Designing studies to answer questions about surgical procedures takes a lot of thought, effort, and experience. Creating robust study designs to investigate pain management related to musculoskeletal conditions and procedures presents additional, unique challenges.
On November 19, 2019, more than 30 orthopaedic researchers and journal editors convened to identify—and propose solutions for—those challenges. The one-of-a-kind Pain Management Research Symposium was supported by a grant from the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS award number 1R13AR076879-01) and hosted by The Journal of Bone & Joint Surgery.
Several themes emerged from the daylong discussions and presentations:
- Despite the fact that 80% of opioid prescriptions worldwide originate in the US, outcome measures going forward should focus on effective pain management rather than reduced or “zero” opioids.
- The wide variability of definitions of key research terms such as “opioid naïve” and “persistent opioid use” makes it difficult to reach robust conclusions from prior opioid/pain management research.
- Beware false equations/assumptions. For example, opioid prescription filling is not the same as opioid consumption, and persistent opioid use after surgery does not equal iatrogenic opioid dependence.
- Surgeons and other physicians must maintain a biopsychosocial perspective on pain management. Risk factors for persistent use of opioids include mental/emotional states such as depression and catastrophizing.
- Despite some equivocal reports in the orthopaedic literature, there is no convincing evidence that NSAIDs negatively affect fracture healing. Therefore, absent specific patient contraindications, NSAIDs can be considered for pain management in trauma cases.
Many more details from the Pain Management Research Symposium will appear in a special JBJS supplement, scheduled for publication in the first half of 2020.
The Journal would again like to thank all the participants for their time and energy and NIAMS for its support.
Much has been written in recent years about the orthopaedist’s predilection for prescribing opioids, most of which has been aimed at helping us become better stewards of these medications. It is imperative that we continue learning how best to prescribe opioids to maximize their effectiveness in postoperative pain management, while minimizing their many harmful and potentially lethal effects. With some patients, finding that balance is much easier than with others. Learning to identify which patients may struggle with achieving that equilibrium is one way to address the current opioid epidemic.
In the September 18, 2019 issue of The Journal, Prentice et al. identify preoperative risk factors that are associated with prolonged opioid utilization after total hip arthroplasty (THA) by retrospectively evaluating the number of opioid prescriptions dispensed to >12,500 THA patients. Many of the findings are in line with those of previous studies looking at this question. Prentice et al. found that the following factors were associated with greater opioid use during the first postoperative year:
- Preoperative opioid use
- Female sex
- Black race
- Higher BMI
- Substance abuse
- Back pain
- Chronic pulmonary disease
For me, the most noteworthy finding was that almost 25% of all patients in the study were still using opioids 271 to 360 days after their operation. That is a much higher percentage than I would have guessed prior to reading this study. Somewhat less surprising but also concerning was the finding that 63% of these patients filled at least 1 opioid prescription in the year prior to their THA, leading the authors to suggest that orthopaedic surgeons “refrain from prescribing opioids preoperatively” or “decrease current opioid users’ preoperative doses.”
Although some readers may be suffering from “opioid fatigue” in the orthopaedic literature, I encourage our community to continue addressing our role in the current opioid crisis. While I believe that we have changed our prescribing practices since the data for this study were collected (2008 through 2011), we cannot dismiss these findings. The opioid epidemic is multifactorial and has many deep-rooted tendrils in our healthcare system. We owe it to our patients and to the public at large to be as significant a part of the solution as possible.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
When planning for any type of surgical procedure, the orthopaedist considers many patient and injury-specific variables. With a distal radius fracture, for example, the main goal of the surgery—anatomic reconstruction of the distal radius—remains constant. However, there are numerous other variables (fracture morphology and patient age, just to name 2) that have to be considered to achieve that goal. Yet, when it comes to postoperative pain control, I imagine that most orthopaedic surgeons prescribe the same amount of opioids to almost every patient undergoing an open reduction/internal fixation of a distal radius fracture, regardless of unique patient characteristics. Our medical mantra that “no two patients are the same” seems to fall by the wayside when it comes to postoperative pain control.
This disconnect is what I thought about while reading the article by Stepan et al. in the January 2, 2019 issue of The Journal. The authors’ institution developed and disseminated to all prescribers a 1-hour opioid education program and consensus-based postoperative opioid prescription guidelines. They then compared the number of opioid pills and total oral morphine equivalents prescribed after 9 ambulatory procedures within 3 subspecialty services (sports medicine, hand, and foot and ankle) prior to and after implementation of the guidelines. Stepan et al. found a significant decrease in the amount of narcotics prescribed after 6 of the 9 surgery types after implementation of the guidelines. Over the course of a year, those decreases would have equaled about 30,000 fewer opioid pills!
Interestingly, there was no significant post-guideline decrease in opioid prescribing after any of the 3 foot-and-ankle procedures. The authors attribute that finding to the slow adoption of the guidelines due to adherence to previously developed pain-management recommendations in this subspecialty.
It has become apparent that we tend to overprescribe opioids postoperatively (see related OrthoBuzz post). This study supports previous data showing that prescription guidelines can be useful in decreasing the amount of postoperative narcotics prescribed to patients, while maintaining adequate pain management and good levels of patient satisfaction. While further work in developing educational tools and procedure-specific “standards” to help surgeons guide their postoperative prescribing practices would be useful, a surgeon’s mindfulness is equally important. We need first to recognize that orthopaedic surgeons tend to overprescribe postoperative opioids—and second, we must be willing to change our habits. Without both awareness and willingness, the best guidelines and recommendations will be ignored, and an opportunity for us to help curb the opioid crisis in our country will be wasted.
Chad A. Krueger, MD
JBJS Deputy Editor for Social Media
Somewhere between 10% and 15% of patients are unsatisfied with their outcome after primary total knee arthroplasty (TKA). In some cases, dissatisfaction is related to poor range of motion, but more often it is related to residual—or even intensified—pain in the knee several weeks after surgery.
In the January 2, 2019 issue of The Journal, Koh et al. report the results of a prospective randomized trial assessing the effects of duloxetine (Cymbalta) in TKA patients who were screened preoperatively for “central sensitization.” In central sensitization, a hyperexcitable central nervous system becomes hypersensitive to stimuli, noxious and otherwise.
Koh et al. randomized 80 centrally sensitized patients (mean age of 69 years), 40 of whom received a multimodal perioperative pain management protocol plus duloxetine, and 40 of whom received the multimodal protocol without duloxetine. During postoperative weeks 2 through 12, patients taking duloxetine reported better results in terms of pain and functional and emotional outcome measures than those not receiving the drug. Patients in the duloxetine group expressed greater satisfaction with pain control (77% vs 29%) and daily activity (83% vs 52%) at postoperative week 12, compared with those in the control group.
This research represents an important advance in identifying and treating patients who are prone to poor outcomes after TKA. The concept of central sensitization is relatively new to the orthopaedic community, and this pharmacologic intervention is likely to be just the first among many that will help these patients. I think it is probable that other, nonpharmacological interventions will eventually be as or even more successful in helping TKA patients with central sensitization. Koh et al. make a valuable contribution in this article by educating us as to the neurophysiologic basis of this condition, and their work should pave the way for more important research in this area.
Marc Swiontkowski, MD
Experienced orthopaedic clinicians understand that anxious patients with high levels of pain are some of the most challenging to evaluate and treat. Both anxiety and pain siphon away the patient’s focus and concentration, complicating the surgeon’s job of relaying key diagnostic and treatment information—often leaving patients confused and dissatisfied. Moreover, such patients usually want a quick solution to their physical pain and mental angst, whether that be a prescription for medication or surgery. At the same time, despite controversy, variously defined levels of “patient satisfaction” are being used as a metric to evaluate quality and value throughout the US health-care system. This reinforces the need for orthopaedists to understand the complex interplay between biological and psychological elements of patient encounters.
In the November 7, 2018 issue of The Journal, Tyser et al. use validated instruments to clarify the relationship between a patient’s pre-existing function, pain, and anxiety and the satisfaction the patient received from a new or returning outpatient visit to a hand/upper extremity clinic. Not surprisingly, the authors found that higher levels of physical function prior to the clinic visit correlated with increased satisfaction after the visit, as measured by the widely used Press Ganey online satisfaction survey. They also noted that higher antecedent levels of anxiety and pain, as determined by two PROMIS instruments, correlated with decreased levels of patient satisfaction with the visit. The authors assessed patient satisfaction only with the clinic visit and the care provider, not with any subsequent treatment.
Most patients are likely to experience some level of pain or anxiety when they meet with an orthopaedic surgeon. To leave patients more content with these visits, we need to set appropriate expectations for the visit in advance of the interaction and develop real-time, in-clinic strategies that help patients cope with anxiety. Such “biopsychosocial” strategies may not by themselves dictate the ultimate treatment, but they may go a long way toward helping patients understand their options and feel satisfied with the care provided. Secondarily, such strategies may help improve the satisfaction scores that administrators, rightly or wrongly, are increasingly using to evaluate musculoskeletal practitioners.
Marc Swiontkowski, MD
Previously this month, Chad A. Krueger, MD, JBJS Deputy Editor for Social Media, selected what he deemed to be the most clinically compelling findings from among the more than 150 studies cited in the January 17, 2018 Specialty Update on Adult Reconstructive Knee Surgery. In this OrthoBuzz post, Gwo-Chin Lee, MD, author of the Specialty Update on Adult Reconstructive Knee Surgery, selects his “top five.”
Nonoperative Knee OA Treatment
—Atukorala et al. found a significant dose-response relationship between all KOOS subscales and percentage of weight change across all weight-change categories. Participants required ≥7.7% of weight loss to achieve a minimal clinically important improvement in function.1
—A prospective cohort study showed that patients undergoing arthroscopic procedures for degenerative meniscal tears did not have clinically meaningful differences in outcomes compared with patients with traumatic meniscal tears.2
Postoperative Pain Management
—Authors of a Cochrane Systematic Review ascertained that liposomal bupivacaine at the surgical site appears to reduce postoperative pain compared with placebo. However, because of the low quality and volume of evidence, it is not possible to determine its effect compared with conventional agents.3
Avoiding Post-TKA Complications
—In a randomized trial, the use of a tourniquet resulted in upregulation of peptidase activity within the vastus medialis but did not result in an increase in muscular degradation products. The authors concluded that the relationship between tourniquet-induced ischemia and muscle atrophy is complex and poorly understood.4
—The authors of a registry study found no evidence that fondaparinux, enoxaparin, or warfarin are superior to aspirin in the prevention of PE, DVT, or VTE—or that aspirin is safer than these alternatives. However, enoxaparin is as safe as aspirin with respect to bleeding, and fondaparinux is as safe as aspirin with respect to risk of wound complications.5
- Atukorala I, Makovey J, Lawler L, Messier SP, Bennell K, Hunter DJ. Is there a dose-response relationship between weight loss and symptom improvement in persons with knee osteoarthritis? Arthritis Care Res (Hoboken). 2016 Aug;68 (8):1106-14.
- Thorlund JB, Englund M, Christensen R, Nissen N, Pihl K, Jørgensen U, Schjerning J, Lohmander LS. Patient reported outcomes in patients undergoing arthroscopic partial meniscectomy for traumatic or degenerative meniscal tears: comparative prospective cohort study. BMJ. 2017 Feb 2;356:j356.
- Hamilton TW, Athanassoglou V, Mellon S, Strickland LH, Trivella M, Murray D, Pandit HG. Liposomal bupivacaine infiltration at the surgical site for the management of postoperative pain. Cochrane Database Syst Rev. 2017 Feb 1;2:CD011419.
- Jawhar A, Hermanns S, Ponelies N, Obertacke U, Roehl H. Tourniquet-induced ischaemia during total knee arthroplasty results in higher proteolytic activities within vastus medialis cells: a randomized clinical trial. Knee Surg Sports Traumatol Arthrosc. 2016 Oct;24(10):3313-21. Epub 2015 Nov 14.
- Cafri G, Paxton EW, Chen Y, Cheetham CT, Gould MK, Sluggett J, Bini SA, Khatod M. Comparative effectiveness and safety of drug prophylaxis for prevention of venous thromboembolism after total knee arthroplasty. J Arthroplasty. 2017 Nov;32(11):3524-28.e1. Epub 2017 May 31.
Surgeons often prescribe more postoperative pain medication than their patients actually use. That’s partly because there is limited procedure-specific evidence-based data regarding optimal amounts and duration of postoperative narcotic use—and because every patient’s “relationship” with postoperative pain is unique. Nevertheless, physician prescribing plays a role in the current opioid-abuse epidemic, so any credible scientific information about postoperative narcotic usage will be helpful.
The Level I prognostic study by Grant et al. in the September 21, 2016 issue of The Journal of Bone & Joint Surgery identified factors associated with high opioid use among a prospective cohort of 72 patients (mean age 14.9 years) undergoing posterior spinal fusion for idiopathic scoliosis.
Higher weight and BMI, male sex, older age, and higher preoperative pain scores were associated with increased narcotic use after surgery. Somewhat surprisingly, the number of levels fused, number of osteotomies, in-hospital pain level, self-reported pain tolerance, and surgeon assessment of anticipated postoperative narcotic requirements were unreliable predictors of which patients would have higher postoperative narcotic use.
Because the authors found that pain scores returned to preoperative levels by postoperative week 4, they say, “further refills after this point should be considered with caution.” Additionally, after reviewing the cohort’s behavior around disposing of unused narcotic medication, the authors conclude, “We consider discussion of narcotic use and disposal to be an important component of the 1-month postoperative visit…This important educational opportunity could help decrease abuse of narcotics.”
Most studies investigating the psychosocial determinants of orthopaedic pain and disability have focused on the spine, hand, hip, and knee. But in the December 16, 2015 JBJS, Menendez et al. looked at psychosocial associations among 139 patients presenting with shoulder complaints. Similar to findings regarding those other anatomical areas, Menendez et al. found that patient variability in perceived symptom intensity and magnitude was more strongly related to psychological distress than to a specific shoulder diagnosis, which included rotator cuff tear, impingement, osteoarthritis, and frozen shoulder.
The authors measured patient pain and disability scores upon presentation using the Shoulder Pain and Disability Index (SPADI). They then analyzed the SPADI scores in relation to sociodemographic data and patient responses to three additional validated tests measuring depression, tendencies to catastrophize, and self-efficacy. They found that disabled and retired work status, higher BMI, catastrophic thinking, and lower self-efficacy (i.e., ineffective coping strategies) were associated with greater patient-reported symptom intensity and magnitude of disability.
Interestingly, BMI was the only biological influence on pain and disability scores. Also, retirement had a negative influence on pain and disability scores, which was somewhat surprising considering that retirement often has positive effects on well-being.
The authors conclude that future research focused on the effect of psychosocial factors on postoperative pain and response to treatment might “allow surgeons to identify patients who are at risk for a treatment-refractory course.” They further surmise that “interventions to decrease catastrophic thinking and to optimize self-efficacy…before shoulder surgery hold potential to ameliorate symptom intensity and the magnitude of disability.”