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 opioid.
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 patients 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 alternative treatments in the form of nerve blocks," said Peter K. Sculco, MD, orthopedic surgeon 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, early intervention 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).
Authors include: Ameer Elbuluk, MD; Michael Ast, MD; Michael Alexiades, MD; Michael Cross, MD; and Peter Sculco, MD; all from HSS.
For more information on opioid prescription and pain management at HSS, please view the February 2019 issue of HSS Journal.
About HSS | Hospital for Special Surgery
HSS is the world's leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the ninth consecutive year) and No. 3 in rheumatology by U.S.News & World Report (2018-2019). Founded in 1863, the Hospital has one of the lowest infection rates in the country and was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center four consecutive times. The global standard total knee replacement was developed at HSS in 1969. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State. In addition, HSS will be opening a new facility in Florida in late 2019. In 2018, HSS provided care to 139,000 patients and performed more than 32,000 surgical procedures, and people from all 50 U.S. states and 80 countries travelled to receive care at HSS. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Global Innovation Institute was formed in 2016 to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is the world's leading provider of education on musculoskeletal health, with its online learning platform offering more than 600 courses to more than 21,000 medical professional members worldwide. Through HSS Global Ventures, the institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally.