Orthopedic surgeons seek alternatives to opioid prescribing

Patient education on opioid use and disposal may reduce diversion rates.

The opioid crisis has evolved during the past 2 decades and despite progress made on reducing unnecessary exposure to prescription opioids and preventing the development of opioid use disorder, health care providers wrote 58.5 opioid prescriptions per 100 persons in 2017, according to the CDC.

“After the 1990s, there was this cultural expectation of primary opioid pain management in the United States and that contributed to the problems we are seeing now with the inappropriate increases in opioid prescribing. [There is] the large disproportionate usage that we are seeing in the United States as compared to other countries and there are also problems with abuse and overdose deaths that we have seen skyrocket in the past couple of years,” Laurel A. Beverley, MD, MPH, at MetroHealth and assistant professor at Case Western University, told Orthopedics Today.

Source: WVU Medicine

Recently, there has been a push in the orthopedic community to “investigate and explore alternative strategies to keeping patients comfortable after surgery,” according to Nady Hamid, MD, of the Shoulder and Elbow Center at OrthoCarolina and department of orthopedic surgery at Atrium Health. The American Academy of Orthopaedic Surgeons has been at the forefront of addressing the opioid epidemic and has provided instructional course lectures, patient safety tool kits and position statements to educate physicians and the public on the use, misuse and abuse of opioids within orthopedics, he said.

Position statements, guidelines

“[The AAOS] has written letters and position statements to the FDA, to the federal government, to the AMA [and] to the CDC,” Beverley, who is a member of the AAOS Medical Liability Committee, said. “There has been a lot of active work done to try and get a handle on the epidemic, but also make sure that our patients still have access to appropriate pain treatment.”

CDC guidelines recommend that, when treating acute pain, physicians should prescribe opioids at the lowest effective dose and for no longer than the expected duration of pain. In addition, states are passing legislation that requires opioid prescriptions be written for no more than a 7-day supply, which the CDC said some experts believe is the appropriate length of time for an opioid prescription.

“Each state sets the limit depending on how they legislated this and how that law went through rules and how they were promulgated, but Michigan went with a 7-day limit probably based on evidence that opioid tolerance can develop in little as 7 days,” Paul E. Hilliard, MD, medical director of Institutional Opioids and Pain Management Strategy and chair of hospital pain committee at University of Michigan Hospital and Health System, told Orthopedics Today.

This legislation can help patients, but it can cause challenges for physicians when it comes to pain management, especially in states that are more restrictive, he said.

“I think you have to individualize a patient’s pain treatment plan according to the surgery they are having,” Hilliard said.

While the dosage and amount of opioids prescribed usually comes down to the judgment of the physician, prescribing guidelines for common surgical procedures in a study by Heidi N. Overton, MD, and colleagues recommended that opioid-naïve adult patients be prescribed a maximum of zero to 20 opioid tablets depending on the surgery. In terms of patients who undergo orthopedic procedures, they noted zero to 10 opioid tablets be prescribed for arthroscopic partial meniscectomy and zero to 20 opioid tablets be prescribed for arthroscopic ACL/PCL and rotator cuff repairs, and for open reduction and internal fixation of the ankle.

Education is key

However, according to Hamid, the best way to impact the opioid epidemic is by “changing our postoperative protocols and strategies to where we eliminate the prescriptions to be written in the first place.”

“We have looked at and studied some opioid-free strategies where patients can recover from surgery with zero opioids,” Hamid said. “We find that to be the holy grail, meaning ... if we can keep [patients] comfortable, they can recover from a surgery without having to deal with all the side effects that come with opioids.”

Physicians and anesthesiologists currently use a multimodal approach for pain management, which Hilliard noted starts prior to surgery with educating patients on the concerns around opioid use in the perioperative period.

Patients should also be made aware of their options, the prescriptions they will be receiving and what to expect regarding pain management after surgery, Lorraine Hutzler, MPA, associate program director in the Center for Quality and Patient Safety at NYU Langone Orthopedic Hospital, said.

“Talking with patients before surgery, advising them of the risks related to opioid use and establishing reasonable expectations for the management of their pain following surgery is a process that will be well received by most patients,” Brendan M. Patterson, MD, chair of the department of orthopedics at Cleveland Clinic Health System, told Orthopedics Today.

Patients who are already using opioids prior to surgery should be encouraged to reduce the amount being used, according to Hilliard. Physicians should have basic opioid-risk screening tools and surveillance protocols in place during the preoperative assessment to identify patients who may be at risk for developing a substance use disorder, he said.

“Patients who have had a history of trouble with other substances, such as history of DUI, if they have a history of depression and anxiety, family members with a history of substance use disorder, these are all things that can place them at high risk,” Hilliard said. “I think it is important for us, as health care providers, to know before we even pull the trigger on prescribing an opioid that we could be opening Pandora’s box.”

Avenues of pain management

In the intraoperative and postoperative period, Hilliard noted the type of therapy prescribed should be paired with the type of surgery. Anti-inflammatories, NSAIDs, such as ibuprofen, Celebrex (celecoxib, Pfizer), ketorolac and steroids, can all be helpful in the immediate perioperative period after surgery that has an inflammatory component, Hilliard said.

“If it is more soft tissue manipulation and there is not a large inflammatory component, acetaminophen can be helpful,” he said.

Low-dose Neurontin (gabapentin, Pfizer) can help with neuropathic pain, Patterson said.

Hilliard said regional blocks and peripheral nerve catheters can be helpful in patients for whom there is no concern about nerve damage.

“We also can use some local injections at the time of surgery and some of those can have a long half-life, meaning they can last a long time more than just the typical Novocain you would get at the dentist office,” Hamid told Orthopedics Today.

Other avenues of pain management include early mobilization and ice and cold therapy postoperatively, according to Beverley.

Hutzler said some physicians recommend massage, acupuncture and yoga to their patients for pain management.

Use of electronic medical records

Physicians can reduce opioid utilization by analyzing the amount of narcotics they are prescribing, according to Brock A. Lindsey, MD, director of musculoskeletal oncology and adult reconstructive services at West Virginia University.

“Until you start looking into how much [narcotics] you use, you do not know where you stand,” Lindsey told Orthopedics Today.

EMRs have allowed surgeons to install soft stops and hard stops to “help guide the amount of opioids that are prescribed,” according to Beverley, and may include built in calculators that alert the physician if they are prescribing more opioids than the general federal recommendations. EMRs can also help prompt physicians to educate patients on and prescribe Narcan (naloxone, Adapt Pharma Inc.), a drug antagonist that reverses the effects of opioids and can be life-saving for an opioid overdose, she said.

“MetroHealth has created an automatic prescription for Narcan (naloxone). For every opioid prescription that is generated, a provider then has an option to also prescribe naloxone at the same time,” Beverley said. “The theory is that not every patient will need this, but if we offer it to every patient, those that feel that they may have a use for it — or that might know someone that has a use for it —will have access to Narcan if necessary in an overdose situation.”

Drug monitoring programs

Databases help identify how many unused prescriptions patients have had and the average number of opioids patients need to recover after surgery. Hamid said this approach is helpful for prescribing a conservative amount of opioids.

“Large databases give us a view of an entire system, so we can more readily identify outliers,” Patterson said.

“We also have some capabilities that will draw attention to a particular patient who may be at risk for either opioid substance use, opioid use disorder or somebody who is at risk for respiratory depression due to the co-prescription of another medication,” he said.

Many states have developed or mandated the use of prescription drug monitoring programs to track if a patient has already been prescribed opioids. Prescription drug monitoring programs are also supported at the federal level with the Monitor Act of 2017, which Beverley said helps support the uniform electronic format to share information across multiple sites, makes the information available to more physicians and helps with the accuracy of opioid controlled substance information.

“Prescribers will go in and they can see for that specific patient ... if they were given any other controlled substances by another physician, so there are not duplicate prescriptions going out and [patients] are not getting more medication than they should,” Hutzler said.

She said data provided by these databases are key for physicians and prescribers to see if they need to make a change in their prescribing habits.

“A lot of [physicians] do not necessarily realize either how much or how little they are prescribing until they see the numbers and the statistics in front of them and that has been helpful to reduce the prescribing habits,” Hutzler said.

However, Lindsey said physicians need to know how to collect and organize the needed data and how to identify whether the data collected are telling the physician what they need to know.

“If the databases and the data analytics are done right on the front end, it can be a powerful tool to then effect change,” he said. “By that I mean, if you are able to find both specific users of opioids, as well as specific prescribers of opioids, and educate them or help them with the situation ... you may be able to institute change.”

Reduced opioid diversion

As diversion of opioids is a national problem, Hilliard said it is important to educate patients on how to dispose of opioids after they are through the surgical experience.

NYU Langone Orthopaedic Hospital has integrated documents on proper opioid disposal into the EMR system that print out with the prescription, Hutzler told Orthopedics Today. In addition, posters about disposal methods are displayed in physician offices.

The FDA lists bringing unused or expired medications to National Prescription Drug Take-Back events or to Drug Enforcement Administration-registered collectors as the preferred disposal method. Many opioid disposal facilities are run by pharmacies, sheriff departments and states, according to Lindsey.

Larger hospital facilities may have collection boxes for patients to return unused medications, Patterson said.

“We are a big system, so we have the ability within our pharmacies to accept back medications,” he said.

A research letter published in JAMA Surgery showed patients were more likely to dispose of opioids after outpatient elective surgical procedures if they received an activated charcoal bag (Deterra Drug Deactivation System, Verde Technologies) for opioid deactivation (57.1%) compared with patients who received education regarding disposal locations (33.3%) and patients who received usual care (28.6%). The researchers found a 3.8-times greater odds of opioid disposal among patients who received a charcoal bag vs. usual care.

“We see this as a scalable intervention that could greatly reduce the number of unused pills that are available for diversion and abuse,” Chad M. Brummett, MD, co-author of the study, co-director of the Michigan Opioid Prescribing Engagement Network and associate professor of anesthesiology at the University of Michigan, told Orthopedics Today. “While we do not recommend its use in chronic opioid users, as they would be expected to use all of their pills, we can see a role for this or a similar role for all acute care prescriptions (eg, surgery, dentistry or emergency medicine).”

Use of opioids for acute pain

Even with the changes being made in the management of pain in patients after orthopedic surgery, Lindsey said it is not possible for every procedure to be entirely opioid-free.

“Opioids still have a role in acute pain management, and I think they always will,” Beverley said. “They are useful for acute injuries, especially in an emergency setting. They are useful for immediate postoperative pain whether in an outpatient setting or in a hospital.”

Opioids become problematic when the use is persistent and chronic, Hilliard noted. Clinicians need to pay attention to the postoperative course of their patients and have an exit strategy to wean patients off opioids after the acute pain subsides, he said.

“[A]s orthopedic surgeons, we helped recognize this problem early and we came out and were able to help fight the epidemic in this country,” Beverley said. “I would say that we should not lose track of that goal and continue to work on the path that we have set in developing new and better management techniques to help our patients.” – by Casey Tingle

• References:
• 2018 annual surveillance report of drug-related rusks and outcomes. Available at: www.cdc.gov/drugoverdose/pdf/pubs/2018-cdc-drug-surveillance-report.pdf. Accessed April 10, 2019.
• Brummett CM, et al. JAMA Surg. 2019;doi:10.1001/jamasurg.2019.0155.
• CDC guidelines for prescribing opioids for chronic pain—United States, 2016. Available at: www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fmmwr%2Fvolumes%2F65%2Frr%2Frr6501e1er.htm. Accessed April 10, 2019.
• Disposal of unused medicines: What you should know. Available at: www.fda.gov/drugs/resourcesforyou/consumers/buyingusingmedicinesafely/ensuringsafeuseofmedicine/safedisposalofmedicines/ucm186187.htm#how. Accessed April 12, 2019.
• Dowell D, et al. JAMA. 2017;doi:10.1001/jama.2017.15971.
• Information statement: Opioid use, misuse, and abuse in orthopaedic practice. Available at: www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1045%20Opioid%20Use,%20Misuse,%20and%20Abuse%20in%20Practice.pdf. Accessed April 10, 2019.
• Jones MR, et al. Pain Ther. 2018;doi:10.1007/s40122-018-0097-6.
• Naloxone: The opioid reversal drug that saves lives. Available at: www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf. Accessed April 11, 2019.
• Overton HN, et al. J Am Coll Surg. 2018;doi:10.1016/j.jamcollsurg.2018.07.659.

• For more information:
• Laurel A. Beverley, MD, MPH, can be reached at 12301 Snow Road, Cleveland, OH 44130; email: lbeverley@metrohealth.org.
• Nady Hamid, MD, can be reached at 1915 Randolph Road, Charlotte, NC 28207; email: kathleen.davis@orthocarolina.com.
• Paul E. Hilliard, MD, can be reached at 325 E. Eisenhower Parkway, Ann Arbor, MI 48108; email: kylieo@med.umich.edu.
• Lorraine Hutzler, MPA, can be reached at One Park Ave., 5th Floor., New York, NY 10016; email: annie.harris@nyulangone.org.
• Brock A. Lindsey, MD, can be reached at 1 Medical Center Dr., Morgantown, WV 26505; email: heather.sammons@wvumedicine.org.
• Brendan M. Patterson, MD, can be reached at 9500 Euclid Ave., Cleveland, OH 44195; email: homrocj2@ccf.org.

Disclosures: Beverley, Hamid, Hilliard, Hutzler, Lindsey and Patterson report no relevant financial disclosures.

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