HSS orthopedic surgeons address opioid epidemic head on

Orthopedic surgeons at Hospital for Special Surgery (HSS) in New York City have developed a pain management pathway designed to reduce the use of opioid analgesics after joint procedures. The effort is part of the hospital's commitment to minimize the use of opioids by its clinicians and develop alternatives to opioid-based analgesia for its patients.

In 2017, more than 47,000 Americans died after overdosing on opioids, such as heroin or fentanyl, a potent synthetic drug, government data show. Some 1.7 million more had a substance abuse disorder involving a prescription .

Patients who undergo joint replacement surgeries of all kinds conventionally have received an opioid prescription for their recovery—presenting a critical opportunity for reducing the reliance on these medications and preventing abuse of the drugs.

HSS is taking a multi-pronged approach to the problem, explained Michael Ast, MD, an orthopedic surgeon at the institution. HSS recently launched a hospital-wide initiative to reduce opioid use among its and to better understand when the powerful drugs are appropriate to prescribe, and in what quantities. The initiative has involved surgeons, anesthesiologists, nurses and other members of the care team.

A primary focus of the pain-management pathway is the emphasis on multimodal analgesia. The practice involves the combination of local anesthetics, nonsteroidal anti-inflammatory drugs, IV acetaminophen and, possibly but not necessarily, opioids. Multimodal analgesia for knee and hip replacement surgeries has been associated with a decrease in the use of opioids, according to the American Society of Anesthesiologists.

Another aspect of the initiative involves research, and HSS currently has more than a dozen ongoing studies to assess alternatives to opioid analgesia. "We're doing things like intraoperative and post-op acupuncture therapy and we're looking at in the form of nerve blocks," said Peter K. Sculco, MD, at HSS and also senior author on the study said. "We're also looking at understanding prescribing patterns and how that affects how patients use their medication—if they are given a smaller prescription will they use less over time?"

The effort also has a strong patient-centered component. The new pain-management pathway includes educational programs for patients undergoing joint surgeries, including new additions to the preoperative education to manage pain expectations, by the pain management team for patients on preoperative or chronic opioids, and a multi-disciplinary inpatient team to treat and educate patients on alternatives to opioids for pain management. Although still in its early phase, data so far show that the pathway has led to a significant decrease in the use of opioids with no sacrifice in pain control.

Dr. Sculco and his colleagues presented their findings at the 2019 annual meeting of the American Academy of Orthopaedic Surgeons in Las Vegas (exhibit SE35).


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