The challenges of screening for at-risk orthopaedic patients addicted to
ROSEMONT, Ill.-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
"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
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.
from the American Academy of Orthopaedic Surgeons -
Questions and or comments regarding this week's health column please
contact Timothy Woods, MD at Bitterroot Orthopedics and Sports Medicine,
1200 Westwood Drive, Hamilton, MT 59840. Working together to build a healthier