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Be proactive: Avoid adding to the opioid epidemic
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There is an epidemic of opioid use and prescriptions in the United States directly related to physicians’ desire to care for patients with pain. The United States consumes 80% of the worldwide legal opioid supply, despite only being 4.5% of the world’s population.
If one event may be considered a catalyst of the opioid epidemic, it was the designation of pain as the fifth vital sign. In the late 1990s, the American Pain Society promoted pain as the fifth vital sign to be included in every routine assessment by health care providers. It has been one of the most successful marketing programs in medicine, leading to the rapid expansion of pain management.
In 2000, the movement toward better care of pain led to the development of guidelines for pain assessment in Pain as the 5th Vital Sign Toolkit, which later became a Joint Commission standard. That year, President Clinton signed H. R. 3244 which declared 2000 to 2010 as the Decade of Pain Control and Research.
Anthony A. Romeo
Pain is not a sign by any definition. Unlike the original four vital signs, pain is not objectively measured and imparts a patient’s bias and life experience into the assessment. There can be a disconnection from pain symptoms and how they relate to medical or surgical conditions. Pain should not be considered a sign whose presence objectively indicates a specific medical or surgical condition.
Incentives
Other factors have continued to foster a strong emphasis on pain management. Incentives are driven by the false belief that patient care should be free of pain. There is an increasing focus on a patient-centric system that assesses the value of care by patients’ experiences. Topping the list of the patient experience and perceived satisfaction is their evaluation of how health care providers managed their pain. Patient responses directly affect the most influential driving force in health care, which is not the various experts’ opinions on what constitutes value, but rather financial reimbursement. CMS has weighted patient satisfaction at 30% of the purchasing program. Hospitals and other health care systems have implemented patient satisfaction surveys and tools to not only demonstrate value to the patient, but also to provide feedback to physicians and other health care providers on their ability to satisfy patients. The patient’s pain experience plays a vital role in this process.
There is a general belief from policymakers that a satisfied patient, as defined from the patient’s perspective, receives a higher value or benefit from care. One area significantly connected to patient satisfaction is the level of pain. If patients report a lower satisfaction due to pain, then it is expected physicians will improve or increase pain management efforts. Where orthopedic care is frequently associated with high levels of acute pain, patient satisfaction scores can be improved by providing high levels of narcotics and pain management strategies, even though this may not best long term. Patients with a history of presurgical opioid abuse likely will have higher subjective needs for postoperative opioid treatment. A greater number of patients are aware of the ramifications of their satisfaction scores and they have learned to be more demanding with pain management. The overall influence of patient satisfaction scores has a perverse role in providing an environment that fosters opioid abuse without considering that opioid misuser’s overall medical costs are estimated to be eight-times greater than those of non-misusers.
Be more proactive
Orthopedic surgeons are the third highest prescribers of opioid prescriptions among physicians. Despite representing less than 4% of the physician population in the United States, we account for an estimated 7.7% of opioid prescriptions. In addition to influential outside sources such as hospital systems, academic institutions and government, orthopedic surgeons have been trained that patients require substantial narcotic support to tolerate and recover from many treatments.
Although we generally accept the challenges of treating patients already on opioids when we assume their care, orthopedic surgeons need to be more proactive in the management of patients when we initiate care to avoid adding to the epidemic. An awareness of patient factors that predict future opioid abuse helps to establish expectations for postoperative care. The challenge is most patients do not have obvious signs of future substance abuse. Patients have a legitimate need to have pain effectively treated after surgical intervention, but unfortunately, some patients will develop opioid dependency while we are their primary care providers. Without objective measures, we are conflicted in addressing patients’ problems based on our subjective assessment and emphasis on overall patient satisfaction.
The strongest predictive factors for opioid abuse are typically not addressed during orthopedic management, including mental health conditions, and psychotropic medication usage. Other well-recognized factors can provide clues and may encourage an open and honest dialogue, including an effort to set realistic expectations. In a patient’s history, risk factors include a personal or family history of substance abuse, nicotine dependency, and age younger than 45 years, depression or other mental health disorders, and preoperative opioid use. As prescription drug monitoring programs expand to all states, additional information is available to help screen patients for risk. In some settings, it may be appropriate to consider specific opioid risk-assessment tools.
Pain control
We must accept that pain control is an important and frequently evaluated determinant of patient satisfaction. Tremendous effort must be made to set realistic patient expectations about the expected level, effectiveness and duration of pain postoperatively.
The development of standard pain management protocols for specific surgical procedures that describe the medication, duration of pain and plan for tapering its use is valuable. Standard protocols help patients, their families and the health care team identify deviations from protocols that may be the sentinel findings of early opioid abuse. Early intervention may help avoid complicating orthopedic treatment with opioid tolerance, withdrawal, dependency or overdose. Consultation with pain management specialists also may help provide patients with appropriate treatment.
References:
www.unodc.org/documents/wdr2014/World_Drug_Report_2014_web.pdf.
www.va.gov/painmanagement/docs/toolkit.pdf.
For more information:
Anthony A. Romeo, MD, is the Chief Medical Editor of Orthopedics Today. He can be reached at Orthopedics Today, 6900 Grove Rd., Thorofare, NJ 08086; email: orthopedics@healio.com.
Disclosures: Romeo receives royalties, is on the speakers bureau and 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.