The Department of Orthopedic Surgery at NYU Langone Health is leading an institution-wide effort to rethink the role of opioids in patient care. Through a series of linked initiatives developed over the past two years, the department has reduced—and in some cases eliminated—the use of opioids for postoperative pain control in orthopedic surgery.

“We have collaborated with departments from anesthesia and pain management to pharmacy and healthcare information technology (IT), so this effort is truly a cross-functional response to the opioid epidemic,” notes Joseph Bosco III, MD, professor of orthopedic surgery and vice chair of clinical affairs.

Opioid-Sparing Pain Management

Starting in 2017, the department’s divisions strategized opioid-free or opioid-light postoperative pain regimens for their subspecialty procedures.

Roy I. Davidovitch, MD, the Julia Koch Associate professor of orthopedic surgery, spearheaded efforts to develop an opioid-sparing protocol for patients who require hip arthroplasty. The pathway includes acetaminophen and meloxicam on the day before surgery, and only minimal opiates are given to people intraoperatively. Following surgery, patients continue with non-opiate pain control and receive 12 tramadol as a drug of last resort.

“Education is the key point,” Dr. Davidovitch says. “We instruct patients to take the tramadol only on an as-needed basis, after they have exhausted the other medications—and only if their pain is greater than the pain they had before surgery.”

Dr. Davidovitch and colleagues trialed the new pain regimen in late 2017 with patients who had same-day hip replacement. Among this group, in-hospital opioid consumption was reduced by about 75 percent. “The new standard of care is multimodal pain management,” he says.

Division leaders have carefully studied the impact of new pain regimens on patient satisfaction. For example, a group led by Kirk A. Campbell, MD, assistant professor of orthopedic surgery, compared standard opioids with oral nonsteroidal anti-inflammatory drugs (NSAIDs) for patients who require arthroscopic meniscectomy.

Their study, highlighted at the 2018 Annual Meeting of the American Academy of Orthopedic Surgeons, will be published in an upcoming issue of Arthroscopy: The Journal of Arthroscopic and Related Surgery. The study found that patients on an opioid-sparing pathway experienced no significant differences in pain control or satisfaction with care. There was also no difference in one-week opioid use between the two groups, suggesting that patients nationwide are currently overprescribed opioids after this procedure.

Collaborating with the Pharmacy and Healthcare IT to Improve Care

The Department of Pharmacy played a key role in efforts to revise pain management protocols. Lisa Anzisi, MS, PharmD, BCPS, pharmacy utilization manager, worked with orthopedic surgeons to establish morphine milligrams equivalent (MME) conversion factors for all pain medications in use, stratifying the department’s MME data by using a pain threshold scale.

She also worked with faculty to establish clinical protocols based on morphine equivalents. For example, physicians now offer naloxone to any patient receiving 50 milligrams or more of MME pain control per day. Patients receiving 90 or more MME milligrams per day are referred for a pain consult, and use of 120 or more MME milligrams per day triggers an automatic alert for potential overutilization.

“It’s not always clear how the different pain drugs compare milligram for milligram,” Dr. Bosco says. “Calculating morphine equivalents is a way to standardize doses across medications.”

Healthcare IT provided critical backend support for these efforts, working with orthopedic surgery and pharmacy experts to specify MMEs for all opioid analgesic order sets in the electronic health record (EHR), with embedded opioid-specific alerts. Now, for instance, when a physician prescribes an opioid to a patient on a benzodiazepine, the EHR generates a contraindication alert. In addition, patients who receive an opioid prescription automatically get a system-generated document with up-to-date instructions on safe disposal of unused medications.

These initiatives have had a significant effect on opioid usage among orthopedic surgery patients, reducing average postoperative MMEs by approximately 35 percent since 2016.

Educating Others on Opioid Reduction

To embed the opioid reduction initiatives into orthopedic care, the department held several professional development programs in 2018 aimed at educating faculty, residents, and medical students on opioid-sparing pain management strategies. These events included a free continuing medical education webinar on the use and misuse of opioids in postoperative care, convening experts in medicine, law enforcement, and government to provide a multidisciplinary perspective on the opioid crisis. The webinar was organized by Claudette M. Lajam, MD, associate professor of orthopedic surgery and chief safety officer, and Lorraine Hutzler, MPA, associate program director for NYU Langone’s Center for Quality and Patient Safety.

“It’s one thing to say you want to reduce opioid consumption, but it’s not as easy as simply prescribing fewer pills,” says Dr. Bosco. “All of us in orthopedic surgery need to look at our surgeries, reexamine our protocols, and work across our institutions to minimize opioid use while still maximizing patient comfort and recovery.”