Practice of Medicine

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Safety Spotlight: Orthopedics and Opioids…Proceed with Caution!

October 28, 2015

Opioid use has reached epidemic and deadly proportions in the U. S.; overdose deaths increased 124% from 1999-2007. [1]  Opioids cause more deaths than cocaine and heroin deaths combined. The U.S. uses 80% of the global opioid supply and 99% of the global hydrocodone supply, yet only represents <5% of the global population.[2]  Hydrocodone, the most commonly worldwide prescribed opioid, has a consumption of 27,400,000 grams in the U.S. annually compared with 3,237 grams for the UK, France, Germany, and Italy combined.[3]

  • Orthopedists rank 3rd highest of prescribers for opioid prescriptions for patients age 40 plus, and account for approximately 7.7% of all opioid prescriptions in the US in 2009.[4]
  • U.S. patients tend to be prescribed more opioids post orthopedic surgery as compared with patients in the Netherlands according to one study.[5]
  • Orthopedists mainly prescribe Schedule II and Schedule III drugs, both with high abuse and dependence possibility. Hydrocodone was reclassified to a Schedule II drug in 2014 by the FDA due to the increasing opioid use and misuse.[6]
  • Orthopedic trauma patients who have had preinjury opioid use have been shown to be at higher risk for prolonged opioid use post trauma as well as postoperative “doctor shopping”.[7],[8],[9]

Patient Safety Recommendations for Orthopedic Physicians

  • Screen patients for “at risk” behavior and/or opioid abuse potential

Recognizing risk factors for abuse potential, as well as recognizing and monitoring aberrant behavior should be considered as part of an orthopedist’s standard protocol.[10]

Some of these risk factors which may predispose a patient to opioid abuse include: a patient’s tendency to loose prescriptions, make early refill requests, dependency on nicotine, personal or family history of any substance abuse, history of psychiatric diagnoses, and lower education levels. Screening tools are available, especially for long term pain management, and include: Opioid Risk Tool, the Pain Medication Questionnaire, and the Screener and Opioid Assessment for Patients with Pain-Revised.[11]

  • Set reasonable expectations for pain control

Orthopedists should set reasonable expectations for pain control for each of their patients. Establishing standard protocols and regimens for the orthopedic practice will keep consistency among physicians in the group, as well as support staff dealing with phone calls, etc. This can include “opioid tapers” post – surgery.

  • Utilize your state’s prescription drug monitoring program

Forty nine states currently have a prescription drug monitoring programs; data bases that collect data on controlled substance prescriptions to help curtail nontherapeutic opioid use and doctor shopping. However, not all states require physicians to utilize the data base prior to prescribing controlled substances, therefore data bases may be incomplete, resulting in somewhat limited practical benefit at this time.

  • Consult with pain management specialists

Consultation with pain management physicians when pain control is not adequate, or for patients who appear to be headed toward chronic opioid use, is another proactive approach.

  • Take advantage of Pain Management Continuing Education Programs

As an example, MagMutual has developed a Pain Management CME: New Challenges in Chronic Pain Management.

  • Know and comply with State Medical Board opioid management rules and regulations.

Reference article:

Morris BJ, Hassan Mir: The opioid epidemic: impact on orthopaedic surgery. J AAOS 2015, Vol 23, No5:267-271.

  [1] Bohnert AS, Valenstein M, Bair MJ, et al: Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011:305(13):1315-1321

 

[2] Manchikanti L, Singh A: Therapeutic opioids: A ten-year perspective on the complexities and complications of the escalating use, abuse, and nonmedical use of opioids. Pain Physician 2008;11 (2suppl):S63-68

 

[3] Manchikanti L, Helm S II, Fellows B, et al: Opioid epidemic in the United States. Pain Physician 2012;15(3):194-202

 

[4] Volkow ND, McLellan TA, Cotto JH, Karithanom M, Weiss SR: Characteristics of opioid prescriptions in 2009. JAMA 2011;305 (13):1299-1301

 

[5] Lindenhovius AL, Helmerhorst GT, Schnellen AC, Vrahas M, Ring D, Kloen P: Differences in prescription of narcotic pain medication after operative treatment of hip and ankle fractures in the United States and The Netherlands. J Trauma 2009;67(1):160-164.

 

[6] Throckmorton DC: Re-scheduling prescription hydrocodone combination drug products; An important step toward controlling misuse and abuse. FDA Voice. Posted on October 6, 2014. http://blogs.fda.gov/fdavoice/index.php/2014/10/

 

[7] Levy RS, Hebert CK, Munn BG, Barrack RI: Drug and alcohol use in orthopedic trauma patients: A prospective study. J Orthop Trauma 1996;10(1):21-27

 

[8] Massey, GM, Dodds HN, Roberts CS, Servoss TJ, Blondell RD: Toxicology screening in orthopedic trauma patients predicting duration of prescription opioid use. J Addict Dis 2006;24(4):31-41

 

[9] Morris BJ, Zumsteg JW, Archer KR, Cash B, Mir HR:Narcotic use and postoperative doctor shopping in the orthopaedic trauma population. J Bone Joint Surg Am 2014;96(15):1257-1262

 

[10] Owen GT, Burton AW, Schade CM, Passik S: Urine drug testing: Current recommendations and best practices. Pain Physician 2012;15(3 suppl):ES 119-ES133

 

[11] Owen GT, Burton AW, Schade CM, Passik S: Urine drug testing: Current recommendations and best practices. Pain Physician 2012;15(3 suppl):ES 119-ES133

 

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