despite advances to avoid iatrogenic injury during surgery, patients still experience a significant increase in acute pain, and pain remains a challenge to effectively treat.
Every patient has unique needs and responses. More than 50% of patients may describe their pain as moderate to severe 2 weeks or more after surgery, and at least 80% of patients require prescription analgesics. One of four patients will experience an adverse event related to analgesics, which can lead to other orthopedic complications, such as a fracture after a fall. Furthermore, patients who have inadequate pain management are more likely to be inactive and noncompliant with postoperative rehabilitation protocols.
Addressing postoperative pain preoperatively is valuable and can be challenging when the patient is already using narcotic medication. Many studies have demonstrated the inability to achieve equal outcomes for the same diagnosis for patients with and without preoperative narcotic use. This is not just related to their pain experience. It also affects objective outcomes, such as range of motion, strength and function.
Accountability
Orthopedic surgeons are directly and indirectly being held accountable for patients’ experiences. However, our methods to manage pain have not been very sophisticated and often do not adequately respond to patients’ needs.
Anthony A. Romeo
Many orthopedic surgeons have had minimal formal training in understanding pain and how to effectively treat it. Our “go-to” medication has always been a narcotic medication, beginning with intravenous opioids during the monitored care phase, and then converting to an oral narcotic once patients are independent and unmonitored. The process is imprecise, and we use past experiences to try to titrate the amount of medication needed for each patient. We have our own personal biases about pain experiences and the patients we have cared for, and we impart the biases on patients.
If a patient has no history of narcotic, alcohol or drug use, then we give that patient a usual amount of narcotic medication and expect the patient to internally manage the exacerbations of acute pain. If we detect potential risk factors indicating a greater need for pain control, then we may prescribe a stronger dose or stronger narcotic medication for a short period of time, understanding this increases the risk of nausea, vomiting, urinary retention, inactivity and other adverse events. The goal is to treat patients effectively so they do not need to call the office or go to an emergency room, but also to avoid complications. This “guessing game” is played out every day with surgeons of all specialties.
Despite the sense that patients should be held at least partially accountable for their decreased outcomes, they are not. They will be asked by numerous sources about the adequacy of their pain management. This will happen before and after surgery and after discharge from the facility. Their responses to these questions are used to evaluate the quality of the care provided, independent of the patient’s own personal risk factors. Furthermore, inadequately controlled postoperative pain can result in admission to the hospital in up to 2% to 3% of outpatient procedures, which is one of the most costly events in terms of dollars spent on care and the negative impact on physician evaluations.
If we do not do a better job managing patient expectations and pain, then our overall evaluations will be negative. In the future world of value-based care, this will have a direct effect on reimbursement and access to patients. To survey the patient perspective on hospital care, CMS has initiated the Hospital Care Quality Information from the Consumer Perspective. Questions include “During this hospital stay, how often was your pain well controlled?” and “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?”
Perioperative guidelines
In an effort to stimulate better dialogue and to improve the results of postoperative pain management, the American Society of Anesthesiologists (ASA) released perioperative guidelines in 2003. This led to a significant interest in multimodal analgesia during the immediate pain management care provided around the surgical experience. The efforts of the ASA improved patients’ experiences while under the care of anesthesiologists, however, it has taken time for orthopedic surgeons to understand their expanded role in this part of patient care, especially after discharge from an ambulatory surgical care center or hospital. A key factor in this process has been the ability to dramatically reduce the need for narcotic medication and substitute other medications and modalities at various points.
Anesthesiologists have been better about pre-emptive analgesia, including the use of a cocktail of medications such as narcotics, benzodiazepines, acetaminophen and COX-2 inhibitors, combined with regional nerve blocks so patients are less anxious about the pain they are going to experience and have little or no pain immediately after surgery. This can be supplemented by the surgeon providing local long-acting liposomal bupivacaine at the conclusion of the procedure. The use of less narcotic medication, combined with antiemetic medications leads to less nausea, vomiting, somnolence and respiratory depression. These strategies have led to the ability to perform total joint replacements and spine surgery on an outpatient basis.
Multimodal approaches
The evolution of elective orthopedic procedures being performed on an outpatient basis is possible because of multimodal analgesia, which begins before the procedure, continues during the procedure, and is maintained after the procedure and discharge from supervised medical care. Lessons learned from perioperative multimodal approaches are now possible to continue after the patient is unsupervised, such as patient-controlled analgesia through local anesthetic pain pumps, and in the future, through patient-controlled oral drug dispensers that have a safety lockout period and limits on maximal dosages.
This care model leads to improved value to the patient at every possible level of care. Patient and provider ratings are high, the care is efficient and effective, the risk of complications is reduced, and the overall value for the intervention is maximized. Furthermore, the development of significant chronic pain — pain greater than three out of 10 that persists beyond 3 months from surgery — is significantly reduced with the multimodal approach during the acute pain phase.
Develop a clear protocol
As orthopedic surgeons, we are held primarily responsible for patients’ pain experiences and their pain management. Trying to guess the pain tolerance for each patient, knowing little about his or her psychological and physiological makeup, is a lottery game that will affect the value of care and future reimbursement. We cannot achieve a more consistent and effective level of pain management without the incorporation of modern principles of multimodal analgesia.
I encourage you to sit down with the anesthesiologists and develop a plan. Have a clear pre-emptive analgesia protocol, which can include oral medications the night before or the morning of surgery, intravenous medications combined with regional nerve blocks preferably performed with ultrasound guidance, and local anesthetics to block the pain stimulus. Continue with an effort to minimize narcotics during the procedure, maximize the management of nausea, and provide anxiolytics. Postoperatively, consider patient-controlled analgesia techniques and a cocktail of medications that work on different regions of the pain pathway and minimize the use of narcotics.
The future model of perioperative pain management must improve over the current standard of prescribing variable levels of narcotic medication. The multimodal model will be driven by the experience of the patient, the drive toward outpatient surgery and the shared risks among patients, physicians and health care facilities to provide the best value for surgical care.
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Disclosures: Romeo receives royalties, is on the speakers bureau and is a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.