Leading the Way to Solutions to the Opioid Epidemic
These authors point out that in the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion. In addition to reviewing the literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), they authors present some solutions to address the current opioid crisis.
One of the most disturbing parts of this article is 'how we got here'. Below is a summary:
"While opioids have long been used to treat acute pain following traumatic injury and during the postoperative period, the expansion of the use of these opioid analgesics to noncancer pain outside of the acute or immediate postoperative setting started to become more commonplace in the 1990s based on the conclusions published by Portenoy and Foley .. claiming the safety and efficacy of opioids for chronic noncancer pain, despite small patient numbers culled from 2 different studies with moderate results and several complications. At that time, extended-release oxycodone (OxyContin) entered the marketplace with claims of increased effi cacy and safety. Subsequently, the manufacturer admitted to false marketing on the safety of OxyContin , and studies have not demonstrated the increased efficacy of extended release over immediate release. Pain advocacy groups and pain specialists, many of whom have substantial financial relationships with pharmaceutical companies, successfully lobbied... to put pain at the center of all patient assessments. Physicians faced increased pressure to prescribe more opioids . This opened the door for aggressive marketing by pharmaceutical companies to expand the use of opioids to noncancer pain; the marketing included educational materials supplied by The Joint Commission, which were sponsored by Purdue Pharma....most studies were sponsored by the pharmaceutical manufacturers... a "1% risk of addiction” is commonly cited...subsequent studies have demonstrated that the risk of addiction to prescription opioids is 3% to 45% when they are used on a long-term basis. Furthermore, if patients take prescription opioids beyond 12 weeks, 50% will still be taking them at 5 years"
Here are some 'flags' they identified for possible opioid abuse.
Here are some risk factors they associated with opioid abuse.
Here are some non-opioid approaches to pain management around the time of surgery
Comment: This is a most informative article. It points to ways that both surgeons and patients can be part of the solution, not part of the problem.
A thoughtful editorial on this issue has been written by Seth Leopold (see this link). He points out that "the United States represents only 4.6% of the world’s population, but Americans consume 80% of the global opioid supply and 99% of the hydrocodone. In 2015, more than 52,000 people in the United States died from drug overdoses, and some 15,000 of those overdoses involved a prescribed opioid. The CDC reports that prescription-opioid abuse, dependence, and overdose costs the US economy an estimated USD 78.5 billion each year."
Today I was consulted by a 32 year old patient who had chronic pain after orthopedic surgery performed 17 years ago. The patient has had a total of 7 surgeries and is now on Oxycontin and Oxycodone in large doses.
Our practice is to (1) inform patients before surgery that recovery from surgery is likely to be painful, but that is expected and not a sign than things are wrong, (2) let them know that our primary medications for pain control are Tylenol and anti-inflammatory medications - narcotics will be limited to the first two weeks after surgery, (3) avoid using nerve blocks to temporarily 'mask' pain and (4) be very cautious about performing elective surgery on patients taking long-acting and / or high dose narcotics, because pain is likely to persist even after a 'perfect' procedure.
Interested readers may like to read this enchanting book by our late friend and colleague, Paul Brand
These authors point out that in the past 2 decades, overdoses and deaths from prescription opioids have reached epidemic proportions in the United States. The widespread use of opioids complicates management of the orthopaedic surgery patient in the acute and chronic settings. Orthopaedic surgeons are some of the top prescribers of opioids in the complex setting of chronic use, abuse, and diversion. In addition to reviewing the literature regarding the basic science of pharmacologic options for pain management (e.g., opioids and nonsteroidal anti-inflammatory drugs), they authors present some solutions to address the current opioid crisis.
One of the most disturbing parts of this article is 'how we got here'. Below is a summary:
"While opioids have long been used to treat acute pain following traumatic injury and during the postoperative period, the expansion of the use of these opioid analgesics to noncancer pain outside of the acute or immediate postoperative setting started to become more commonplace in the 1990s based on the conclusions published by Portenoy and Foley .. claiming the safety and efficacy of opioids for chronic noncancer pain, despite small patient numbers culled from 2 different studies with moderate results and several complications. At that time, extended-release oxycodone (OxyContin) entered the marketplace with claims of increased effi cacy and safety. Subsequently, the manufacturer admitted to false marketing on the safety of OxyContin , and studies have not demonstrated the increased efficacy of extended release over immediate release. Pain advocacy groups and pain specialists, many of whom have substantial financial relationships with pharmaceutical companies, successfully lobbied... to put pain at the center of all patient assessments. Physicians faced increased pressure to prescribe more opioids . This opened the door for aggressive marketing by pharmaceutical companies to expand the use of opioids to noncancer pain; the marketing included educational materials supplied by The Joint Commission, which were sponsored by Purdue Pharma....most studies were sponsored by the pharmaceutical manufacturers... a "1% risk of addiction” is commonly cited...subsequent studies have demonstrated that the risk of addiction to prescription opioids is 3% to 45% when they are used on a long-term basis. Furthermore, if patients take prescription opioids beyond 12 weeks, 50% will still be taking them at 5 years"
Here are some 'flags' they identified for possible opioid abuse.
And here are some suggestions for surgeon-patient discussions of pain management.
Comment: This is a most informative article. It points to ways that both surgeons and patients can be part of the solution, not part of the problem.
A thoughtful editorial on this issue has been written by Seth Leopold (see this link). He points out that "the United States represents only 4.6% of the world’s population, but Americans consume 80% of the global opioid supply and 99% of the hydrocodone. In 2015, more than 52,000 people in the United States died from drug overdoses, and some 15,000 of those overdoses involved a prescribed opioid. The CDC reports that prescription-opioid abuse, dependence, and overdose costs the US economy an estimated USD 78.5 billion each year."
Today I was consulted by a 32 year old patient who had chronic pain after orthopedic surgery performed 17 years ago. The patient has had a total of 7 surgeries and is now on Oxycontin and Oxycodone in large doses.
Our practice is to (1) inform patients before surgery that recovery from surgery is likely to be painful, but that is expected and not a sign than things are wrong, (2) let them know that our primary medications for pain control are Tylenol and anti-inflammatory medications - narcotics will be limited to the first two weeks after surgery, (3) avoid using nerve blocks to temporarily 'mask' pain and (4) be very cautious about performing elective surgery on patients taking long-acting and / or high dose narcotics, because pain is likely to persist even after a 'perfect' procedure.
Interested readers may like to read this enchanting book by our late friend and colleague, Paul Brand
===
The reader may also be interested in these posts:
Information about shoulder exercises can be found at this link.
Use the "Search" box to the right to find other topics of interest to you.
You may be interested in some of our most visited web pages including: shoulder exercises, shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials' See from which cities our patients come.
