Responsible musculoskeletal pain management is up to the orthopedist

Orthopedists' role in pain management includes counseling, educating patients about opioid misuse

Opioids are a main class of pain management drugs that started to be used more often in the U.S. and Canada about 20 years ago, with the HHS now reporting more than 650,000 opioid prescriptions on average dispensed per day in the U.S. However, prescribing opioids and informing patients about opioid misuse issues is just one part of the orthopedic surgeon’s role in pain management. In this Cover Story, orthopedic surgery, trauma, anesthesiology and pain medicine experts discuss responsible pain management and how orthopedic surgeons should approach pain management and better collaborate with other specialties to achieve optimal resolution of their patients’ pain.

To engage orthopedic surgeons in the process of decreasing the prescribing and misuse of opioids, the American Academy of Orthopaedic Surgeons initiated a public service campaign that includes advertisements. It developed a pain relief toolkit aimed at orthopedic surgeons, which provides them with information about postoperative pain relief, prescribing guidelines for common pain relief situations and strategies for establishing an opioid prescribing policy.

“Orthopedic surgeons are among the highest prescribers of opioids, in general. Although we are not involved necessarily in treating patients when they have opioid problems, we can be more involved in making sure that we are not inadvertently prescribing excess opioids and putting more unnecessary opioids out in the community,” Asif M. Ilyas, MD, program director of hand surgery fellowship at the Rothman Institute and associate professor of orthopedic surgery at Thomas Jefferson University, told Orthopedics Today.

Counseling, educating patients

Source: Christopher S. Ahmad, MD

The orthopedic surgeons’ approach to managing their patients’ pain should be centered around proactive, preoperative opioid counseling, multimodal pain strategies used perioperatively and thoughtful prescribing of opioids postoperatively. In particular, prior to surgery, orthopedists should counsel their patients on what type of pain the patient should expect postoperatively and the pain management options available to safely manage and minimize their pain experience, according to Ilyas.

“Central to this counseling is explaining the risks and benefits of opioids, encouraging non-opioid alternative treatment modalities and preparing them for their likely postoperative pain experience,” Ilyas said. “All of that kind of counseling and education and preparation will help [patients] better manage their discomfort and lead to less and more careful use of opioids, when they are used.”

Preoperative counseling is particularly beneficial now, as outpatient surgery has become increasingly more common, according to sources.

“We cannot have patients learning on the fly how to manage their discomfort in an outpatient setting like that, so preoperative counseling is essential,” Christopher S. Ahmad, MD, chief of sports medicine at Columbia University and head team physician for the New York Yankees, told Orthopedics Today.

Implementing strategies

Orthopedic practices, departments and individual surgeons should establish a pain relief strategy that clarifies the type and number of opioid pills prescribed for a certain diagnosis or procedure. Having set limits for the maximum number of opioids that orthopedists can prescribe per patient helps depersonalize discussions about safe and effective pain relief, David C. Ring, MD, PhD, explained.

“This is the maximum [of opioids] that people will be given for this problem, nobody should need more than that and, if they do for some reason believe they need more than that, then another expert should get involved, whether it is an addiction specialist, a pain medicine specialist, a psychologist, a social worker or a psychiatrist. When people are given opioids after the body has gotten through the initial healing period, that is likely a misdiagnosis of stress and distress. Opioids are not an effective treatment of symptoms of depression or anxiety,” Ring, associate dean for comprehensive care at Dell Medical School at the University of Texas at Austin, told Orthopedics Today.

Another helpful strategy is to avoid the use of extended release opioids. Orthopedic surgeons treat acute pain associated with injury or surgery. There is doubt about whether opioids do more harm than good when used to treat persistent pain, he said.

“Orthopedic surgeons can simply stay out of that by making it practice policy,” Ring said.

“Opioids are habit-forming and dangerous,” Ring, an Orthopedics Today Editorial Board Member, said. “Everyone should take as few pills, of the smallest dose, for the shortest time possible, and mostly for sleep. This is usually for a matter of days after big surgeries.”

Furthermore, “the reason to emphasize pain relief is it should not be about what you are not getting. We should always be about getting patients comfortable. Giving a safe amount of opioids is one aspect of it, but there is so much more to getting comfortable and recovering well,” he said.

Opioids are just one option for musculoskeletal pain management. In fact, orthopedic surgeons in other countries prescribe remarkably few opioids and their patients achieve comparable pain relief, Ring said.

“Most of the world treats pain after surgery or after injury with few opioids,” he said. “If you do any kind of charity or other work in another country, you will witness that first hand. You could do a major surgery, provide acetaminophen for pain relief, and achieve comfort and a patient who is satisfied with their pain relief. That is a striking example of the degree to which psychological and sociological factors determine the intensity of pain experienced for a given degree of nociception — the physiology of potential or actual tissue damage.”

Regional anesthesia and analgesia used intraoperatively should be one of the foundations of orthopedic surgery since both strategies can easily block pain, Asokumar Buvanendran, MD, president of the American Society of Regional Anesthesia and Pain Medicine noted.

Ultrasound for placement of local anesthetic has increased its precision and has therefore resulted in better, more reliable pain relief for patients, he said, noting that using ultrasound for placement of regional anesthesia, in particular, has evolved in the last 5 years to 10 years.

“Therefore, the precision with which we can place local anesthetics close to the nerves that are being operated, and therefore providing prolonged pain relief with combination drugs for the nerve blocks, is tremendous,” Buvanendran told Orthopedics Today.

A multimodal approach, such as creams, pills and injections, may also reduce pain after surgery, according to Ahmad.

“The multimodal strategy is to use other medications in a combination and those medicines typically include acetaminophen, a nerve modulating medicine, gabapentin, in one and then a high-dose anti-inflammatory medicine, Toradol (ketorolac tromethamine; Roche Pharmaceuticals). When that gets started in the immediate postoperative phase when discomfort seems to be the greatest, the amount of narcotic that is needed is dramatically reduced and when that is also combined with icing and cryotherapy strategy and early physical therapy, I have observed an extremely dramatic reduction in the amount of narcotic pain medicine,” Ahmad, who is the Shoulder and Elbow Section Editor for Orthopedics Today, said.

Depending on the injury, F. Todd Wetzel, MD, president of the North American Spine Society, said orthopedists can use gabapentin, acetaminophen, lidocaine, capsaicin or steroids, among other approaches for pain management.

“This is not a ‘cookie cutter’ business where you put everybody on the same thing,” Buvanendran said. “Obviously, you have to tailor the individual surgery to the protocol. Obviously, from experience, you will know what works and what does not work, but each surgical type needs to have a different set of protocols.”

Multimodal management

Research has shown the use of multimodal analgesia postoperatively may help reduce how many opioids are prescribed at discharge from the hospital and be helpful in tackling the opioid crisis, Buvanendran noted.

“Statistically and nationally, we know that part of the opioid crisis is from secondary and tertiary use because normally [surgeons] give 120 tablets or 90 tablets at discharge and maybe less than 50% is used and the remaining [pills] are left in the cabinets and used by secondary users and tertiary users,” Buvanendran said.

Ilyas noted that a study he and his colleagues did of more than 1,400 patients undergoing upper extremity orthopedic surgery found that patients used about one-third of their filled opioid prescriptions, which left two-thirds of the prescribed opioids available for diversion.

Some non-opioid medications have other drawbacks, according to Ahmad, who noted certain pain medicines can mask symptoms of complications, which can be problematic.

“Whenever we do anesthetic injections ... there is a concern we are going to mask symptoms and then the condition can actually get worse,” Ahmad said. “That is where the treating physician has to be considerate of all the factors — where the athlete is in their career, what the consequences are of a worsening condition either in the longer term or the short term.”

Assess medication use

Orthopedic surgeons must consider the types of medications patients are taking prior to surgery as a way to reduce surgical complications.

“Some patients respond well to some specific medicines because they have had history with prior surgery,” Ahmad said. “That is important to know so we do not have to repeat the history of a poor pain management experience.”

Several states have begun tracking pain management prescriptions in the electronic medical record to make surgeons aware of patients who were already prescribed opioids, according to Wetzel.

“That is obviously important to know because ... especially in the postoperative period, the surgeon needs to be the one managing the patient’s postoperative care, including medications, and that is a clear question of too many cooks being in the kitchen, if it is more than one person,” Wetzel said.

For easier management of postoperative symptoms, many spine surgeons wean patients off all pain medication preoperatively, he noted.

John M. Stamatos, MD, medical director of pain management at Syosset Hospital, in Syosset, New York, told Orthopedics Today that continuing patients on long-acting narcotics on the day of surgery may “mitigate any issues with them falling behind in the narcotics before they even get operated on.”

If patients are already having their chronic pain treated with narcotics, he said they may have a harder time finding pain relief after surgery.

For patient who are taking narcotics prior to surgery, “What we are doing is making sure they are getting adequate relief afterwards. If everyone who comes in is given the same formula, you are not going to be able to take care of patients adequately,” Stamatos said.

But, a challenge an orthopedist faces is how to approach pain management in these types of patients after surgery, because narcotics will not be enough to help reduce their pain. Therefore, he said surgeons may want to consider ketamine as an alternative pain reliever.

“[Ketamine] is a totally different drug that [patients] have not seen before,” Stamatos said. “The body is not tolerant to it, so we can give patients good pain relief immediately postop and then, as they get a little further out from the surgery, you can shut off the ketamine and they can go back to their routine chronic narcotics.”

In addition to educating patients on appropriate pain management strategies, orthopedic surgeons must be able to identify patients who are at higher risk for experiencing significant pain after surgery.

“It is always 5% ... of people coming in for surgery [who] have complaints and did not [have] good pain relief,” Stamatos said.

He said, “The orthopedist’s role is identifying patients who are at risk for having issues with their postoperative pain relief and getting them to the anesthesiologist, so we can take care of them.”

They should “treat pain like cardiac disease,” Stamatos said. “If you think someone has a bad heart you are going to get the cardiologist to do a preoperative evaluation and get it together. You should be doing the same thing with pain just to make the postoperative course smooth.”

Review the medical history

Surgeons must take into account the patient’s medical history, sources said.

Wetzel said patients with a history of previous surgery, long-term medication use and inflammatory disease tend to be associated with more difficult pain management.

“[They] need to be taken into account in both the preoperative conversation and the postoperative strategy because the strategy has to be individualized,” Wetzel said.

Patient age, gender and race can also impact the pain experience, Ilyas noted.

Patients with notable symptoms of stress or distress (anxiety or depression) or less effective coping strategies, such as low self-efficacy, experience more pain for a given nociception, according to Ring.

“What I think has been happening is we have been misdiagnosing the cognitive and emotional and stressful sides of recovery from injury and surgery, and mistreating them with opioids, creating or exacerbating the opioid crisis,” Ring said.

Collaboration

Enlisting the help of an anesthesiologist or pain management consultant can help reduce the amount of pain patients may experience after surgery, particularly those patients who are at higher risk for experiencing pain.

“Building a collaborative team between the orthopedic surgeon and the anesthesiologist and encouraging the anesthesiologist to have a regional-based anesthetic and a multimodal concept of pain management will lead to only improved outcomes in pain in your surgical patients,” according to Buvanendran.

Wetzel recommends orthopedic surgeons consult with a pain management specialist as soon as possible. They should also consult a pain management consultant if the patient is healing fine after surgery, but their pain medications are not getting them where they need to be, he noted.

“Postoperatively, if I feel as though a patient is not making appropriate progress in my postoperative management, specifically therapy medications are not getting the patient where they need to be and technically the surgery looks just fine — no problems with recurrent pathology, no X-ray or other imaging signs of failure of hardware — my own threshold has been to ask [physical medicine and rehabilitation] PM&R for help. Kind of what am I missing and how can we get this person back to where they need to be?” Wetzel said.

Orthopedic surgeons can also involve pain management specialists in patient education about pain expectations, particularly related to taking opioids chronically preoperatively, Ilyas noted.

“It is not as much who is doing the education as the education is being done on a formal basis preoperatively, thereby prepping the patient for the surgery or the treatment, preparing them for the pain they are going to have, understanding what their pain medication options are, including and emphasizing non-opioids whenever possible, understanding the expected duration of pain, understanding the risk factors for addiction if they are taking [opioids], so that they can have a good postoperative experience and avoid the pitfalls of opioid misuse,” Ilyas said.

Orthopedic surgeons should not be afraid to ask for help from their orthopedic colleagues or colleagues in pain management, anesthesiology or neurology, Wetzel said. However, orthopedic surgeons should not refer out patients who present with pain issues, but should help in their treatment.

“You are the musculoskeletal expert and you should be the person who understands that,” Wetzel said. – by Casey Tingle

• References:
• Kim N, et al. J Bone Joint Surg Am. 2016;doi:10.2106/JBJS.15.00614
• Managing pain with medications after orthopaedic surgery. Available at: http://orthoinfo.aaos.org/topic.cfm?topic=a00650. Accessed Sept. 29, 2017.
• Opioids: The prescription drug & heroin overdose epidemic. Available at: https://www.hhs.gov/opioids/index.html. Accessed Sept. 29, 2017.
• Pain relief toolkit. Available at: https://www.aaos.org/Quality/PainReliefToolkit/?ssopc=1. Accessed Sept. 29, 2017.
• Prescription opioid overdose data. Available at: https://www.cdc.gov/drugoverdose/data/overdose.html. Accessed Sept. 29, 2017.
• Prescription safety. Available at: http://www.orthoinfo.org/topic.cfm?topic=A00771. Accessed Sept. 29, 2017.
• The opioid epidemic: By the numbers. Available at: https://www.hhs.gov/sites/default/files/Factsheet-opioids-061516.pdf. Accessed Sept. 29, 2017.

• For more information:
• Christopher S. Ahmad, MD, can be reached at 622 W. 168th St., Columbia University, New York, NY 10032; email: csa4@cumc.columbia.edu.
• Asokumar Buvanendran, MD, can be reached at 1653 W. Congress Parkway, #759, Chicago, IL 60612; email: asokumar@aol.com.
• Asif M. Ilyas, MD, can be reached at 925 Chestnut St., Philadelphia, PA 19107; email: asif.ilyas@rothmaninstitute.com.
• David C. Ring, MD, PhD, can be reached at 1701 Trinity St. 6.706,, Austin, TX 78712; email: david.ring@austin.utexas.edu.
• John M. Stamatos, MD, can be reached at 221 Jericho Turnpike, Syosset, NY 11791; email: jstamatos@nappm.com.
• F. Todd Wetzel, MD, can be reached at 3401 N. Broad St., #1003, Philadelphia, PA 19140; email: todd.wetzel@temple.edu.

Disclosures: Wetzel reports he has stock options in Relevant Medical Systems. Ahmad, Buvanendran, Ilyas, Ring and Stamatos report no relevant financial disclosures.

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