March 20, 2018

The Opioid Epidemic in Orthopedics

The opioid epidemic in the United States is nothing new. It has been a persistent problem that we failed to address for many decades. At this point,the US accounts for less than 5% of the world’s population, and consumes 80% of world’s opioid supply.

Orthopaedic surgeons are the third-highest opioid prescribers among all physicians, making orthopaedic surgery a major contributor to the current epidemic. With all the media coverage over the years, there has been a rising awareness in the orthopeadics community and many surgeons have started prescribing less opioids to their patients. Despite the efforts, however, the decline in opioid use has not been fast enough to bring meaningful impacts. So what have been the roadblocks?

The first is derived from the current trend towards value-based care and its emphasis on patient satisfaction. Since hospitals are financially incentivized to obtain high scores on the HCAHPS survey, which captures key elements of patient satisfaction -- including treatment and management of pain-- providers are naturally inclined to prescribe opioids. Jena et al. have reported a significant correlation between a hospital’s rate of post-discharge opioid prescriptions and patients’ reporting of “well-managed pain” via HCAHPS.

Second, a large portion of opioids are being prescribed to patients who actually need opioids. According to Bob Twillman, PhD, executive director of the Academy of Integrative Pain Management, a large share of the opioid consumption in the US could be attributed to chronic high-pain patients. Many of these patients have already developed opioid-induced hyperalgesia and resistance to low-dose opiate therapies prior to their orthopedic surgeries, making it unethical to dramatically limit their access to their opioid medications.

So what can we do? The complexity of the opioid crisis requires a collaborative, systematic approach. Everyone, from medical professionals to legislators to educators, has a role to play in order for these systematic changes to come to fruition. We must strive to establish interventions that prevent new patients from developing opioid dependence while continuing to support those who are already dependent on opioids. Here are some key approaches:

Implementing new evidence-based prescribing practices

Physicians must consider all other non-opioid treatment options prior to any opioid prescription. Every physician should be under a strict yet easy-to-follow opioid prescribing protocol like that of Kaiser Permanente where physicians encounter a series of decision support prompts within their prescription systems before they can assign any opioid medication. In addition, there needs to be a continued effort to validate long-term efficacy of opioids at varying dose ranges. Implementing evidence-based insights would allow physicians to prescribe the right dose, at the right time, in the right way.

Developing predictive tools

Care teams should identify patients who are at greater risk for opioid addiction based on their baseline characteristics and medical histories. For example, patients with a history of alcohol or drug abuse and who had been on high doses of controlled substances for extended periods of time, require more attention and education.

Fostering clear communication

Providers should fully explain the risks of opioids to patients and their families during their visits. Also, it is crucial to understand their attitudes and concerns about postoperative pain as setting reasonable expectations would allow patients to better cope with pain, without relying too much on their opioid prescriptions. Lastly, practicing on-going and more empathetic communication, especially with patients who are at higher risks of becoming opioid dependent, is key. Patients feel more comfortable taking fewer opioids when they know their providers better. Using an online messaging platform, such as Force Therapeutics, could be an effective way for both inbound and outbound communication.

The opioid epidemic has been decades in the making. Addressing this crisis will obviously require a lot of resources and efforts from everyone involved. It will be a long, slow process requiring much patience and consistency, but we need to remind ourselves that every step counts and we need to keep going.