David L. Nelson, MD
Member, IASP
The Opiod Epidemic in the US: Strategies to Reduce Narcotic Use While Controlling Pain in Diverse Practice Environments
Introduction
The United States represents 5% of the world’s population yet accounts for 99% of the global hydrocodone (Vicodin, Norco) production. Since 1999, the amount of opioids prescribed in the US has quadupled, but the amount of pain had not decreased. According to the CDC, there has been a parallel increase in opioid overdose deaths in the US in the last 15 years: deaths from prescription opioids have more than quadupled since 1999. More Americans died from overdose deaths in 2014 than any previous year on record, nearly half a million since 2000. Hydrocodone (Vicodin, Norco) and oxycodone (Percocet), the drugs you probably prescribe for post-surgical pain, continue to be involved in more overdose deaths than any other type of opioids. This translates to 33,000 deaths per year, 91 deaths every day. This course is designed to help you understand our contribution, as surgeons, to this epidemic, and to give you a straightforward game plan to implement when you return to your office to institute changes in your opioid management.
Multimodal PeriOperative Pain Program in Private Practice: Results after 24 years
This presentation will outline two studies of pain management done in my private hand surgery practice, and I think both of them should be applicable in your own practice.
Study 1: Pain Management in the Opioid Epidemic Era: A Prospective Evaluation of a Pain Management Protocol
Introduction Surgeons are caught in a dilemma: they must provide excellent pain relief but avoid excessive prescribing. On the one hand, surgeons must manage postop pain well: pain is the "fifth vital sign" and CMS is recording surgeons' success in managing pain. However, overprescribing must be avoided: we are caught in an opioid epidemic, as prescription pain medications now kill more people than trauma or heroin/cocaine (CDC data).
The purpose of this study was to:
(1) prospectively evaluate the effectiveness of a pain program (2) as assessed by a patient-centered outcome measure (3) in a common, moderately painful surgery (ORIF distal radius) (4) that could decrease the amount of opioids prescribed (5) and could be used as a comparative measure across orthopedic practices to allow surgeons to evaluate their own pain management programs
Methods All patients treated by an ORIF for a distal radius fracture by a single surgeon used a pain-control protocol as follows: (1) preoperative counseling, (2) pre-operative oral long-acting acetaminophen and long-acting non-steroidal (celecoxib), (3) pre-incision lidocaine block, (4) intraoperative bupivicaine block, (5) non-PRN acetamenophen and non-steroid for 48 hrs post-operatively and thereafter PRN, (6) hydrocodone/acetaminophen 5:500 (Vicodin) Q4H for break-through pain, (7) post-operative telephone call, and (8) assessment at the first followup visit. Outcome measure: number of opioid doses (Vicodin) taken within 10 days of surgery. Exclusion criteria were multiple trauma and concurrent use of opioids for other conditions. Data were verified by an independent ASSH member.
Results Seventy-two consecutive patients were eligible for the study, fifty-nine patients met inclusion criteria. The average age was 62. The average number of hydrocodone/acetaminophen doses taken within 10 days of surgery was 0.68 pills. Seventy-two per cent of the patients took none. The review by an independent ASSH member verified the data.
Summary
The pain management protocol was effective based on the low usage of narcotic analgesics. This can serve as a model for other surgeons to design their own program for peri-operative pain management that can minimize the use of opioids.
Study 2: A Method for Changing the Opioid Prescribing Habits of Surgeons
Most surgeons, in light of the opioid epidemic, are making or considering modifications to improve their peri-operative pain management protocols. However, there are no benchmarks with which they can evaluate the effectiveness of their approach and it is difficult to compare practices since the scope of each practice is unique. We have previously demonstrated that volar plating for distal radius fractures could serve as an index surgery for this kind of evaluation, because (1) all surgeons do it in a virtually identical manner, (2) it is moderately painful and therefore a good test of pain management, and (3) it is common enough to allow quick accumulation of data.
Hypotheses (1) What is the average, range, and nature of the opioid and other medication routinely prescribed for a volar plating of a distal radius fracture, and (2) does feedback of this data to the surgeon result in a change of prescribing habits?
Method The method was to interview surgeons by email who perform ORIF of distal radius fractures using a volar plate as to their normal perioperative pain management protocol, with specific reference to the choice of opioid and how many were prescribed. Opioid prescriptions were translated into Morphine Equivalents (ME=s), for comparison. Feedback was given to the surgeon how they compared to the study average in terms of ME=s, choice of opioid, supplementary medication, as well as the characteristics of the highest 5 prescribers and the lowest 5 prescribers in the study. A second interview was conducted to determine if this feedback prompted the surgeon modify their pain management protocol.
Results 78 surgeons completed the first interview with enough data to allow completion of the analysis. The number of opioids ranged from 5 morphine equivalents (ME=s) to 160 ME=s, with a mean of 46.0 and a mode of 30. The lowest 5 respondents prescribed an average of 13 ME=s, usually hydrocodone, reported that their patients= pain was well-controlled, and refill requests were rare. The highest 5 responds prescribed an average of 115 ME=s and used more Dilaudid and Percocet than the group as a whole. Fear of weekend requests for opioid refills was cited as a main reason for prescribing large amounts of opioids. Upon re-interview after feedback of the results, 95% had already begun, or planned to, decrease their opioid prescription number, change to less-addictive opioids, and to increase multimodal approaches.
Summary ORIF of a distal radius fracture can serve as an index procedure for perioperative pain management, allowing comparison across diverse practices. Giving feedback to surgeons regarding how they compare to their peers is useful in prompting evaluation of their perioperative pain program and in decreasing the quantity of opioids prescribed.