HSS Journal®: The Musculoskeletal Journal of Hospital for Special Surgery

In the midst of the nationwide opioid epidemic, our institution began an effort to improve the education of opioid prescribers and disseminate procedure-specific guidelines for the number of opioid pills to prescribe post-operatively for total joint arthroplasty. The number of opioid pills suggested for total hip or knee replacement was 70 tablets.

We sought to evaluate the impact of the new institutional guideline on opioid prescribing practices, hypothesizing that it would lead to a decrease in the number of pills prescribed but an increase in patient call volume after discharge.

After the new guidelines were implemented in February 2018, we retrospectively reviewed all opioid prescriptions written for patients on the joint-replacement service from March 2016 to March 2018. In addition, we tabulated post-operative telephone calls made to the nurse practitioner service before and after guideline implementation. The majority of calls to the nurse practitioner service are for opioid renewals.

We included 9514 patients in the analysis. Prior to guideline implementation, the mean number of pills prescribed after primary total joint arthroplasty was 91 ± 26.6 pills and after it was 65 ± 16.3 pills. The monthly number of unique patient telephone interactions was statistically significantly lower after the implementation of the new guidelines.

An institutional guideline for opioid prescribing after total joint arthroplasty significantly reduced the number of pills prescribed to patients without causing a significant increase in the number of phone calls to the service.

Resident physicians have been shown to possess negative attitudes toward individuals with substance use disorders (SUDs), even if the residents believe they have adequate knowledge and skills to care for these patients. Residents’ negative attitudes may have an adverse impact on patient engagement, treatment, and outcomes.

The goal of this study was to examine the impact of an online training module on residents’ attitudes toward people with SUDs. We hypothesized that residents who received the educational intervention would show improved attitudes toward people with alcohol and opioid use disorders.

A web-based questionnaire, including demographic information and the Medical Condition Regard Scale (MCRS) about individuals with alcohol and opioid use disorders, was sent to internal medicine and psychiatry residents before and 6 months after they took an online training module on stigma toward individuals with SUDs.

A total of 46 residents completed the initial questionnaire and 29 completed the follow-up questionnaire 6 months later. Attitudes toward individuals with SUDs, as reflected by an increase in MCRS scores, were improved 6 months after the online training module.

Residents’ attitudes toward individuals with SUDs improved after taking an online training module. This is encouraging, as studies have shown that attitudes toward individuals with SUDs tend to decline during residency training and negatively affect patient care. Larger studies are needed to determine if such online modules can improve attitudes of other groups of clinicians, result in sustained change over time, and improve patient outcomes.

Prospective collection of patient-reported opioid consumption and pain levels post-surgically may hold value in highlighting solutions related to the opioid crisis. Traditional methods for collecting patient-reported outcomes after surgery, such as paper surveys, often have poor response rates, and electronic messaging may offer more convenience and therefore yield more robust data.

The purpose of this study was to evaluate whether a novel mobile phone short message service (SMS) platform would lead to better patient response rates to surveys on pain and opioid use than data-collection tools.

An SMS text messaging platform was created and implemented between September 2017 and May 2018 at an orthopedic specialty hospital. The purpose was to collect reports on opioid consumption and pain levels twice a day for 6 weeks post-surgery from patients who had undergone total hip or knee arthroplasty or a single-level lumbar microdiscectomy or decompression spine surgery. Patients who responded to fewer than 50% of the text messages were excluded.

Our mobile phone text messaging platform was used by 183 patients, demonstrating a significantly higher response rate (96.1%) than our institution's post-operative email registry capture, as well as the majority of published response rates for post-operative outcomes captured through electronic and traditional data-collection systems. Response rate remained consistently high among the various surgeons and across patients, regardless of age.

This application of a widely available technology can improve the measurement of post-operative patient-reported outcomes. Such data can in turn be used in the development of strategies to reduce post-operative opioid use. The adoption of novel technologies at a patient level will play a key role in combating the opioid epidemic.

Pain management after anterior cruciate ligament reconstruction (ACLR) may pose a risk of prolonged opioid use.

The purposes of this study in ACLR were to investigate the efficacy of a surgeon-administered local–regional block of specific genicular nerves on post-operative analgesia following ACLR and to quantify the outpatient opioid consumption and duration through the complete post-operative course.

Prospectively, all patients undergoing primary ACLR by a single surgeon were studied over a 10-month period. Exclusion criteria consisted of history of pre-operative opioid use, revision surgery, multi-ligament surgery, allergy to oral opioids, and allergy to local anesthetic. ACLR was performed using autograft or allograft patellar tendon bone (PTB) graft under general anesthesia. At the conclusion of the procedure, all patients received a local anesthetic (bupivacaine 0.25%) injection by the surgeon including a unique circumferential genicular nerve and fat pad block performed based on anatomic landmarks without use of image guidance. Post-operatively, the quantity and duration of opioid use (hydrocodone 5 mg) and pain scores were recorded for 4 months prospectively. Statistical analysis was performed to evaluate risk factors for increased opioid use.

A single surgeon performed 75 ACLRs. After exclusions, a total of 70 patients were enrolled and followed prospectively. None were lost to follow-up. Total opioid consumption ranged from 0 to 30 tablets. The average number of opioid tablets used over the 4-month post-operative course was 5.5 (± 6.7). After surgery, 84% of patients took between 0 and 10 tablets and 21% of patients took no opioids throughout their entire post-operative course. The average duration of consumption was 2.6 days (± 3.1). No patients were taking opioids at the 6-week or 4-month follow-up. There were no refills required. No statistically significant differences were seen in regard to graft choice of autograft PTB (n = 48) vs allograft PTB (n = 22) in total opioid consumption or duration of use. In comparing adolescent (n = 31) versus adult (n = 39), no significant difference was seen in total opioid consumption or duration of use. All patients were satisfied with the post-operative pain management protocol.

Opioid use was unexpectedly low among patients undergoing ACLR after a surgeon-administered circumferential genicular nerve block and fat pad infiltration. With this protocol, the graft choice and patient age did not correlate with increased opioid use. These results could be useful in guiding post-operative opioid prescribing after ACLR.

Drug overdoses are the leading cause of death due to injury in the USA. Currently, 49 states have prescription drug-monitoring programs (PDMPs) available to prescribers.

We aimed to assess knowledge and practice of two groups of acute-care prescribers regarding controlled substances.

A 16-question survey was distributed to a list of surgical and emergency medicine prescribers at our institution. The survey asked about prescriber demographics, previous experiences with a PDMP, and opinions about patient risk factors available within an electronic medical record (EMR).

We received 60 responses (27.1% response rate). All prescribers recognized a growing problem with opioids, both in general and in their own practices, with an average rating of 8.3/10 and 7.9/10, respectively. Although 95% were aware a PDMP was available, only 60% were registered users. Emergency medicine prescribers were significantly more likely to have registered and used the database; 52% said the PDMP was too time-consuming and 23% said the information was not easy to use. All respondents who reported PDMP use indicated it carried some clinical utility, with 87% reporting it to be “somewhat” or “very” useful. Emergency medicine prescribers were more likely to use the PDMP regularly, with 73% selecting “somewhat frequently” or higher, while only 9% of surgery prescribers indicated the same. Of all respondents, 97% agreed that an integrated alert in the existing EMR would be helpful.

Acute-care prescribers at our institution are universally aware of the opioid epidemic, but efficient and useful tools for identifying at-risk patients are lacking. Our prescribers desired an alert system integrated into the EMR to highlight targeted risk factors.

Elective total joint arthroplasty may be a gateway to long-term opioid use.

We sought to review the literature on multimodal and regional analgesia as a strategy to minimize perioperative opioid use and control pain in patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA).

We conducted a narrative review to assess the state of the evidence informing opioid-sparing analgesics for THA and TKA. A PubMed search was conducted for English-language articles published before April 2018. We preferentially included well-designed randomized controlled trials, systematic reviews, and meta-analyses. Where the highest levels of evidence were not yet apparent, we evaluated retrospective and/or observational studies.

Multimodal analgesia emphasizing nonsteroidal anti-inflammatory agents and acetaminophen is associated with decreases in perioperative opioid use for THA and TKA. Regional analgesia, including peripheral nerve blocks and local infiltration analgesia, is also associated with decreased perioperative opioid use for THA and TKA. Emerging topics in post-arthroplasty analgesia include (1) the value of nonsteroidal anti-inflammatory drugs, (2) the use of peripheral nerve catheters and extended-release local anesthetics to prolong the duration of opioid-free analgesia, and (3) novel peripheral nerve blocks, exemplified by the IPACK (interspace between the popliteal artery and posterior capsule of the knee) block for TKA.

The use of multimodal analgesia with regional techniques may decrease perioperative opioid use for patients undergoing THA and TKA. These techniques should be part of a comprehensive perioperative plan to promote adequate analgesia while minimizing overall opioid exposure.

Current research on opioid use within orthopedic surgery has focused on efforts to identify patients at risk for chronic opioid use. Studies addressing prevention of opioid misuse related to orthopedic care are lacking. Evidence-based interventions to reduce the reliance on opioids for post-operative pain relief will be a key component of any comprehensive institutional opioid policy.

The purpose of this systematic review was to evaluate institutional strategies that reduce opioid administration or consumption after orthopedic surgery.

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist, a search was conducted of the PubMed database for English-language articles that analyzed interventions by physicians, nurses, pharmacists, physical therapists, or other hospital staff to reduce post-operative opioid use or narcotic prescription amounts after surgery. Studies that contained objective outcome measures (i.e., no expert opinion articles) were selected. Investigations on the effect of pharmacologic adjuvants, cryotherapy, or regional nerve blockades on opioid use were excluded.

The initial search yielded 6598 titles, of which 13 full-text articles were ultimately selected for inclusion in this systematic review. The review identified two major categories of interventions—patient-focused and provider-focused (e.g., physicians, nurses, physical therapists, pharmacists). Formal patient education programs were most effective in reducing opioid use. On the provider side, prescribing guidelines appear to decrease the overall number of pills prescribed, often without changes in patient satisfaction or requests for refills.

Researchers are just beginning to establish the most effective ways for institutions to reduce opioid use and promote responsible post-operative prescribing. Institutional prescribing guidelines, standardized bedside pain-management programs, and formal patient education curriculums are all evidence-based interventions that can achieve these goals. The available research also supports an interprofessional approach in any institutional opioid-reduction strategy.

The opioid prescribing patterns of orthopedic surgeons have been shown to play a role in exacerbating rates of opioid misuse among post-surgical patients. Demonstrable success has been appreciated by combining policy-level approaches and clinical education–based strategies to inform patients of alternative modalities of post-operative analgesia.

The purpose of this review was to address two questions: What are the most substantiated measures orthopedic surgeons can take to limit opioid misuse or addiction among their patients? What advantages are gained in orthopedic surgeons’ collaborating with other healthcare professionals with influence over patients’ post-operative opioid exposure?

We searched two databases for articles on multidisciplinary policy–based solutions to mitigating the opioid overdose crisis among musculoskeletal patients. Articles produced from the search were searched for further evidence supporting the use of standardized clinical and administrative protocols in mitigating opioid misuse within this patient population. Successful approaches to mitigating misuse of opioids in this demographic were synthesized from recurring themes in the studies.

Multiple articles support orthopedic surgeons being aware of the risk factors for chronic opioid use among their patients, as well as multidisciplinary strategies involving orthopedic surgeons and other healthcare/governmental professionals to address the burden of the opioid crisis on surgical patients.

Addressing the misuse of opioids among orthopedic patients requires appropriate prescribing practices and long-term support of patients. Collaboration between surgeons and policymaking entities is recognized as an effective population-wide approach to preventing opioid dependence, misuse, and addiction.

Given the high prevalence of musculoskeletal conditions in the USA, it is important for orthopedic surgeons to promptly identify patients who may be at risk for opioid misuse.

The aim of this literature review was to elucidate various musculoskeletal pathologies and complications, as seen on imaging, that may indicate opioid misuse or opioid use disorder.

A literature search was conducted using the PubMed, Scopus, and Cochrane Library databases for articles related to imaging findings associated with chronic opioid use or misuse in orthopedic patients. Two independent reviewers conducted the search utilizing pertinent Boolean operations.

We reviewed 36 full-text articles and categorized the radiographic evidence of opioid misuse as follows: soft-tissue radiologic findings, cellulitis, necrotizing fasciitis, abscess formation, retained needles, discitis, myopathy and rhabdomyolysis, osteomyelitis, septic arthritis, and septic thrombophlebitis.

Knowledge of the radiologic findings of opioid misuse will assist orthopedic surgeons in making timely diagnoses that may alter therapeutic regimens for their patients.