Collaboration at NorthShore Orthopaedic & Spine Institute reduces postoperative narcotic use
At NorthShore Orthopaedic & Spine Institute, one of the cornerstones in reducing opioid prescriptions has been learning techniques that allow surgeons to not only reduce pain but speed up recovery without the use of narcotics after surgery.
“It wasn’t that long ago that total joint replacement patients were hospitalized for 3 days, didn’t return to work for up to 6 weeks and didn’t resume regular activities for 3 months,” Ravi K. Bashyal, MD, director of outpatient hip and knee replacement surgery at NorthShore Orthopaedic & Spine Institute, said. “How do you take that operation and improve techniques so you can get somebody home the same day, be working on their computer from home and be back to their office within a day or two?” he told Healio Orthopedics. “Part of it is on the surgical side, training [and] continuing to learn so that we have techniques from a surgical standpoint that allow us to decrease pain, speed up recovery and allow people to get back to their lives more quickly.”
Bashyal added the other part of reducing pain medication after surgery involves collaborating across multiple disciplines on patient pain management. He noted each specialty has its own areas of knowledge that, when used together, can help reduce patient pain and demand for pain medicine after surgery. These differences in knowledge and that the patient will still have some pain after surgery make it essential for each member of the team — including the surgeon, anesthesiologist, floor nurse, home health nurse, physical therapist, etc. — to all be on the same page.
“[All team members] have to understand what the goals of the surgery are. They have to understand what the limitations of pain medicines are and they have to understand how all of those go together,” Bashyal said.
Multimodal pain management
In addition, Nirav N. Shah, MD, anesthesiologist and interventional pain management specialist at NorthShore Orthopaedic & Spine Institute, noted they incorporate multimodal medications to reduce opioid prescriptions, including duloxetine, pregabalin and gabapentin, as well as higher doses of around-the-clock scheduled acetaminophen and anti-inflammatories, such as meloxicam or celecoxib.
“We will sometimes initiate these beforehand to decrease the opioid requirements that patients are on,” Shah told Healio Orthopedics. “Then, we can sometimes use interventional techniques, such as genicular nerve blocks and radiofrequency ablation or even peripheral nerve stimulation because it is approved for acute and chronic pain before surgery to decrease their opioid requirements and enable prehabilitation to facilitate optimal postoperative outcomes.”
Shah added they use physical therapy to minimize postoperative recovery time by enhancing patient functional pain and disability-related outcomes and have instituted system-wide practice advisories to help surgeons and primary care physicians in their decision-making.
“It is not going to tell them how to practice, but it [gives] them some online tools, some ways that [they] can monitor patients on opioids to see if it is an appropriate therapy for them, monitor for any signs of dependence, abuse [and] diversion, and, when in doubt, send that patient to our pain center so we can more thoroughly evaluate them and give recommendations for what might be an optimal course of therapy for that patient and their pain diagnosis,” Shah said.
Amplify effect of non-narcotic medication
Since the implementation of these protocols, Bashyal noted approximately 50% of patients undergoing outpatient total joint surgery do not use narcotics after they leave the hospital. Of the patients who do receive narcotics at discharge, he said approximately 95% do not need narcotics 3 or 4 days postoperatively.
“Part of the anesthetic that they get in the hospital might involve some narcotics at the time of surgery, but over 50% of them use zero narcotics from the day they leave,” Bashyal said.
While Bashyal believes they have identified certain non-narcotic medications that work well postoperatively for patients, he noted they need to continue to collaborate to narrow down which combination of non-narcotic medicines “amplify each other’s affect” and apply their use to more patients.
“Our mantra within orthopedics is minimally invasive surgery, rapid recovery, less pain and get back to what you need to do, what you want to do, as quickly as possible, and I think that effective pain management and effective non-opioid or opioid-sparing management is an important cornerstone of that,” Bashyal said. “The collaboration ... is probably [what] we are proudest of with regard to our program, both from a surgical outcomes standpoint, as well as from an opioid minimization standpoint.” – by Casey Tingle
Disclosures: Bashyal and Shah report no relevant financial disclosures.