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    Orthopaedic Trauma Patients and the Opioid Epidemic

    Dr. Alexander Crespo and Dr. Philipp Leucht comment on a recently published study that quantified discharge prescriptions for opioids in an orthopaedic trauma population and defined which patients were at risk for opioid abuse months after discharge.

    Authors

    Alexander Crespo, MD, and Philipp Leucht, MD

    Article

    Ruder J, Wally MK, Oliverio M, Seymour RB, Hsu JR, the PRIMUM Group. Patterns of opioid prescribing for an orthopaedic trauma population. J Orthop Trauma. June 2017. 31(6): e179-185.

    Summary

    Opioid-based analgesics are the most commonly prescribed drugs for orthopaedic surgery patients despite their association with poor long-term postoperative outcomes and well-known risk for abuse, addiction, and overdose.

    In a retrospective study, Ruder et al sought to determine opioid-prescribing practices in the orthopaedic trauma population at a large Level 1 trauma center over a 1-month period. They reviewed data on morphine milligram equivalents (MMEs) prescribed per day, number of opioid prescriptions, and duration of opioid treatment prescribed on discharge and through 2-month follow-up in 110 consecutive patients.

    In addition, they determined which patients were at risk for opioid abuse, with at-risk patients defined as those meeting any of the following criteria prior to injury:

    • A current opioid prescription with more than 50% remaining expected doses (“early refills”)
    • More than 2 visits to the emergency department or an urgent care center that included onsite opioid treatment within 30 days of the current prescription
    • More than 3 prescriptions for opioids within 30 days prior to presentation
    • Any previous presentation for opioid overdose
    • Any positive screening for blood alcohol content (BAC), cocaine, or marijuana

    They found that the 110 patients in the study were discharged with 135 prescriptions, including 110 prescriptions – 1 for each patient – for opioid analgesics.

    The mean MMEs prescribed at the time of discharge was 114 mg (range: 54 to 300 mg), well above the 90 MMEs/day risk threshold for overdose and maximum MMEs dose per day recommended by the Centers for Disease Control and Prevention. The mean prescription duration was 7.21 days (range: 2 to 36.7 days).

    Interestingly, there was no difference in the mean MMEs prescribed per day between patients who were treated operatively versus those who did not require surgery.

    Only 33.6% of patients underwent a toxicology screen on presentation, but about half of these patients (16.4% of all patients) had a positive BAC, marijuana, or cocaine result. Furthermore, 25% of patients met criteria to be considered at risk for opioid abuse prior to injury.

    Although patients with pre-injury risk factors for abuse were prescribed discharge opioids for similar duration as those not at risk (7.00 vs. 7.30 days, respectively; P = 0.81), they were prescribed significantly more MMEs/day (130 mg vs. 108 mg; P < 0.05) and were more likely to receive long-acting formulations. Notably, all extended-release formulations were prescribed by non-orthopaedic providers (ie, pain management specialists).

    During the 2-month follow-up period, 42.7% of patients received at least 1 additional prescription for opioids (range: 1 to 4 prescriptions). The mean MMEs/day prescribed at follow-up was 99.2 mg.

    At-risk patients received significantly more MMEs/day than patients not at risk for opioid abuse (215 mg vs. 79.5 mg, respectively; P < 0.05) and the prescriptions were for a significantly longer duration (11.8 days vs. 4.37 days; P < 0.05).

    Finally – and perhaps most important – an additional 9.1% of patients met criteria to be considered at risk for opioid abuse during the 2-month follow-up period.

    No attempt was made to quantify postoperative outcomes or patient satisfaction.

    Clinical Relevance

    In 2001, The Joint Commission introduced mandatory pain assessment standards for all patients and recommended that pain be considered the “fifth vital sign.” Concurrently, pharmaceutical companies engaged in a massive marketing surge to promote prescription opioids.

    As a result, the guarantee of adequate pain monitoring and treatment has been incorporated into the Patient Bill of Rights at many institutions.

    In addition, patients’ assessment of pain control – including the question, “During this hospital stay, how often did the hospital staff do everything they could to help you with your pain?” – accounts for 10% of questions in the HCAHPS surveys. These surveys are then used in the Hospital Value-Based Purchasing (VBP) Program, an initiative from the Centers for Medicare and Medicaid Services (CMS) that rewards acute care hospitals with incentive payments for superior results.

    During this same period, basic science studies showing negative effects of non-steroidal anti-inflammatory drugs (NSAIDS) on fracture healing caused orthopaedic surgeons to be reluctant to use NSAIDS in the acute post-injury period.

    The summation of these factors has produced an environment in which:

    • Patients have a high expectation for pain management
    • Healthcare providers are highly incentivized to aggressively treat pain
    • Opioid-based analgesics are often the primary monotherapy

    The opioid epidemic is now well-established in the US, and prescription opioid use currently results in more deaths than cocaine and heroin use combined. Furthermore, a significant surge in heroin addiction rates has occurred.

    Healthcare providers’ opioid prescription practices continue to face increasing scrutiny – and blame – for the alarming rise in opioid addiction. Of the medical specialists in the US, orthopaedic surgeons are the third highest prescribers of opioids, and as such, our specialty will continue to be at the center of the epidemic.

    Current healthcare standards have created an environment in which the assessment and management of pain have become paramount. However, patients may have an unrealistic expectation of pain management. Orthopaedic trauma patients may fail to appreciate that some degree of pain and discomfort is inherent to their injury and recovery. As a result, some patients may become over-reliant on medication-based therapies.

    Further compounding this issue, the subjective patient-based assessment of adequate pain management has been engineered into the VBP Program, which directly impacts hospital and physician reputation and reimbursement.

    Healthcare providers have been presented with a dilemma in which we bear an increasing burden of blame for the opioid epidemic while simultaneously being incentivized to aggressively manage pain and “do everything they could to help you with your pain.

    Nonetheless, it is our distinct responsibility to follow safe prescription practices and curtail reliance on opioid monotherapy. For example:

    • A move away from opioid monotherapy and toward a more comprehensive pain management strategy that includes multimodal analgesia and cognitive behavioral therapy is essential.
    • Judicious use of immediate-release opioids, rather than extended-release opioids, should strongly be considered.
    • Electronic medical records should establish “red flags” to alert healthcare providers of patients at risk for opioid abuse.
    • A re-evaluation of the clinical risks and benefits of NSAIDs in orthopaedic trauma patients is warranted.

    We must make every effort to ensure our patients’ pain is maximally treated in a manner that minimizes the risk for lifelong addiction and disability.

    Reference

    1. Washington State Agency Medical Directors Group (AMDG). Interagency Guideline on Prescribing Opioids for Pain. Olympia, WA: Washington State Agency Medical Directors’ Group; 2015. Accessed July 27, 2017 at http://www.agencymeddirectors.wa.gov/Files/2015AMDGOpioidGuideline.pdf.

    Author Information

    Alexander Crespo, MD, is an orthopaedic surgery resident at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York. Philipp Leucht, MD, is an Assistant Professor of Orthopaedic Surgery and Cell Biology at NYU Langone Medical Center – Hospital for Joint Diseases, New York, New York.