Research Points to Ways to Reduce Opioid Use Following Common Orthopedic Surgeries
Opioid prescription rates can be significantly curbed following several orthopedic surgical procedures, according to new studies presented by researchers from NYU Langone Health’s Department of Orthopedic Surgery at the 2019 annual conference of the American Academy of Orthopaedic Surgeons (AAOS) in Las Vegas.
Opioid abuse has tripled in recent years, according to the AAOS, and orthopedic surgeons are the third-highest prescribers of these medications. NYU Langone orthopedic surgeons led an institution-wide effort to reduce the use of opioids in patient care for subspecialty procedures, to make more common procedures opioid-free or “opioid light.” Results of these efforts, coordinated across divisions of the department, may be applicable to other orthopedic programs across the country, according to the authors.
“NYU Langone orthopedic surgeons have collaborated closely with other hospital stakeholders, including anesthesia, pain management, pharmacy, and healthcare information technology, to develop a cross-functional response to the opioid epidemic,” says Joseph Bosco III, MD, professor of orthopedic surgery and vice chair of clinical affairs at NYU Langone, and second vice president of the AAOS.
“Our results reflect that 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,” says Joseph D. Zuckerman, MD, chair and the Walter A.L. Thompson Professor of Orthopedic Surgery at NYU Langone.
Randomized Trial Reports Opioid Reductions for Arthroscopic Shoulder Instability Repairs
Sports medicine orthopedic surgeons at NYU Langone, led by Kirk A. Campbell MD, assistant professor of orthopedic surgery, enrolled 80 patients, average age of 33 years, between December 2017 and May 2018, who underwent arthroscopic shoulder instability repair. Forty were randomized to receive ibuprofen 600mg and a 10-pill rescue prescription of oxycodone 5mg, and 40 received only a prescription of 30 tabs of oxycodone 5mg. The number of opioids patients used were recorded on days one, four, and seven after surgery, and patients were administered a visual analog scale (VAS) test to measure their pain intensity.
Dr. Campbell and colleagues reported that the total amount of opioid consumption was significantly lower in the group given ibuprofen with a rescue opioid prescription, compared with the opioid-alone group (6.9 vs 10.1, p<0.04). There were no significant differences in pain intensity scores at any time point after surgery between the two groups.
“Although both groups showed similar pain levels postoperatively, it is nevertheless possible to alleviate postoperative pain with lower amounts of opioids than what are typically being prescribed. Our research also shows adding nonsteroidal anti-inflammatory medications to the regimen may too decrease opioid use,” says Dr. Campbell.
Similarly, Dr. Campbell and colleagues led another prospective study published in Arthroscopy this February that reported no difference in pain control, satisfaction, and opioid use, between patients undergoing another common sports medicine surgery, arthroscopic meniscectomy.
“The public health crisis of opioid abuse requires an immediate solution beginning with the reduction of postoperative narcotics distribution for common arthroscopic sports medicine procedures,” says Dr. Campbell.
Sparing Opioids Following Hip Replacement and Other Surgical Procedures
More than 300,000 individuals undergo a total hip replacement each year in the United States, according to the AAOS, making it one of the most common adult reconstructive procedures. Opioid use is common before the procedure, and may continue afterward as well.
Efforts spearheaded by Roy I. Davidovitch, MD, the Julia Koch Associate Professor of Orthopedic Surgery at NYU Langone, looked at developing an opioid-sparing protocol for patients undergoing hip arthroplasty. The pathway included acetaminophen and meloxicam on the day before surgery, and only minimal opiates intraoperatively. Following surgery, patients continue with nonopiate pain control and receive 12 tramadol as a drug of last resort.
“Education is key. 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,” says Dr. Davidovitch.
He and his colleagues trialed the new pain regimen in late 2017 with patients undergoing anterior approach, same-day hip replacement patients. Among this group, in-hospital opioid consumption was reduced by about 75 percent.
“The new standard of care for a hip replacement should be a multimodal pain management treatment. As more orthopedic departments and clinics adopt these principles, rates of opioid dependence among these patients should fall,” he concluded.
His group’s findings will be presented in a Scientific Exhibit at the AAOS 2019 Annual Meeting. The purpose of the exhibit is to review the various initiatives across NYU Langone’s orthopedic surgery divisions and their respective success, which researchers say can be adopted by orthopedic surgeons at other institutions.
In another Scientific Exhibit at the AAOS, led by Claudette M. Lajam, MD, associate professor of orthopedic surgery and chief safety officer, researchers examined the ethics of modifying opioid prescribing behaviors to protect patients from risks associated with medications.
They conclude that a comprehensive program to combat the growing opioid crisis must include both educational reform for the physicians and supplementary tools to decrease the use of this class of drugs and monitor the dosing for avoidable usage.
“Physicians have a moral obligation to manage their patients’ pain without putting them at risk for future addiction whenever possible,” says Dr. Lajam.
To further embed the opioid reduction initiatives into orthopedic care and departmental treatment philosophy, the team hosted several professional development programs in 2018 to educate faculty, residents, and medical students on opioid-sparing pain management strategies. These events included a free continuing medical education webinar, organized by Dr. Lajam and colleagues, 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.
Opioid Medication Use Before and During Transformational Lumbar Interbody Fusion Surgery May Predict Long-Term Use
New retrospective studies led by Charla R. Fischer, MD, associate professor of orthopedic surgery and director of quality and patient safety at NYU Langone’s Spine Center, show that the number of opioids taken before and during hospital stays by patients who need a transformational lumbar interbody fusion (TLIF) surgery may predict long-term risk of opioid abuse. TLIF is a common spine surgery that has been demonstrated to improve a patient’s quality of life and spinal stability. However, the effects of opioid usage before or after the operation have not been well studied in literature.
“With spine surgery, patients often experience a lot of pain before surgery and may come in after taking opioids for a prolonged period of time. As orthopedic surgeons, we need to better understand how spine surgery may affect their pain levels and ultimately impact their overall outcomes,” says Dr. Fischer. “In light of the current opioid epidemic, prudent prescriptions of opioids by orthopedic surgeons is necessary now more than ever.”
The first study looked at 53 consecutive patients who underwent a 1, 2, or 3-level primary TLIF at NYU Langone Orthopedic Hospital between 2014 and 2017. Questionnaires were given to patients before surgery, and three months after, to determine patient-reported outcomes such as pain intensity, in order to evaluate the effectiveness of the surgeries and their medication usage.
Thirty-two patients had not taken opioids prior to surgery for back pain, while 21 had. The researchers found that patients with a history of preoperative opioid use had worse baseline scores for pain and disability and greater functional improvement postoperatively compared with opioid-naïve patients. Nevertheless, the patients on preoperative opioids experienced a longer length of stay, were prescribed more opioids as inpatients following surgery, and continued taking opioids for a longer duration postoperatively.
“Spine surgeons may want to take a multidisciplinary approach, and work closely with pain and addiction medicine specialists to address the prolonged utilization of opioids at six months after TLIF surgery in patients who took opioids preoperatively,” says Dr. Fischer.
In a separate study, Dr. Fischer’s team looked at the number of opioids taken in the hospital following TLIF, and whether that might impact usage rates following surgery. They retrospectively reviewed the medical records of TLIF procedures between 2014 and 2017, and identified 172 patients. They were separated into groups based on how many opioids they took during their inpatient hospital stays: 44 percent received less than 250 total morphine milligram equivalents (MMEs), 26 percent received between 250 and 500 MMEs, and 27 percent exceeded 500 MMEs during their hospital stay.
Patients who underwent a TLIF and received fewer than 250 MMEs of opioids had a 3.73 times smaller probability of requiring opioids at 6-month follow-up, compared with people who received 500 MMEs or more, who had a 4.84 times greater of requiring opioids at 6 months. A subanalysis showed that patients with preoperative opioid use who received less than 250 total MMEs had a 7.09 times smaller probability of requiring opioids at 6-month follow-up while those who received more than 500 total MMEs had a 5.43 times greater probability of taking the medications at 6-month follow-up. Patients who did not take opioids prior to surgery and were given less than 250 total MMEs or more than 500 total MMEs in the hospital did not have a statistically significant probability of requiring opioids at 6-month follow-up.
This is the first study to date that assesses the thresholds for postoperative opioid dosages that can predict continued long-term opioid use, according to the researchers.
“If your patient is requiring a lot of pain medication in the hospital, that’s a flag to get them into a pain medicine or addiction specialist as soon as possible,” says Dr. Fischer.