An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery

Soffin, Ellen M.; Waldman, Seth A.; Stack, Roberta J.; Liguori, Gregory A.

doi:10.1213/ane.0000000000002433

Cited by 115 publications

(101 citation statements)

References 50 publications

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“…28 Although not fully understood, narcotic prescription patterns among orthopaedic surgeons may be playing a critical role in the prolonged utilization of narcotics. [29][30][31] As such, this is a potentially preventable situation as we believe that the majority of patients with ulnar sided wrist pain from UIS are not typically prescribed narcotics for preoperative pain relief. This is very evident given newly published level 1 data that showed no benefit from opioid consumption for chronic orthopaedic conditions such as low back and knee pain.…”

Section: Demographic and Socioeconomic Factorsmentioning

confidence: 99%

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

et al. 2019

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Background The purpose of this study is to characterize patient- and surgery-specific factors associated with perioperative pain level in patients undergoing ulnar shortening osteotomy (USO) for ulnar impaction syndrome (UIS). We hypothesize that preoperative opiate consumption, tobacco utilization, and severity of ulnar variance will be associated with less postoperative pain relief. Methods All cases of USO between January 2010 and December 2016 for management of UIS were retrospectively reviewed. Patient demographics, smoking status, type of labor, and opioid utilization before surgery were recorded. Radiographic measurements for ulnar variance, radial tilt and inclination, as well as triangular fibrocartilage complex and distal radial-ulnar joint (DRUJ) morphology were assessed. Pre- and postoperative pain score were recorded. Regression analysis was performed to determine predictors of pain scores. Results A total of 69 patients were included for the final analysis with a mean age of 44 years (range 17–73 years). Seventeen patients reported use of daily opioid medications at the time of surgery (25%). Patients who used opioid analgesics daily, active laborers, smokers, and patients involved in worker compensation claims had significantly less pain relief after surgery. Patients with osteotomy performed at the metaphysis had significantly more pain relief than patients that had diaphyseal osteotomy. Regression analysis identified tobacco utilization and anatomic site of osteotomy as independent predictors of postoperative pain. Conclusion The results from this study identified smoking and location of osteotomy as independent predictors of postoperative pain relief. While smoking cessation is paramount to prevent delayed/nonunion it may also help improve pain relief following USO. The potential to achieve greater shortening with a metaphyseal osteotomy suggests that in addition to the mechanical unloading the carpus, pain relief after USO may also stem from tensioning the ulnar collateral ligaments of the wrist, the ECU subsheath, and the radioulnar ligaments. Level of Evidence This is a Level III, therapeutic study.

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Section: Demographic and Socioeconomic Factorsmentioning

confidence: 99%

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

et al. 2019

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“…Different surgical specialties have shown that decreasing opioid prescribing in the postoperative setting is possible when protocols and standardized prescribing regimens are implemented . Preoperative education, preoperative risk stratification, procedure‐based pain thresholds, standardized prescribing regimens, and postoperative analysis are all components of a comprehensive pain management protocol.…”

Section: Introductionmentioning

confidence: 99%

Impact of perioperative pain management protocol on opioid prescribing patterns

et al. 2019

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Objectives/Hypothesis: The objective of this study was to demonstrate the impact of preoperative education, patient risk stratification, and a postoperative pain management protocol for common head and neck procedures on opioid prescribing patterns and postoperative pain reporting.Study Design: Retrospective cohort study. Methods: A postoperative pain management protocol was developed and implemented for patients undergoing head and neck surgical procedures. Medical charts were queried and postoperative patient satisfaction surveys were administered. Opioid prescribing patterns were evaluated in cohorts of patients undergoing procedures with anticipated mild pain (e.g., thyroidectomy, parotidectomy, lymph node biopsy) before and after the implementation of the protocol. Postoperative patient surveys were analyzed in the postimplementation group.Results: A total of 302 patients were included for analysis. One hundred fifty-four patients and 148 patients underwent surgery before and after the implementation of the protocol, respectively. There was a decreased incidence of oxycodonecontaining prescriptions (83% to 26%), and tramadol became the most common discharge medication (70%). There was a significant decrease in the total number of pills prescribed after the implementation of the protocol (34.71 to 25.36, P < .001). Ninety percent of patients reported high satisfaction (≥8) with pain management.Conclusions: This study shows that a comprehensive pain management protocol can significantly reduce the amount and potency of opioid pain medication prescribed after head and neck procedures while maintaining high patient satisfaction.

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“…There are multiple opportunities for the anesthesiologist, surgeon, and institution to reduce opioid exposure and minimize patient harm. 16,31,33 The best-characterized clinical strategies include the use of multimodal analgesia (MMA) and enhanced recovery after surgery (ERAS) initiatives to standardize care and improve outcomes while providing satisfactory perioperative pain control. MMA has been consistently demonstrated to minimize opioid consumption and related side effects and is considered a vital component of ERAS pathways.…”

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confidence: 99%

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

Soffin

Wetmore

Beckman

et al. 2019

Neurosurgical Focus

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OBJECTIVEEnhanced recovery after surgery (ERAS) and multimodal analgesia are established care models that minimize perioperative opioid consumption and promote positive outcomes after spine surgery. Opioid-free anesthesia (OFA) is an emerging technique that may achieve similar goals. The purpose of this study was to evaluate an OFA regimen within an ERAS pathway for lumbar decompressive surgery and to compare perioperative opioid requirements in a matched cohort of patients managed with traditional opioid-containing anesthesia (OCA).METHODSThe authors performed a retrospective analysis of prospectively collected data. They included 36 patients who underwent lumbar decompression under their ERAS pathway for spinal decompression between February and August 2018. Eighteen patients who received OFA were matched in a 1:1 ratio to a cohort managed with a traditional OCA regimen. The primary outcome was total perioperative opioid consumption. Postoperative pain scores (measured using the numerical rating scale [NRS]), opioid consumption (total morphine equivalents), and length of stay (time to readiness for discharge) were compared in the postanesthesia care unit (PACU). The authors also assessed compliance with ERAS process measures and compared compliance during 3 phases of care: pre-, intra-, and postoperative.RESULTSThere was a significant reduction in total perioperative opioid consumption in patients who received OFA (2.43 ± 0.86 oral morphine equivalents [OMEs]; mean ± SEM), compared to patients who received OCA (38.125 ± 6.11 OMEs). There were no significant differences in worst postoperative pain scores (NRS scores 2.55 ± 0.70 vs 2.58 ± 0.73) or opioid consumption (5.28 ± 1.7 vs 4.86 ± 1.5 OMEs) in the PACU between OFA and OCA groups, respectively. There was a clinically significant decrease in time to readiness for discharge from the PACU associated with OFA (37 minutes), although this was not statistically significantly different. The authors found high overall compliance with ERAS process measures (91.4%) but variation in compliance according to phase of care. The highest compliance occurred during the preoperative phase (94.71% ± 2.88%), and the lowest compliance occurred during the postoperative phase of care (85.4% ± 5.7%).CONCLUSIONSOFA within an ERAS pathway for lumbar spinal decompression represents an opportunity to minimize perioperative opioid exposure without adversely affecting pain control or recovery. This study reveals opportunities for patient and provider education to reinforce ERAS and highlights the postoperative phase of care as a time when resources should be focused to increase ERAS adherence.

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An Evidence-Based Approach to the Prescription Opioid Epidemic in Orthopedic Surgery

Cited by 115 publications

References 50 publications

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Determinants of Pain and Predictors of Pain Relief after Ulnar Shortening Osteotomy for Ulnar Impaction Syndrome

Impact of perioperative pain management protocol on opioid prescribing patterns

Opioid-free anesthesia within an enhanced recovery after surgery pathway for minimally invasive lumbar spine surgery: a retrospective matched cohort study

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