The orthopaedic community worldwide—and especially those of us in the US, the nation most notorious for over-prescribing—has become very cognizant of the epidemic of opioid abuse. Ironically, the current problem was fueled partly by the “fifth vital sign” movement of 10 to 20 years ago, when physicians were encouraged (brow-beaten, in my opinion) to increase the use of opioid medications to “prevent” high pain scores.
Researchers internationally are now pursuing clarification on the appropriate use of these medications. The societal consequences of opioid addiction, which all too often starts with a musculoskeletal injury and/or orthopaedic procedure, have been well documented in the social-science and lay literature. In the May 17, 2017 issue of The Journal, Smith et al. detail an additional consequence to the chronic use of opioid drugs—the negative impact of preoperative opioids on pain outcomes following knee replacement surgery.
Approximately one-quarter of the 156 total knee arthroplasty (TKA) patients analyzed had had at least one preoperative opioid prescription. Patients who used opioids prior to TKA obtained less pain relief from the operation than those who had not used pre-TKA opioids. The authors also found that pain catastrophizing was the only factor measured that was independently associated with pre-TKA opioid use.
To be sure, we need to disseminate this information to the primary care community so they will be more judicious about prescribing these medications for knee arthritis. Additionally, knee surgeons should consider working with primary care providers to wean their TKA-eligible patients off these medications, with the understanding that chronic use preoperatively compromises postsurgical pain relief and functional outcomes.
We have previously published in The Journal the fact that the use of opioids is largely a cultural expectation that varies by country; physicians outside the US often achieve excellent postoperative pain management success without the use of these medications. My bottom line: We must continue to press forward to limit the use of opioid medications in both pre- and postoperative settings.
Marc Swiontkowski, MD
The current prescription-opioid/heroin epidemic in the US has been much publicized of late. According to a recent AAOS information statement, the nearly 100-percent increase in the number of narcotic pain-medication prescriptions between 2008 and 2011 corresponds to an increase in opioid diversion to nonmedical users as well as a resurgence in heroin use.
Among the strategies the AAOS statement calls for to stem the tide of opioid abuse and manage patient pain more safely and effectively are the following:
- Opioid-prescription policies at the practice level that
- set ranges for acceptable amounts and durations of opioids for various musculoskeletal conditions,
- limit opioid prescription sizes to only the amount of medication expected to be used,
- strictly limit prescriptions for extended-release opioids, and
- restrict opioid prescriptions for nonsurgical patients with chronic degenerative conditions.
- Tools (such as the opioid risk tool at MDCalc) that identify patients at risk for greater opioid use.
- Empathic communication with patients, who “use fewer opiates when they know their doctor cares about them as individuals,” according to the statement.
- An interstate tracking system that would allow surgeons and pharmacists to see all prescriptions filled in all states by a single patient.
- CME standards that require periodic physician CME on opioid safety and optimal pain management strategies.
Noting that stress, depression, and ineffective coping strategies tend to intensify a person’s experience of pain, the statement concludes that “peace of mind is the strongest pain reliever.”