Self-Reported Marijuana Use Is Associated with Increased Use of Prescription Opioids Following Traumatic Musculoskeletal Injury
Cannabinoids are among the psychoactive substances considered as alternatives to opioids for the alleviation of acute pain. We examined whether self-reported marijuana use was associated with decreased use of prescription opioids following traumatic musculoskeletal injury.
In the last decade, the widespread use of regional anesthesia in total knee arthroplasty has led to improvements in pain control, more rapid functional recovery, and reductions in the length of the hospital stay. #JBJS #JBJSInfoGraphics #visualabsrtact
Early on, patients with knee osteoarthritis (OA) often get sufficient pain relief with nonsteroidal anti-inflammatory drugs. But as the condition progresses, many opt for knee replacement. Although knee replacement shows remarkable long-term results, immediate postsurgical pain management is a crucial consideration for orthopaedists and patients.
On Tuesday, December 13, 2016 at 12:30 PM EST, The Journal of Bone & Joint Surgery (JBJS) and PAIN, the official journal of the International Association for the Study of Pain, will host a complimentary webinar focused on relieving pain before and after surgery for knee arthritis.
- Sachiyuki Tsukada, MD, coauthor of a study in JBJS, will compare pain relief and side effects from intraoperative periarticular injections versus postoperative epidural analgesia after unilateral knee replacement.
- PAIN author Lars Arendt-Nielsen, Dr.Med.Sci, will delve into findings from a study examining biomarker and clinical outcomes associated with the COX-2 inhibitor etoricoxib in patients with knee OA.
Moderated by JBJS Associate Editor Nitin Jain, MD, the webinar will include an additional perspective from musculoskeletal pain-management expert Michael Taunton, MD. The last 15 minutes will be devoted to a live Q&A session, during which the audience can ask questions of all three panelists.
Seats are limited, so register now!
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.”
Every clinician treating musculoskeletal injury or disease knows that pain perception among patients is highly subjective and variable. Given the same objective magnitude of a pain stimulus, one person will grade it a 2 on the visual analog scale (VAS), while another will rate it an 8. I am sure that every dentist experiences similar patient variability! What is behind this, and what can we do with our decision making related to pain management to ensure compassionate and effective orthopaedic care?
We know that cultural and social factors play a role in pain perception, as do smoking and opiate-abuse history. Now, in a prognostic study in the August 5, 2015 edition of The Journal of Bone & Joint Surgery, Ernat et al. identify an association between pharmacologic treatment for anxiety and depression and poor outcomes, including higher postoperative pain scores, following primary surgery for femoroacetabular impingement (FAI) among members of the US military. The between-group difference in pain scores was significant only for antidepressant use, but 33 of the 37 patients in the study who took mental-health medications were on antidepressants.
I wonder whether the anxiety and depressive response to situational or relational stimuli that prompt an individual to seek mental-health treatment may be closely related to the same person’s response to painful musculoskeletal stimuli. Alternatively, incompletely treated anxiety or depression may influence a patient’s pain response to surgical treatment of FAI.
Either way, we need more research in this area so we can better manage our patients. An interesting study by Kane et al. that tested various approaches to standardizing patient pain reports showed how difficult normalizing pain scores is, but we still need to encourage further research into responses to painful stimuli, whether they be psychological or physical.
Marc Swiontkowski, MD
For over 125 years, the Journal of Bone & Joint Surgery (JBJS) has been the premier journal for orthopaedic surgeons. Today, our publication portfolio has grown to 4 peer-reviewed, evidence-based journals. Two of these journals offer continuing medication education (CME) for orthopaedic generalists, specialists and allied health personnel. The development of the CME activities is overseen by a committee consisting of editors from The Journal and JBJS Reviews.
The JBJS CME program is designed to enhance the knowledge, competence and performance of orthopaedic surgeons worldwide, and to improve musculoskeletal health for their patients. Our CME program addresses a range of clinical topics including: adult hip and knee reconstruction, foot and ankle surgery, spine surgery, shoulder and elbow surgery, pain management, sports medicine, pediatrics, and trauma. After successful completion of the period of Provisional Accreditation, JBJS received full accreditation for our CME program in March of 2015.
The Journal of Bone and Joint Surgery, Inc. is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The Journal of Bone & Joint Surgery offers two CME activities: The Quarterly CME Activity and the Subspecialty CME Activity. Each of these CME activities is an interactive educational experience of examination questions based on articles published in the Journal of Bone & Joint Surgery. The Quarterly CME Activity contains 50 questions and is also designated for a maximum of 10 AMA PRA Category 1 Credits™. The Subspecialty CME activity contains 10 questions and is designated for a maximum of 5 AMA PRA Category 1 Credits™.
The Quarterly CME activity is approved by the American Board of Orthopaedic Surgery (ABOS) as a Self-Assessment Examination (SAE) that qualifies for SAE CME under the Board’s Maintenance of Certification (MOC) Program. Each Quarterly activity grants 5 SAE credits and must be submitted in pairs for maintenance of certification
JBJS Reviews, our newest journal, offers a journal-based CME activity with each article. Each article contains 5 CME assessment questions that can be completed and submitted after reading the article for 1 AMA PRA Category 1 Credit™.
JBJS is committed to providing timely, relevant CME to orthopaedic surgeons and allied health providers worldwide, promoting effective decision-making and clinical practice based on the gold-standard of peer-reviewed, scientific information contained within our publications.
You can access JBJS CME activities by visiting the JBJS Orthopaedic Education Center.