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Opioid use during orthopedic surgery requires assessment of risk, other options
Approximately 1 million physicians practice medicine in the United States. While orthopedic surgeons comprise only about 2% of these clinicians, they are the fourth-highest prescribers of opioids. 1 Opioid-based analgesia is used extensively in orthopedic procedures and is an effective strategy for managing pain in this setting.2
However, in spite of the high number of opioid prescriptions written by orthopedic surgeons, the clinically appropriate scenarios for these medications in orthopedics are limited, according to Laurel A. Beverley, MD, MPH, of MetroHealth in Cleveland and Case Western Reserve University.
“For orthopedic surgeons, there’s a limited scope of use for opioids,” she said. “It’s only used in the setting of acute pain, either after an injury, like in the case of fracture care or in the event of multi-trauma, or after surgery. In those circumstances, using a stronger pain medication such as an opioid is clinically appropriate.”
Part of the reason for this limited use of opioids in orthopedics is because of the shift in who manages pain, according to Beverley. More and more, providers with specialty training in pain management are managing patients with chronic pain.
However, for orthopedic surgeons managing pain before and after a procedure, or in the setting of acute injury, one of the most important factors to consider is the use of short- vs. long-acting opioids. In this setting, only short-acting agents should be prescribed and for the shortest duration possible.3 This recommendation, which was included in clinical practice guidelines published in the Journal of Orthopaedic Trauma, was issued as a strong recommendation with high-quality evidence.3
“Opioids are medications that we know carry a lot of risk. We should be limiting their use to only as long as severe pain necessitates,” Beverley said. “We should be using the short-acting opioids, not the extended-release opioids. They’re not appropriate for what most of us do in orthopedic surgery.”
A statement from the American Academy of Orthopaedic Surgeons states that extended-release opioids are “intended for severe, long-lasting pain from cancer.” It also notes that, with one exception, extended-release opioids are not approved by the FDA for managing acute pain.4
In addition to the type of opioid prescribed, it is also important to consider the length of time that patients will use these drugs, according to Beverley. This is particularly important for patients who have a documented history of abuse.
“In a surgical setting, the use of opioids is unavoidable – you need to use these medications to treat these patients,” she said. “You want to discuss what you and the patient can do to ensure that the patient does not leave the hospital with any opioids. This helps to avoid putting the patient in a situation where they are likely to relapse.”
Assessing risk for opioid misuse, abuse
These conversations are a “necessary step” for patients with and without a history of misuse or abuse, according to Beverley. They should begin during the patient’s preoperative visit, in which postoperative pain expectations, management and policies can be discussed.5
During the visit, the provider is able to assess the patient’s risk for opioid use or abuse. Directions for appropriate disposal of unused opioids is an important part of the conversation to help “avoid opioid diversion or further the risk for substance abuse by the patient.” A handout can also be given to the patient that summarizes the points discussed during the visit and what to expect after surgery.5
These conversations will vary depending on the patient’s history of opioid exposure, according to Beverley.
“If it’s someone at low risk for abuse, it can be a very short conversation,” she said. “It can be as simple as, ‘I’m prescribing you a stronger pain medication. As you probably know, these are medications that can lead to addiction. I want you to use this in a limited amount – I want you to use this sparingly – and I want you to stop using this when you no longer need it anymore.’”
Greater awareness about potential misuse or abuse is necessary when working with patients who have a documented history of these problems, Beverley continued. In these circumstances, a “prophylactic discussion” with the patient is warranted.
“You can say to these patients: ‘You have these characteristics that increase your risk for developing a problem with opioid abuse. Let’s work as partners to make sure that doesn’t happen and also that your other issues, such as pain, are being attended to throughout the process,’” she said. “If you have a patient with a documented history of opioid abuse, whether it be in pill or injectable form, you have to be upfront when opioid medications are going to be used.”
Opioid use prior to surgery has been consistently identified as a risk factor for misuse or abuse following a procedure. Additionally, two studies that looked at the use of opioids after total knee arthroplasty found that current smokers were more likely to misuse or abuse opioids compared with nonsmokers.6,7
Other patient characteristics that may increase an individual’s likelihood to misuse or abuse opioids include sex, age and mental health conditions, including anxiety, depression and bipolar disorder.6,7 Interestingly, one study that found that men are more likely to misuse or abuse these agents noted that previous research demonstrates this is more often a concern for women.6 This was shown in another study that found that women are significantly more likely than men to refill opioids in the months following an orthopedic procedure.7
Providers may think that all patients are aware of the opioid crisis, according to Beverley, but that may not be the case. As a result, this is information that providers “need to share” with all patients.
“It’s just like any other medication we prescribe,” she said. “We talk about the risks and the benefits.”
Role of multimodal pain management
In the broader context, there are other factors to consider when discussing pain management with patients undergoing orthopedic surgery. It is critical to remind patients that opioids are not the only tool for managing pain, according to Beverley.
“With the pain management protocols that are out there now, there are ways to do multimodal pain management where you can, potentially, do a narcotic-free or an opioid-free surgery in certain patients,” she said. “We have techniques that can send people home with no narcotic prescriptions.”
Multimodal pain management strategies employ multiple medications that work on various locations of the pain pathway to bring about relief.8 The first step in this approach involves preoperative education about what to expect in terms of postoperative pain and what the pain management protocol will involve.8 Further, with this information, patients know they will receive preoperative pain medications, information that is meant to limit anxiety about delays from the onset of pain to the delivery of medications.8 Another aspect of this preoperative education involves information about safe opioid use and recommendations for specific over-the-counter pain medications, including acetaminophen and ibuprofen.9
In the multimodal pain management approach, medications administered prior to surgery may include acetaminophen, COX2 inhibitors and gabapentin.8,10 During surgery, analgesics like morphine sulfate, NSAIDs, epinephrine, methylprednisolone and local anesthetics such as bupivacaine or ropivacaine can be used.10 Other strategies during surgery may include epidural anesthesia, regional blocks like adductor canal nerve blocks and periarticular injections; these agents have been shown to reduce postoperative pain, increase patient satisfaction and accelerate the transition to physical therapy.8 In the postoperative setting, peripheral and central agents may heighten response to analgesia and eliminate the need for opioids; these agents include NSAIDs and other COX inhibitors, peripheral nerve blocks, oral opioids and gabapentin, as well as ice.8
One of the most important aspects of this multimodal pain management approach is talking with patients about efficacy, according to Beverley.
“When we talk about multimodal pain treatments and approaches, letting patients know that all these techniques actually work is helpful,” she said. “I’ve found that one particularly useful piece of information is educating patients about why we use cold therapy. I don’t think any patients realize that the inflammatory cascade that occurs after an injury or surgery slows down in cold temperatures. If you share that information, patients say, ‘Wow. There’s a reason I should be using this.’ You see the light go on and know that they’re on board with what you’re doing.”
Findings from Dwyer and colleagues emphasize the importance of sharing information with patients. Those researchers found that written guidelines for surgeons, as well as educational handouts for patients, “significantly reduced opioid prescription sizes by 35% to 55% while achieving high patient satisfaction with pain control and a low refill rate.”9
Impact of anxiety, depression
The patient’s mental health is also important to consider when determining the risks associated with opioids. The presence of anxiety or depression may affect which patients are more likely to misuse or abuse these agents.
“When working with at-risk patients, I find it’s important to have a discussion with those who also have anxiety or depression,” Beverley said. “Patients with these mental health issues sometimes accidentally try to treat those issues with narcotics rather than the appropriate techniques. Someone with depression or anxiety may experience temporary relief from an opioid, but it doesn’t last. This becomes a very ineffective and dangerous approach, because the patient will continue to experience depression and anxiety.”
The rate of depression among orthopedic patients is thought to be greater than it is in the general population.11 In addition to an increased risk for higher opioid consumption after surgery, patients with depression, as well as anxiety, are more likely to use opioids before surgery.11,12 There is also a correlation between chronic pain and opioid use.11
Addressing these issues in a straightforward manner, and ensuring that they understand the information is meant to help them, may help patients have control over the situation.
“You can address this head-on by saying to your patients, ‘I want to make sure we’re treating the right things with the right medicines; I want to make sure we’re not using opioids to treat anxiety,’” Beverley said. “This will often make patients aware of something they were doing unconsciously and you can then redirect their efforts to treat the appropriate diagnoses with the appropriate methods. If you continue to treat anxiety with oxycodone, you’re in a losing battle.”
On the other hand, while it is important to discuss the potential harms of opioid misuse and abuse, it is equally as important to ensure patients that there are tools for managing pain and that it will be taken care of.
“We need to make sure we don’t shut down pain medication and access inappropriately and work to preserve access to appropriate use,” Beverley said. “It’s important to remember, too, that everyone is a little different. There are going to be different levels of pain tolerance and different approaches toward pain management.”
This balance can be achieved through personalized discussions with every patient, she continued.
“If you’re talking with a patient who is at greater risk for opioid misuse or abuse, you can tell them, ‘We have standard protocols and limits for opioid use. It doesn’t apply to just you. You’re being treated the same as all the other patients in our practice,’” Beverley said. “If you use empathetic language, you can let patients know you are partnering with them to manage their pain and reduce the risk of adverse outcomes, such as addiction or death.”
References:
- Mir HR, Sanders RW. J Orthop Trauma. 2019;doi:10.1097/BOT.0000000000001479.
- Raneses E, et al. J Am Acad Orthop Surg. 2019;doi:10.5435/JAAOS-D-16-00750.
- Hsu JR, et al. J Orthop Trauma. 2019;doi:10.1097/BOT.0000000000001430.
- American Academy of Orthopaedic Surgeons. Information statement: Opioid use, misuse and abuse in orthopaedic practice. Available at: https://aaos.org/globalassets/about/bylaws-library/information-statements/1045-opioid-use-misuse-and-abuse-in-practice.pdf. Accessed August 7, 2019.
- Donahue GS, et al. Foot & Ankle Orthopaedics. 2018;doi:10.1177/2473011418764463.
- Kim KY, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2017.07.041.
- Bedard NA, et al. J Arthroplasty. 2017;doi:10.1016/j.arth.2017.03.014.
- Trasolini NA, et al. J Arthroplasty. 2018;doi:10.1016/j.arth.2018.07.002.
- Dwyer CL, et al. J Hand Surg Am. 2018;doi:10.1016/j.jhsa.2018.01.021.
- Zhao J, Davis SP. Int J Nurs Stud. 2019;doi:10.1016/j.ijnurstu.2019.06.010.
- Rubenstein W, et al. Arthroplast Today. 2018;doi:10.1016/j.artd.2018.07.002.
- Westermann RW, et al. Arthroscopy. 2019;doi:10.1016/j.arthro.2018.08.056.
Disclosures: Beverley reports no relevant financial disclosures.