There are more than 75,000 deaths each year in the U.S. attributable to the opioid epidemic. Pharmaceutical companies and physicians have contributed to this crisis. Multiple studies have also cited prescription opioid medications, found in the home, as a significant initiating-incident causing individuals to become addicted to illegal drugs. The Department of Orthopedic Surgery at NYU Winthrop Hospital is making every effort to minimize opioid use in its orthopedic and spine patients. A major component of its approach to postoperative pain control is what’s known as pre-loading—having medications in a patient’s body before an operation begins to decrease the need for pain medications after surgery. This is an effective course, proven out by multiple studies, that decreases the need for potentially addictive opiates.
However, according to James D. Capozzi, MD, chairman of the Department of Orthopedic Surgery at NYU Winthrop Hospital, “Minimizing opioid use is not as simple as prescribing less medication. Orthopedic patients are often undergoing a major surgical procedure—and surgery causes pain.”
NYU Winthrop reviewed the last three years of patient-reported pain scores, data, and treatment protocols to find areas for improvement and, from that, developed a multimodal approach to pain control. This multipronged approach begins long before surgery. For elective surgeries, such as major joint replacements, NYU Winthrop’s orthopedic surgeons begin the pain control process weeks before surgery. Preliminary work involves mentally preparing the patient.
“Patents are told to expect some degree of pain and that an expectation of zero postoperative pain is unrealistic,” says Jan A. Koenig, MD, chief of the Division of Joint Replacement Surgery at NYU Winthrop. “Patients do best when their expectations are realistically set.
Pre-Loading and Anesthesia
Several days before surgery, Dr. Capozzi says physicians begin pre-loading patients with a combination of non-narcotic medications including acetaminophen (Tylenol®); pregabalin (Lyrica®), a nerve stabilizer; and celecoxib (Celebrex®) or meloxicam (Mobic®) anti-inflammatory medications. This mixture of medications given before surgery has significantly decreased postoperative pain levels—and decreased the need for potentially addictive opiates. Additionally, whenever possible, the orthopedic surgeons use regional anesthesia instead of general anesthesia, and they may also perform nerve blocks after surgery to provide additional pain relief.
The orthopedic team also provides patients with preoperative nutritional drink supplements to decrease postoperative nausea, which can be caused by the multiple medications. Less nausea allows the patients to more quickly participate in their physical therapy. Early mobilization improves functional outcomes and decreases postoperative pain. Cooling devices and other non-medication modalities are also used. Studies have demonstrated that with a multimodal approach of preoperative loading, regional anesthesia, rapid mobilization, and non-narcotic postoperative medications, 80 to 90 percent of patients will require minimal narcotic medications for pain control after surgery—or none at all. A small amount of opioids is used only for breakthrough or uncontrolled pain.
Patients also submit pain level scores daily, which helps our physicians monitor their symptoms, prevent complications, and minimize pain issues before they occur. To date, over 8,000 pain scores have been collected at NYU Winthrop. The hospital also refers patients to educational and exercise videos, which patients have reported as having helped limit discomfort and improve function. The NYU Winthrop Orthopedic Healthcare team also has an app called Force Therapeutics that allows patients to access their personalized care plan and report outcomes.
Monitoring Pediatric Patients
Since the opioid crisis often begins with children and young adult patients, NYU Winthrop’s orthopedic team is especially examining pain issues among those age groups. That includes ensuring parental understanding of postoperative pain expectations, proper dosing of over-the-counter medications, and age-appropriate education of the pediatric patient. Attention is also placed on distraction and coping techniques to decrease anxiety and pain.
“Depending on the patient’s age, this may be as simple as blowing bubbles at the bedside or allowing a parent or guardian to stay with their child until they’re under anesthesia in the operating room,” adds Sharon Newman, a pediatric orthopedic physician assistant. “Sometimes redirecting a patient’s focus away from pain leads to conversations about the latest trending movie or television show.”
In short, NYU Winthrop is continuously searching for new ways to manage patient pain with the least amount of opioids possible.