August 01, 2014
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Surgeons explore non-opioid options for pain management

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Postoperative pain management after orthopedic procedures requires physicians to balance the risks of respiratory depression, delayed ambulation and opioid abuse with the goal of lessening patient discomfort after surgery, and many physicians are looking to multimodal routes to accomplish this objective.

“Opioids have been the mainstay for treatment of postoperative pain for many years, but over the last several years, both physicians and patients have noticed more adverse reactions or side effects for opioids and they are numerous,” said Paul F. Lachiewicz, MD, of the Department of Orthopaedic Surgery at Duke University Medical Center in Durham, N.C. Among the risks of opioid use are abuse, confusion, nausea, vomiting, itching, constipation and respiratory depression. Patients who are administered too much opioid medication can undergo respiratory arrest and require admission to the intensive care unit and possible intubation, Lachiewicz told Orthopedics Today.

Patients with sleep apnea, particularly undiagnosed, are at an increased risk for respiratory adverse effects with opioids, according to physicians interviewed for this story.

“These [sleep apnea] patients already have trouble breathing, so to add the respiratory depression to opioid use, can cause increased complications,” said Sheyan J. Armaghani, MD, of the Department of Orthopaedics and Rehabilitation at Vanderbilt University Medical Center in Nashville. “At our institution, we send all patients with a history of sleep apnea who need opioids post-surgically to a monitored unit to help prevent respiratory complications.”

Clinton James Devin

Clinton James Devin, MD, said that multimodal pain management allows for reduced dosage of opioids, improved pain control and more rapid mobilization.

Image: Joe Buglewicz

Opioids also can induce potential adverse events, such as hypotension, and gastrointestinal effects including nausea, vomiting and constipation. Elderly patients — particularly those who have never taken opioid medications — are more likely to suffer cognitive effects.

“If older patients, say in their 80s and older, are not used to taking Percocet or other oral opioid medications and then are given opioids in the hospital, they can get confused, disoriented or delirious,” Lachiewicz said.

Obese patients present an added concern for practitioners as opioids can accumulate in fatty tissue. Patients with psychiatric conditions also may be more likely to abuse opioids, according to Clinton James Devin, MD, assistant professor of orthopaedic surgery and Neurosurgery at Vanderbilt Spine, Nashville. “Opioids are then used to not only manage the perceived pain, but also the patients attempt to decrease their worsening depressive or anxiety symptoms,” he told Orthopedics Today.

Complications and comorbidities often have a lasting effect for patients since they can lead to a delay in ambulation, and overall recovery. “We are trying to mobilize, get the patients up and walking, participating in physical therapy, and finally getting them out of hospital early after major surgery,” Lachiewicz said. “If the patient has respiratory depression, gastrointestinal upset or confusion, they are not going to be able to do [physical therapy] PT, and they are not going to be able to get out of the hospital per protocol.”

Orthopedic surgeons also consider the potential for abuse when prescribing pain medication, though long-term usage of medications most often falls under the purview of a pain physician. However, surgeons often screen for opioid abuse or potential in patient interviews. Selene G. Parekh, MD, MBA, an orthopedic foot and ankle surgeon, at the North Carolina Orthopaedic Clinic and Duke University Durham, N.C., said he looks for warning signs such as depression, history of opioid abuse and drug abuse, or past medical or social issues, gathered from self-reported information on patient intake forms. “If there is something that gets flagged in the electronic medical [record] history, then we bring that to the attention of the patient and discuss it,” he said.

Parekh also said that in cases where there is prior abuse, he only allows a designated pain management physician to prescribe narcotics to patients to eliminate the possibility that multiple practitioners are providing narcotic medications.

Abuse risk with opioids

Patient information also can be cross-checked with databases in many states, according to Armaghani.

“In Tennessee, we are fortunate to now have a state-wide database that registers opioid prescriptions, including dose, amount and date prescription filled, that providers can look up online to see if a patient has been doctor shopping,” he said. “This has been a great tool to identify those who are abusing the system and looking for prescriptions.”

Andrew Gurman

Andrew W. Gurman

In the absence of database checks, nurses and physicians can inquire about medical history and attempt to determine if a patient is abusing medications or is prone to such behavior. “You start with a history as part of documentation and hope patients are forthright about what they are telling you,” said Andrew W. Gurman, MD, an orthopedic hand surgeon at Altoona Hand & Wrist Surgery in Altoona, P.A., and Speaker of the AMA House of Delegates.

Given the potential for abuse with opioids, Devin asks patients to sign a contract that they will be expected to “achieve opioid independence at 12 weeks” after surgery. He noted that opioids such as hydrocodone act on the same receptor as the illicit drug heroin, and that legislation that has restricted the ability to obtain opioid prescriptions coincides with an increase in heroin usage, suggesting that opioids could be a “gateway” drug for some patients, he said.

Opioid-tolerant patients, recovery

Separately, patients who have regularly relied on opioid pain medications for medically valid reasons prior to surgery — most often for ongoing spine, hip or knee pain — are likely to face a more difficult recovery after surgery. “The problem with opioids is that most patients will develop a tolerance to the medication, requiring increasing doses to obtain the same effect,” Armaghani told Orthopedics Today.

Lachiewicz also noted patients who had received opioids for long periods prior to surgery are difficult to treat postoperatively. “As an orthopedic surgeon, we have seen more patients recently with arthritis of their hips and knees who are given opioid prescriptions by their family practice doctor or other primary care provider for knee or hip arthritis pain,” he said. “Patients become habituated to [opioids] so that when they do come into the hospital, it is difficult to treat them.”

The use of narcotics for non-cancer pain management greatly increased beginning about 2 decades ago, according to several of the sources interviewed for this article. In 1995, the American Pain Society and American Society of Anesthesiologists suggested that pain was under-managed, and the Veteran’s Affairs system named pain as an important care consideration with the “fifth vital sign initiative” in 1998, said Devin. The Joint Commission followed in 2001 with revamped pain management standards.

All of these factors coalesced into increased usage of opioids and narcotics, he said. According to Devin, during the late 1990s and early 2000s physicians began to turn to narcotics to manage pain following joint procedures, and related to musculoskeletal issues; prior to that time narcotics were typically reserved for cancer-related pain. As a result of the increase in narcotics and opioid prescriptions, it is not uncommon for orthopedic surgeons to encounter surgical candidates who have been regularly managing their pain with opioids, said several of the physicians interviewed.

Some physicians suggest asking patients to detoxify in order to have adequate control over their postoperative pain by breaking their dependence on opioids.

Sheyan J. Armaghani

Sheyan J. Armaghani

“We do ask most patients who are taking opioids to try and wean themselves as much as they can [prior to] surgery as this does increase their hospital stay and makes their pain control postoperatively more challenging,” Armaghani said. “Unfortunately, sometimes we do not have time to wait for a patient to wean from opioids if they are involved in a trauma or have an emergent condition, and in these cases, we certainly proceed with surgery when indicated.”

In instances when patients are not weaned of opioid dependence, pain management is often difficult to achieve, Devin said. Opioid-dependent patients and patients who have not used narcotic medications previously can experience barriers to managing pain, he said. Additional costs due to readmission can be linked to a lack of adequate pain management. A 2002 Journal of Clinical Anesthesia article concluded that pain was the top reason for readmission after outpatient surgery, and leads to added follow-up costs at an average of $13,900 per patient.

Furthermore, Armaghani and his colleagues were able to establish a link between preoperative use of opioids and poorer outcomes in a study published in the Journal of Spinal Disorders & Techniques. “Although much of what we have demonstrated is intuitively true, we were able to demonstrate in a prospective fashion in a busy tertiary care center that patients on preoperative opioids have decreased outcomes, longer hospital stay, have trouble weaning from opioids after surgery, and are more likely to have depressive [or] anxious symptoms than those who are not,” he said. Data analysis revealed “that for every 100 morphine equivalents a patient is taking preoperatively; their stay is extended 1.1 days,” according to the abstract.

Devin also said pain control is tied to costs in terms of patient satisfaction and reimbursements. “The ACA administers a survey to patients after their hospital admission and one key section of questions is based around how well a patient’s pain was controlled,” he said. “The results of this metric will be utilized for reimbursement to physicians and hospitals.” Low patient-awarded scores for alleviating pain means reduced reimbursement for the provider. “Therefore, pain control is important, not only because it is the right thing to do for our patients, but it also has financial implications,” Devin said.

Reframing pain management

Since pain remains a problematic factor in patient satisfaction and recovery, and opioids can present risks for complications and abuse, physicians are moving away from simplistic pain management. “With both inpatient and outpatient orthopedic surgery, the state of the art now is multimodal perioperative pain management,” Lachiewicz said.

Varying combination therapies of short-acting opioids, NSAIDs, preoperative “cocktails,” nerve blocks or other alternatives can be used to avoid heavy use of intravenous morphine or Fentanyl, he said. “Generally, we follow the American Society of Anesthesiology guidelines for multimodal pain management, Lachiewicz said. “That means the patient should get around the clock non-opioids — that would include NSAIDs, coxibs and/or acetaminophen — all of these can be given either orally or intravenously and there are different properties of these drugs when used intravenously.” Preoperative “cocktails” often include oral acetaminophen, gabapentin and celecoxib, though orthopedic surgeons should be aware that often patients do not properly absorb oral medications prior to surgery, due to stress or partial gastric paralysis, he said. Lachiewicz said he forgoes a preoperative cocktail and nerve blocks, and prefers to use a spinal anesthetic, an intraoperative periarticular injection of local anesthetics, followed by intravenous acetaminophen during surgery and postoperatively for 24 hours. He also uses an intravenous nonsteroidal medication in appropriate patients and low dose, short-acting oral opioid medication.

Regarding multimodal pre-emptive pain management, Armaghani said, “Intraoperatively, our anesthesiologists are able to use different non-opioid medications such as ketamine and Precedex (Hospira), which also decrease pain without having to use large doses of opioids. Our outpatient services such as hand, foot and ankle, and sports services do routinely utilize nerve blocks which allow the patient to go home following surgery.”

Multimodal options

Combination therapies allow for reduced dosage of opioids, said Devin. However, other medications do have drawbacks as well. For instance, NSAIDs can inhibit bone healing and contribute to bleeding and renal toxicity; gabapentin and pregabalin can cause sedation; and local anesthetics, which can be administered subcutaneously during surgery or via epidural catheter, are expensive, Devin said.

Gurman said he often employs a local anesthetic at the start and during operations in order to alleviate pain without narcotics. “I find the use of local anesthetics are helpful with patients who are habituated,” he said. “If I do a local on the way in and on the way out, that usually takes care of it.” Physiologic reactions to pain such as increased heart rate even seen under general anesthesia are reduced with the use of local anesthetics, he said.

In addition, nerve blocks can provide immediate postoperative pain relief. However, physicians interviewed for this story noted that their effectiveness is limited to certain surgeries, patients are temporarily paralyzed in the operative area as a result of most nerve block procedures and breakthrough pain is common at 24 hours to 36 hours after surgery. Surgeons performing hip and knee procedures often do not utilize nerve blocks as these are less effective than foot and ankle nerve blocks and are associated with higher risks for complications. “If the anesthesiologist is familiar with the procedure, an abductor canal nerve block supposedly gives pain relief but not muscle paralysis in the leg,” said Lachiewicz, noting that most anesthesiologists are not trained in that procedure. He has not had success with this nerve block, and now no longer includes nerve blocks in his postoperative protocol.

Paul F. Lachiewicz

Paul F. Lachiewicz

Achieving postoperative pain relief can be particularly troublesome and lead to patient refusal to ambulate, according to Armaghani. “Breakthrough pain is difficult to control in some patients, as this typically happens when they are moving or participating in physical therapy,” he said. “It is important to explain to patients after surgery that they can feel pain with movement and to use short-acting pain medicines to help control this pain to a manageable level to participate in therapy.” Uncontrolled pain may “develop a fear of moving, and in the early postoperative period, this can hurt outcomes as range of motion is important following certain surgeries such as total knee arthroplasty,” he said.

The duration for opioids postoperatively depends on the procedure. “Hip replacement patients hurt less than knee replacement patients,” Lachiewicz said. “Usually hip replacement patients need an oral opioid for 7 days to 14 days after surgery, and knee replacement patients in my experience, especially if their knees are deformed or they have difficulty bending them, they need opioids 4 weeks to 6 weeks.”

Armaghani noted that pain management techniques vary based on procedure and provider. “A carpal tunnel release should not require opioids after the sutures are removed; however, a large spinal deformity correction may need opioids for a couple months,” he said. “In our clinics, we usually do not provide opioids 3 months postoperatively, and if they are still needed, they are referred to pain management if they continue to require high doses of opioids, non-opioid medications are not working, or are not able to wean.”

Lachiewicz noted that superior pain relief options are available — intravenous acetaminophen for example may provide comparable pain relief to opioids without the narcotic-associated adverse events — but are less often provided through hospital formularies due to higher costs. Parekh, however, saw a positive trend away from addictive and long-acting medications in the next decade. “Industry will try to find effective pain modalities that are not addictive,” he said. “As industry pushes more medications, FDA will critically look at that data to see what is most addictive.”

He said the conversation will continue on the half-life of medications, length of time a prescription or refills last, and better models such as novel delivery methods, multimodal pain management and reservoirs. Lachiewicz said that one such medication providing an alternative to opioids is Exparel (Pacira Pharmaceuticals), which delivers a local analgesic via intraoperative injection. Lachiewicz, who has given one paid lecture on the medication, said the medication has led to improved pain management for his patients. Parekh said the medication “has become the centerpiece of pain management” in his practice, with many patients using half as many Percocets as previously prescribed, and alleviating pain for patients who are opioid resistant or dependent.

Armaghani said future resources could be devoted to information sources or regulations that would support physician efforts to curb misuse of opioids. “Ideally, a national database should be kept to keep track of patients who are obtaining multiple prescriptions from different providers and to shut down so called ‘pill mills’,” he said. “Also banning refills on opioids for non-cancer patients along with putting a limit on the amount of pills that can be prescribed in a certain time period [may help].” Physicians are coming up against patient expectations for pain relief and “it is difficult for providers to say no to prescribing opioids to patients who are requesting them, especially in this day where the emphasis is on patient satisfaction,” he said. – by Katie Pfaff

References:
Armaghani SJ. J Spinal Disord Tech. 2014.
Coley KC. J Clin Anesth. 2002.
Rodgers J. J Hand Surg Am. 2012;doi: 10.1016/j.jhsa.2012.01.035.
For more information:
Sheyan J. Armaghani, MD, can be reached at Vanderbilt University Medical Center, 1161 21st Ave. S. #T1217, Nashville, TN 37232; email: sheyan.armaghani@vanderbilt.edu.
Clinton J. Devin, MD, can be reached at Vanderbilt Spine, 719 Thompson Ln. #23108, Nashville, TN 37204; email: clinton.j.devin@vanderbilt.edu.
Andrew W. Gurman, MD, can be reached at Altoona Hand and Wrist Surgery, 1701 12th Ave. #C2, Altoona, PA 16601; email: andrew.gurman@ama-assn.org.
Paul F. Lachiewicz, MD, can be reached at Duke University Regional Hospital, 3643 N. Roxboro St., Durham, NC 27704; email: paul.lachiewicz@gmail.com.
Selene G. Parekh, MD, MBA, can be reached at the North Carolina Orthopaedic Clinic, Duke Medicine, 3609 SW Durham Dr., Durham, NC 27707; email: selene.parekh@gmail.com.
Disclosures: Armaghani and Gurman have no relevant financial disclosures. Devin is a consultant for DePuy Spine and Pacira Pharmaceuticals, and receives grant funding for outcomes research from Stryker Spine. Lachiewicz is a consultant with Cadence Pharmaceuticals, makers of Ofirmev, and has given one paid lecture for Pacira Pharmaceuticals. Parekh is a consultant for Pacira Pharmaceuticals.
POINTCOUNTER

Do you find it beneficial to create and execute patient contracts outlining the expectation that patients will no longer receive opioids after a designated date following surgery?

POINT

Contracts damage the physician-patient relationship

Wellington Hsu

Wellington K. Hsu

Opioid medication in the postoperative period after surgery, although necessary, must be managed carefully by the treating physician because of the potential safety risks with excessive or long-term use. One needs not to look any further than the recent Drug Enforcement Administration’s probe into prescription drug abuse in National Football League locker rooms to understand the danger and addiction issues when it comes to narcotic use. Consequently, prior to surgery, physicians must carefully outline the postoperative course, discuss potential risks of opioid use and estimate the reasonable amount of time that a patient will require these medications after surgery.

However, patient contracts to execute these terms can be harmful for the surgical outcomes. In our society today, a written contract is used when a verbal or informal agreement is not adequate to ensure protection for both parties. For example, these are necessary between an employer and employee, home seller and buyer, and corporate entities during a merger.

The physician-patient relationship is a significantly different bond that is built upon not only the trust a patient hands over when his medical record and body are thoroughly scrutinized, but also a physician’s invitation of patients into his or her practice “family” where their health and well-being are treated like that of a true family member. The use of written contracts to enforce the understanding within this relationship denigrate the uniqueness and importance of this bond.

This being said, preoperative discussion of expectations and counseling regarding the use of opioids are critical whether a written contract is utilized or not. Because every clinical situation is different, patients must understand what the general expectations are as it pertains to narcotic use after surgery. More importantly, case-by-case considerations including invasiveness of surgery, length of stay, prior narcotic use, psychosocial comorbidities and social support system must be taken into account during these discussions.

Wellington K. Hsu, MD, is Clifford C. Raisbeck Distinguished Professor of Orthopaedic Surgery, Director of Research, Department of Orthopaedic Surgery at Northwestern University Feinberg School of Medicine, Chicago.
Disclosure:
Hsu has no relevant financial disclosures.

COUNTER

Patient contracts should not be routine

Carlos Lavernia

Carlos Lavernia

I certainly do not agree with the routine use of “contracts on pain.” In these routine cases, patients may feel that their medical care could be compromised for the perception of breach and they affect not only their open communication, but their relationships with their surgeons. In addition, it “lawyerizes” the encounter with the physician. However for problem patients, drug abusers and chronic pain narcotic users, the utilization of contracts makes it clear for both the physician as well as the patient that there are certain rules regarding the postoperative course and the prescription of opioids. These documents or contracts remind the team and surgeon that on these “special cases” a professional pain management team may be needed, and a bridge between the surgical pain and chronic pain needs to be created and defined. When utilized, this bridge between the postoperative opioid prescription and the pain management team needs to also be discussed in the document that both physician and patient sign. Although I disagree with using the term “contract,” I think that having a document educating and clarifying the specific timeline for discontinuation of the pain medication is an excellent concept for both the patient and the physician. This allows both to discuss one of most important aspects of surgery which is pain management. Patients who abuse opioids are extremely manipulative and have abusive drug-seeking behavior. This document defines a boundary in terms of opioid prescribing and clarifies the issues. These contracts or documents are similar to prenuptial agreements in relationships. They are not needed in most cases, but are key for both parties in some.

Carlos Lavernia, MD, is director at Center for Advanced Orthopedics and chief of orthopedics at Larkin Hospital, Miami.
Disclosure:
Lavernia has no relevant financial disclosures.