Rothman Orthopaedic Institute opioid protocol linked to reduced consumption, refill rate
In the past few years, physicians and staff at Rothman Orthopaedic Institute have begun to implement a series of preoperative, intraoperative and postoperative protocols to decrease the opioid prescribing, consumption and refill rates.
In an interview with Healio.com/Orthopedics, Asif M. Ilyas, MD, president of Rothman Orthopaedic Institute’s Opioid Research and Education Foundation, noted they have implemented a number of acute and chronic pain strategies and have begun guiding the number of opioids being prescribed through research for different procedures.
“There is generally a lot of variability in opioid prescribing, where different doctors prescribe different amounts of opiates for similar procedures. We are trying to develop a more evidenced-based strategy to prescribing,” Ilyas said. “We have done a lot of research that has shown us the typical amount of opiates people consume after different procedures and we are trying to customize prescriptions accordingly.”
Preoperatively, Ilyas noted they are also providing counseling to patients on what opiates are, what the opioid epidemic is and safe ways to use opioids postoperatively. Ilyas, also professor of orthopaedic surgery at Thomas Jefferson University, said Rothman Orthopaedic Institute has championed the use of physician drug monitoring programs.
“We do not provide opiates until we check [the drug monitoring program] to make sure [the patient is] not getting opiates from different places,” Ilyas said. “We also use e-prescribing tools where we are no longer writing prescriptions on paper where they could be manipulated or lost or forged. We now send them all electronically.”
He added they are also controlling patient pain postoperatively through multimodal pain strategies, such as using local and regional blocks, anti-inflammatories and acetaminophen instead of opioids perioperatively, which are customized to various orthopedic procedures.
Cannabinoids for pain management
For pain management postoperatively, Ari C. Greis, DO, director of the medical cannabis department at Rothman Orthopaedic Institute, noted they have begun to recognize when to transition patients onto non-opioid medications, including cannabis, which was legalized in Pennsylvania in 2018.
“It is not a prescription because the drug is still schedule 1, but you can certify that a patient has an approved medical condition and then that allows them to register with the health department and get a medical cannabis identification card that they use to shop at an approved state-run dispensary,” Greis told Healio.com/Orthopedics.
However, he said it can take “a few weeks to a couple of months to figure out which cannabinoids work” for a particular patient due to potential side effects.
“I do not think [cannabis] is this perfect drug that works for everybody, but it is definitely working for some people and we are still learning more about how to recommend it since we cannot prescribe it,” Greis said.
Educate physicians, patients
Since the implementation of these protocols, Ilyas noted they have found decreased consumption of opioids by patients, as well as a decrease in refill rates, despite prescribing less opioids than previously done.
“By using this kind of multimodal strategy, we are educating them. We are giving them multimodal pain strategies. We are giving them more customized opiates. We are monitoring what they use. We are seeing a significant decrease in what people use and their refill rates,” Ilyas said.
Hospitals and physicians looking to implement opioid protocols should review opioid prescribing, opioid consumption patterns and patient pain experiences critically, he noted.
“That means surveying your patient population. That means using tools whenever possible like physician drug monitoring programs and other monitoring programs whenever possible to see what people are doing,” Ilyas said.
Patients and physicians should be educated on safe opioid consumption and prescribing habits for every procedure, he said.
Physicians should also be educated on how to recognize patients who are at risk for opioid addiction, refer patients to a pain management specialist pre-surgery and discuss opioid alternatives, according to Greis.
“Educating the doctors and their patients that the sooner they discontinue these medications, the better from a safety standpoint and oftentimes co-administering alternative pain medications, such as gabapentin and pregabalin, perioperatively can make a difference in preventing chronic pain from setting in after a procedure,” he said. – by Casey Tingle
Disclosures: Ilyas reports he is a member of the board of directors of Rothman Orthopaedic Institute. Greis reports no relevant financial disclosures.