The opioid epidemic and its impact on orthopaedic care

The United States makes up less than five percent of the world's population but consumes 80 percent of the global opioid supply and approximately 99 percent of all hydrocodone--the most commonly prescribed opioid in the world. And, according to the authors of a new literature review in the May issue of The Journal of the American Academy of Orthopaedic Surgeons, orthopaedic surgeons are the third highest prescribers of opioid prescriptions among physicians in the United States--behind primary care physicians and internists.

"The past few decades have seen an alarming rise in opioid use in the United States, and the negative consequences are dramatically increasing," says study co-author Hassan R. Mir, MD, MBA, associate professor of orthopaedics and rehabilitation at Vanderbilt Orthopaedic Institute. "Management of pain is an important part of patient care; however, the increased usage of opioids for the treatment of pain has led to several unanticipated aftereffects for individual patients and for society at large."

Opioids are now also prescribed by physicians more frequently to treat chronic conditions, including musculoskeletal pain of the spine and limbs, while prescriptions for non-opioids like nonsteroidal anti-inflammatory drugs (NSAIDs) or acetaminophen have remained constant. The increased usage of opioids for pain management has led to unanticipated consequences:

• Patients building up tolerance to drugs;

• Worse treatment outcomes for conditions including work-related musculoskeletal disorders, joint replacements and spine surgery;

• Unlawful sale or sharing of opioid medications with others; and,

• When used inappropriately, addiction and unintentional overdose deaths can result.

"Orthopaedic patients can experience a tremendous amount of pain with acute injuries and chronic conditions, and the treatment plan may involve opioid prescriptions for relief of discomfort," says Dr. Mir. "A significant number of orthopaedic patients and their families are at risk for repercussions from opioid use. We must work together with all prescribers and patients to decrease the use of opioids for musculoskeletal pain."

Study co-author Brent J. Morris, MD, a shoulder and elbow surgeon with the Lexington Clinic Orthopedics - Sports Medicine Center, says "Physicians should aim to control pain and improve patient satisfaction while avoiding overprescribing opioids. A comprehensive strategy of risk assessment is needed to identify patients who may be at risk for opioid abuse. Objective measures including patient history, recognition of aberrant behavior, urine drug testing, state prescription drug--monitoring programs, and opioid risk-assessment screening tools may be necessary in select cases." Reasonable expectations should be established for pain management discussions and follow-up visits, and incorporate a protocol for a patient to be transitioned off of an opioid to acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) at a specific time point following surgery.

According to Drs. Mir and Morris, the patient-physician relationship is built upon trust. Orthopaedic surgeons trust that patients will accurately report their level of pain and only use opioids when appropriate. Patients trust their surgeons to assess and adequately treat the pain associated with their orthopaedic conditions. Unfortunately, a small percentage of patients use opioids non-therapeutically and doctor shop for additional opioids making this a delicate balancing act for physicians.

Source: American Academy of Orthopaedic Surgeons