As Americans have the highest opioid use rates, leading to abuse,i the orthopaedic community has committed itself to studying prescription methods and patient populations to help mitigate potential addiction. A new scientific review article titled, “Ninety-day Postoperative Narcotic Use After Hospitalization for Orthopaedic Trauma,” published in the July issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), found a correlation between patient-reported pain at discharge from inpatient surgery and the number of opioids prescribed during the 90-day postoperative period. These results suggest that reducing patient-reported pain at the time of discharge may help to reduce opioid consumption.
“The 90 days following surgery represents a critical window in terms of patient dependence on opioid pain medication,” said lead author Kenneth A. Egol, MD, FAAOS, orthopaedic surgeon and vice chair in the Department of Orthopedic Surgery at NYU Langone Health. “We chose to study factors such as the type of surgery and certain patient characteristics to help us predict which patients might be prone to using more pain medication than others.”
Long-term opioid therapy has been characterized as episodes lasting more than 90 days with 10 or more opioid prescriptions or 120 plus days’ supply of opioids dispensed, usually with daily or near daily use and an average daily dose of 55 mg.ii
The retrospective review used an electronic medical record (EMR) query of 5,030 patients at NYU Langone Health from 2012 to 2015. The team conducted a multivariate analysis of patients who fell into specific diagnosis-related groups for spine surgery, adult reconstruction and orthopaedic trauma procedures, and were admitted for longer than 24 hours. The EMR was used to retrieve age, comorbidities, length of stay (LOS), all visual analog scale (VAS) pain scores reported during the admission, and all narcotic pain medication prescribed (including refills) during the 90-day postoperative period. To ensure consistency, a morphine milligram equivalent (MME) was calculated for all pain medications. MME is a standardized dosing unit that allows for comparison across opioid types––since different opioids have different strengths per milligram.
The study found that patients who underwent elective spine surgery such as disk replacement, degenerative spine surgery or deformity spine surgery had the longest LOS with an average of approximately five days, which was significantly longer than both arthroplasty (three days) and trauma (four days) patients. Spine patients also reported the highest mean VAS pain scores during their LOS, which was significantly higher than trauma patients (4.7 vs. 4.1); and were prescribed the most morphine in the 90-day postoperative period, followed by trauma and then arthroplasty patients.
The study also discovered:
- Patient-reported pain scores were comparable between trauma and arthroplasty patients (4.1 vs. 4.1); however, trauma patients did have a significantly longer LOS than arthroplasty patients (4 vs. 3 days).
- Pain scores at discharge were similar between both spine and arthroplasty patients (4.1 vs. 4.1), while trauma patients had significantly lower pain scores at discharge than both spine (3.9 vs. 4.1) and arthroplasty (3.9 vs. 4.1) patients.
- The amount of morphine equivalents prescribed was found to be significantly different between trauma and spine patients (1,375 vs. 1,797 morphine equivalents), but not between trauma and arthroplasty patients (1,375 vs 1,232 morphine equivalents).
“We’re performing surgeries to alleviate pain, so it’s important to have a greater understanding of high-risk populations to help orthopaedic surgeons safely address pain management following surgery,” said Dr. Egol. “For example, we can obtain a pain management consult before discharge to lower their VAS pain score or use a multimodal analgesia protocol (a regimen of nonopioids and anesthesia to minimize the use of perioperative opioids) during surgery.”
As a result of this study, Dr. Egol and his colleagues created the NYU Langone “Lopioid” or a low-opioid protocol which uses several medications such as regional blocks, anti-inflammatory medication, nerve pain medications and weaker opioids––working synergistically to reduce the dependence on stronger narcotics for trauma patients. With this protocol, their group has been able to significantly lower the number of narcotics prescribed to orthopedic trauma patients.
“We’re definitely seeing a trend in the orthopaedic community to develop pain management alternatives, opioid prescription awareness for our patients, educating prescribers and reducing narcotic prescriptions,” said Dr. Egol. “However, as we continue to uncover granular details about orthopaedic procedures and their impact on patient populations, we’ll continue to provide our patients with safe and effective care.”
For more information about optimal opioid stewardship in patients following surgery, check out the AAOS’ Pain Alleviation Toolkit. The toolkit provides physicians and patients with resources to encourage communication and decision-making to help reduce patients’ postoperative pain as much and as safely as possible.
i 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(suppl 2):S63-S88.
ii Von Korff M, Saunders K, Thomas Ray G, et al: De facto long-term opioid therapy for noncancer pain. Clin J Pain 2008;24: 521-527.