January 01, 2012
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With concerns over narcotics, some surgeons develop alternative pain management protocols

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Discuss in OrthoMind
Discuss in OrthoMind

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.

Thomas F. Higgins, MD
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

“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.

Richard H. Rothman, MD, PhD

“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

“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.

Simon C. Mears, MD, PhD

“This is a topic that we need more education from the resident level all the way up.”
— Simon C. Mears, MD, PhD

“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.

Jeffrey D. Swenson, MD

“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

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.

point/counter

What are your indications for prescribing prescription narcotics for pain?

Point

Watch out for chronic use

Douglas W. Jackson, MD
Douglas W. Jackson

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
.

Counter

A shift from long-term use

Peter Abaci, MD
Peter Abaci

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.