Attitudes among orthopedists about the use of
narcotics for
pain management vary, as some feel they provide the best
option for acute pain and others fear the potential for patient abuse,
dangerous side effects and related lawsuits. However, pain management
specialists note that these medications can be safely prescribed and highlight
alternative treatment methods such as new
pain management protocols, nerve blocks and catheters.
According to a study published in Pain Physician, the
United States consumes 99% of the world’s hydrocodone pills and 80% of the
planet’s prescription opiates. A recent survey of the Orthopaedic Trauma
Association conducted by Thomas F. Higgins, MD, found that 36% of members
reported that medicolegal concerns enter into their thinking about pain
management in at least half of all cases.
“If you look at where prescriptions are coming from, orthopedic
surgeons are third in line in terms of who is providing these after family
doctors and internal medicine doctors,” Higgins told Orthopedics
Today. “But there are far more family practice and internal
medicine doctors, so I think we are overrepresented in terms of prescribing and
it is a national epidemic in terms of mortality.”
Determining an adequate dose of narcotics can be tricky as dosing varies
by patient. As the population grows older and more obese, Jeffrey D. Swenson,
MD, an anesthesiologist with the University of Utah School of Medicine in Salt
Lake City, said there is an increased risk of respiratory events. Some
orthopedists have developed alternative methods for pain control using smaller
doses of opioids to treat patients with sleep apnea. Swenson told Orthopedics
Today that he uses acetaminophen, an anti-inflammatory and a continuous
peripheral nerve block to treat such cases and highlighted the importance of
treating patients on an individual basis.
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In terms of treating patients with pain and the
potential for prescribing pain medication, Thomas F. Higgins, MD, said that
surgeons should document their discussions with patients and reasoning for
treatment.
Image: Elizabeth Banuelos-Totman
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“In terms of postoperative respiratory depression or catastrophic
outcomes, you prevent those kinds of complications one patient at a time,”
Swenson said. “You have to look at each patient as an individual and say,
‘Okay, is this person safe to send home?’ or ‘How can I best
treat them and avoid respiratory depression?’”
Carlos Lavernia, MD, of the Orthopaedic Institute at Mercy Hospital in
Miami recommends lower doses of narcotics for elderly or thin patients or those
with respiratory illnesses.
“In the older patient population, they do not metabolize as well,
so it is important that you really adjust the dose properly,” Lavernia
told Orthopedics Today. “The very elderly and respiratory
compromised are two types of patients with whom you have to be kind in dosing
opiates. When you operate, you have to adjust the doses.”
However, some patients may require higher doses of narcotics, such as
those with chronic pain who have developed a tolerance to the drugs or patients
who are alcoholics.
“People who drink a lot will actually not respond to narcotics, so
drinkers require higher doses of narcotics to keep the patient comfortable
after surgery,” Lavernia said.
Richard H. Rothman, MD, PhD, of the Rothman Institute in Philadelphia
stipulates that high-tolerance patients must detoxify preoperatively.
“We tell our patients that if someone has a long history of
narcotic utilization, they have to detoxify and get off narcotics before we
will do elective surgery on them,” Rothman told Orthopedics
Today.
Detecting addiction
Determining whether a patient has an
addiction is another concern for those managing pain.
According to Swenson, warning signs of patient addiction include the following:
- asking for more opioids after 10 days to 2 weeks of treatment;
- saying they are allergic to any other non-narcotic analgesics; or
- requesting specific opioids by name.
Other signs include patients with multiple reports of lost prescriptions
or those who receive narcotics from more than one physician.
Higgins noted that prescription narcotics abuse has become easier to
detect as 37 U.S. states have implemented databases that record patients
filling prescriptions for opiates.
“If someone comes in and we suspect they have multiple providers
and are not being entirely honest with us, we just query the database,”
Higgins said.
Lavernia suggests taking patients off prescription narcotics when they
have exceeded a 6-week period of continuous use. Lavernia and Swenson also
stressed the importance of referring patients with chronic pain to a pain
specialist after a period of continuous use.
Legal dilemmas
Lawsuits for mishandling narcotics prescriptions are possible, though
rare, Mark A. Lee, MD, an orthopedic trauma surgeon with Lawrence J. Ellison
Ambulatory Care Center in Sacramento, told Orthopedics Today. The
possibilities for lawsuits range from over medication leading to death from
overdose or under medication for under treating pain.
“We tell our
patients that if someone has a long history of narcotic utilization, they have
to detoxify and get off narcotics before we will do elective surgery
…”
—Richard H. Rothman, MD,
PhD |
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“To the best of our knowledge, there is not to date a precedent for
someone winning a legal action after bringing suit for under-treatment of
pain,” Higgins said. “But, it certainly is a concern.”
Lee consulted with local California personal injury and medical
malpractice attorneys, who noted that orthopedists could be sued for inadequate
pain management, negligent pain management or third party negligence. Patients
could also sue for supervisorial negligence, Lee said. An orthopedist could be
held liable for anyone under their supervision who writes prescriptions for
narcotics, such as a physician’s assistant or resident, he said.
“Nurses need to understand that in addition to focusing on what [a
patient’s] pain score is, the primary determinant of whether patients get
more opioids is not mental status or respiratory rate because a lot of them
will fail them,” Swenson said. “The patient will be very sedated, but
say their pain is an eight out of 10, and that pushes the nursing staff to give
more opioids, when in reality, you reach a point at which you say that safety
trumps analgesia.”
“The other key is documentation of your thinking, your discussions
with your patients, and your reasoning in terms of why you did as you did or
prescribed as you prescribed,” Higgins said.
Some orthopedists prevent overmedication using pain contracts. Rothman
and his team tell a patient that after acute operative pain dissipates, usually
at 3 weeks, they will no longer supply narcotics and then document the
conversation. Higgins uses a limit of 6 weeks in his orthopedic trauma
patients.
This way, “we do not get the addicted, litigious, depressed patient
calling us and harassing us for continued prescription drugs,” Rothman
said.
Lee is also open with his patients from the beginning of treatment and
lets them know his expectations for the severity of their injury and pain, and
how they will transition off of the narcotics.
Protect yourself and your practice
“[Orthopedists] have to be familiar with the statutes in their own
states,” Higgins said.
In California, Lee noted that there are published guidelines about
detailed record keeping, periodic review and informed consent. Orthopedists can
go to their state’s medical board website to find out current laws.
California and some other states require that orthopedists obtain pain CME as
part of their ongoing licensing and notify patients about pain control
specialists.
“Doing a little self education [can] protect the patients and you
in a medicolegal sense,” Lee said.
In a recent study, Simon C. Mears, MD, PhD, and colleagues from Johns
Hopkins University surveyed orthopedic residents, nurses and therapists at one
hospital and found that the medical staff lacked adequate knowledge of pain
management. They concluded this lack occurred because the hospital relied on
the “apprenticeship model” for the staff to learn pain management and
the hospital lacked formal pain management training. The study participants
expressed a desire for formal training and the investigators discovered that
the medical staff reported concerns about the proper dosing of pain medications
for the elderly and those with chronic narcotic use.
“This is a
topic that we need more education from the resident level all the way up.”
— Simon C. Mears, MD, PhD |
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“This is a topic that we need more education from the resident
level all the way up,” Mears told Orthopedics Today.
“This is not a topic that is much addressed in the curriculum of
orthopedic surgery.”
Multi-modal pain management
Many orthopedists have moved away from complete reliance on narcotics
for pain to step-wise, multi-modal analgesia or pre-emptive pain management
techniques using mild opioids.
“I think one thing that has been stressed by a lot of
anesthesiologists right now is to have a new paradigm shift where we do not use
opioids as the foundation for our analgesia,” Swenson said.
Swenson recommends a multi-modal, step-wise approach for postoperative
pain control tailored to each patient’s needs. The components of this
approach are acetaminophen plus NSAIDs, pregabalin and peripheral
nerve blocks.
“We use different types of analgesics that work via different
pathways so that the sum total of these different drugs is excellent analgesia,
but the side effects of any given agent are low because we are not using any
one exclusively.”
Swenson’s choice of analgesic depends on the operation and the
health risks of the patient. He manages less painful operations with a
combination of acetaminophen and anti-inflammatories such as ibuprofen.
“Something as simple as acetaminophen or anti-inflammatories can
reduce your opioid consumption by 30% to 40% and the side effects of those
too,” Swenson said. “So, for procedures that are minimally or
moderately painful, you can get by without using opioids.”
For more severe cases, Swenson “builds on the base of Tylenol and
anti-inflammatory with low-dose opioids such as hydrocodone or oxycodone.”
For the most painful surgeries, he adds pregabalin and a peripheral nerve block
in the form of either a single injection or indwelling catheter.
Pre-emptive pain management
Lavernia and Rothman opt for pre-emptive multi-modal pain management to
knock out as much pain as possible preoperatively and perioperatively, although
their analgesic cocktails differ. Lavernia’s pain protocol involves
around-the-clock pain medication beginning the morning of the surgery with a
course of OxyContin (oxycodone, Purdue Pharma), Tylenol (acetaminophen,
McNeil), Celebrex (celecoxib, Pfizer) and Ultram (tramadol, Jansen
Pharmaceuticals Inc.) with dosing adjusted to each patient’s size and
needs.
“Something as
simple as acetaminophen or anti-inflammatories can reduce your opioid
consumption by 30% to 40% and the side effects of those too. ”
— Jeffrey D. Swenson, MD |
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Patients undergoing knee replacement receive femoral and sciatic blocks
for 2 days, and those undergoing hip surgery receive lumbosacral plexus blocks
for 2 days. In the operating room, patients receive Marcaine (bupivicaine,
AstraZeneca), morphine sulfate and sodium chloride periarticular injections.
Postoperatively, patients receive Tylenol, OxyIR (oxycodone, Purdue Pharma),
OxyContin, Celebrex, Ultram and morphine. After discharge home, patients
receive Vicodin (acetaminophen and hydrocodone, Abbott Laboratories), Ultram
and Celebrex.
In 2008, Lavernia and his team conducted a prospective analysis of 1,136
patients undergoing primary total knee arthroplasty. They compared 358 patients
who received the multi-modal pre-emptive course of pain medications to 778
patients who did not receive the regimen. The treatment course cut the rate of
manipulation under anesthesia in half.
“The incidence of arthrofibrosis, which is partly due to not
controlling pain in the perioperative period, was reduced significantly,”
Lavernia said. “You do not have the spikes of pain [like] in the old
times.”
Rothman employs a slightly different mixture of pain drugs in his
pre-emptive plan with Tylenol, Lyrica (pregabalin, Pfizer) and Celebrex given
preoperatively. During surgery, patients receive intravenous Zofran
(ondansetron, GlaxoSmithKline) for nausea. Once he is finished operating,
Rothman injects the knee capsule with a mixture of Marcaine, epinephrine (to
prevent bleeding) and Toradol (ketorolac, Roche). As he closes the wound,
Rothman leaves a Q-ball in the knee to infuse the joint with the trio of drugs
for 48 hours.
“With those measures, there is really no pain when the patient
leaves the operating room. It is the most remarkable phenomena,” Rothman
said.
Postoperatively, patients receive Tylenol, Lyrica and Toradol. If
patients have breakthrough pain after hip or knee surgery, Rothman prescribes
Tramadol or Norco (hydrocodone bitartrate and acetaminophen, Watson). After 3
weeks to 4 weeks, Rothman advises patients take acetaminophen or ibuprofen.
“The around-the-clock concept and pre-emptive pain management, are
the most important concept in the perioperative management of pain past 20
years,” Lavernia said. – by Renee Blisard
References:
- Cordts GA. A qualitative and quantitative needs assessment of pain
management for hospitalized orthopedic patients. Orthopedics.
2011; 8:34(8):e368-e373.
- Manchikanti L, Singh A. Therapeutic opioids: a ten-year perspective
on the complexities and complications of the escalating use, abuse, and
nonmedical use of opioids. Pain Physician. 2008;11(2):S63-88.
- Lavernia C. Multimodal pain management and arthrofibrosis. J
Arthroplasty. 2008; 23(6 Suppl 1):74-79.
- Thomas F. Higgins, MD, can be reached at the Department of
Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108;
801-587-7109; email: thomas.higgins@hsc.utah.edu.
- Carlos Lavernia, MD, can be reached at Orthopaedic Institute at
Mercy Hospital, Mercy Hospital Outpatient Center, 3659 South Miami Ave. Suite
4008, Miami, FL 33133; 1-888-544-2148; email:
carlos@orthomercy.com.
- Mark A. Lee, MD, can be reached at University of California Davis
Medical Center, 4860 Y St., Suite 3800, Sacramento, CA 95817; 916-734-5677;
email: mark.lee@ucdmc.ucdavis.edu.
- Simon C. Mears, MD, PhD, Department of Orthopedic Surgery, Johns
Hopkins Bayview Medical Center, 4940 Eastern Ave, #A665, Baltimore, MD 21224;
410-550-0453; email: smears1@jhmi.edu.
- Richard H. Rothman, MD, PhD, can be reached at the Rothman
Institute, 925 Chestnut St., Philadelphia, PA 19107; 267-339-3500; email:
barbara.hand@rothmaninstitute.com.
- Jeffrey D. Swenson, MD, can be reached at University of Utah
Orthopaedic Hospital, University Of Utah Anesthesia, 30 North 1900 East, Suite
3C444, Salt Lake City, Utah 84101; 801-581-6393; email:
jeff.swenson@hsc.utah.edu.
- Disclosures: Higgins, Mears, Lee, Lavernia, Swenson and
Rothman have no relevant financial disclosures.
What are your indications for prescribing prescription narcotics for
pain?
Watch out for chronic use
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Douglas W.
Jackson
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Most orthopedic surgeons use
opiates selectively and effectively in the management of acute
pain in their patients. Acute pain has a definite starting point, and
orthopedic surgeons know the range for the expected time to recovery from the
pain producing process. Part of this acute care management involves weaning the
patient off of the opiate and moving to milder or no analgesics as the
underlying pain producing condition resolves. The real problem for the
clinician is when this normal expected transition of opiates is replaced by
their chronic use. The orthopedist can play a critical role in preventing the
chronic scenario of dependence and addiction that can develop with opiates.
Chronic pain management is more than repeatedly filling opioid
prescriptions. Complicated and longer standing chronic pain management is often
more then a busy orthopedic surgeon can carry out in their office setting. It
usually involves a multidisciplinary approach once it becomes established.
There is no significant evidence that opioids are effective in altering
chronic pain symptoms, and yet according to the Office of National Drug Control
Policy, opioid painkillers continue to be the most commonly prescribed
medications in the United States. They are often being used in increasing doses
by some physicians to address the complaints of chronic pain with no plan for
dealing with the patient’s whole disability issues. If chronic use of
opiates develops, it must be recognized that more of its use is not part of a
solution, and its sustained use contributes to the overall dysfunction of the
given patient.
Douglas W. Jackson, MD, is the Chief
Medical Editor of Orthopedics Today.
Disclosure: Jackson has
no relevant financial disclosures.
A shift from long-term use
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Peter Abaci
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Opioid-based prescription pain medications remain a mainstay for the
treatment of acute pain, postoperative pain, and for cancer pain management and
palliative care.
In the setting of chronic pain management, our practice has shifted our
focus away from using long-term opioids and more toward a comprehensive
interdisciplinary model that educates the patient on how to develop tools to
manage pain and improve function and quality of life indices. The practitioner
needs to carefully weigh factors including outcome studies on long-term opioid
use, the effects of opioid use on the nervous system, as well as data on the
rise in abuse of prescription pain killers when working with chronic pain
patients.
In my experience, there has been too much emphasis on the long-term use
of opioids at the expense of other valuable treatment modalities. While opioids
can be a valuable tool when used carefully, medications simply can’t take
the place of employing an approach that uses a biopsychosocial model to
transform the needs of the individual.
Peter Abaci, MD, is an
anesthesiologist and pain management specialist. He is the founder and medical
director of Bay Area Pain and Wellness Center in Los Gatos, Calif.
Disclosure: Abaci has no relevant financial disclosures.