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Offering Optional Opioid Prescriptions for Orthopaedic Postoperative Pain Control
Michael Terry MD examines eliminating opioid medications for postoperative pain control. He discusses his study and shares the multimodal approach used at Northwestern Medicine that significantly reduces the number of unused opioids circulating in the community.
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Learn more about Michael Terry, MD
Michael Terry, MD
Michael Terry, MD is the Head Team Physician, Chicago Blackhawks Team Physician, USA Volleyball Team Physician, Northwestern University Varsity Athletics.Learn more about Michael Terry, MD
Transcription:
Offering Optional Opioid Prescriptions for Orthopaedic Postoperative Pain Control
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we examine eliminating opioid medications for post-operative pain control. Is it possible? Joining me is Dr. Michael Terry. He's the Dr. Charles and Leslie Snorf Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Terry, it's a pleasure to have you with us today. This is a really great topic. It's one that is of interest to consumers and other providers alike. We know that peri-operative pain management is such an important aspect of quality patient care. Why is it so important for physicians to pay special attention to the amount of opioids that they're prescribing patients? What's going on in the world? Tell us a little bit about some of the parameters.
Michael Terry, MD (Guest): Well, as you know, opioids have a long list of side effects that are problematic for people, whether they be small things like constipation to large things like respiratory arrest. So we’ve long known that, and the trouble that opioids present with regard to addiction and abuse. I think that's become clearer, more recently as it seems that everyone has noticed now, the opioid epidemic and the addiction epidemic that's around. So, as providers, we need to be careful, to do everything we can to avoid leaving excess opioids out in public, after people are done using them, and to not over prescribing and I think that lately the public has become much more aware of it, too.
Host: Well, certainly it's been, really talked about more in the media. Is there an optimal number of opioids to prescribe after an orthopedic procedure? Does it vary from patient to patient? Obviously, pain tolerance is somewhat subjective. So, tell us any parameters that you've got now or guidelines in the past. What's different now? Tell us a little bit about how stewardship is working for you.
Dr. Terry: Yeah, so it's a great question. And the answer is it varies by a lot of different things. We find that people that have been using preoperative medications, pain medications, or even muscle relaxants will require more narcotics. Certainly, the subjectivity of pain tolerance is also another factor. And what procedure you have done, a knee scope would be a much different pain generator, than for instance, an osteotomy, or some of our bigger procedures. I think it's important to have the conversation and to follow up with people about it so that you can get an estimate of what you need.
We looked at a systematic review of literature regarding pain medicine, and what we found is that, on average, people are prescribing 30 to in some cases, 60% too many pain pills.
Host: Wow. That's quite a statistic. So, what have you observed? Tell us a little bit about some of the recent studies and how do you personally determine when to initiate or continue opioids?
Dr. Terry: One of the things that we do is we try multimodal pain management prior to jumping to opioids. We know that the opioid utilization after surgery will be higher if it's used before. So, we really try to pull back on that. Now you can't do it all the time, but I think you can do it. And I think very often, if you tell the patients that, they'll be a lot more responsive to trying different things so that they can avoid that extra medication that we know they'll need post-operatively. So, we try a multimodal approach. We try to make the patients aware, so that they work with us on trying to limit, or eliminate opioid use for the varying procedures that we do.
Host: As I said before, it's a great topic. So, you recently published a study in the American Journal of Sports Medicine that was determining if patients would take fewer opioids, if given an optional prescription versus patients with opioids included in this multimodal pain management plan. Tell us a little bit more about the study, the methods you used. Give us a little overview.
Dr. Terry: Yeah, so, in the study, one of the things that we were considering is if patients didn't have pain medicine, they had to do something to get it and would they utilize pain medicine in the same way? Would we have less utilization if patients had to go fill an extra prescription for pain medicine only if they needed it. And what we found is that's not the case. People utilize the same amount of pain pills in both groups. What we did find is that there were fewer unutilized pills, with the patients beforehand. So, it was interesting, because that's one of the things that we know is problematic from an opioid abuse standpoint is having pills around and available and not having pain at the time.
Host: Tell us about the results. What'd you find?
Dr. Terry: So, we found that patient’s utilization of pain medication, whether they have the option, to avoid filling a prescription or they just have the prescription from the beginning, were the same. The procedure, and the patient are probably what makes the biggest difference, not whether you, you make them jump through a hurdle, but if you do give people the option not to fill the medication, some people won't. So, I think that will lead to fewer prescription opioids being available for abuse.
Host: Well certainly and circulating in the community, as you said before. So, speak a little bit more. Expand for us on that multimodal approach used at Northwestern Medicine and for other providers, Dr. Terry, tell them what that means and what you're doing that's pretty unique.
Dr. Terry: So, we use a lot of different for things in different situations to try to avoid using narcotics. And some of the most common things are, standard first aid, rest, ice, elevation that can help people avoid pain and get their pain levels down. We utilize a lot of anti-inflammatories. Anti-inflammatories and orthopedics, seem to go hand in hand.
We use ice, with just about every surgery that we do. We send people home with an ice pack that can circulate ice water 24 hours a day. Acetaminophen is another good analgesic and it's nonnarcotic. So, we try to do all of those things before we even open the door to narcotic use, opioid use.
Host: Well then now, kind of the elephant in the room, how has COVID-19 pandemic affected this? Has the recommendation or patient desire to delay elective orthopedic surgeries, increased patient's reliance on opioids? Tell us what this pandemic has sort of reaped as far as what you've seen happen with people that have had surgery, maybe right before the pandemic or any elective surgeries that you are doing now, how are you managing pain during this?
Dr. Terry: You're absolutely right. The pandemic has changed people's desire to get elective surgery. And very often in our arena, or most often in our arena, patients are having that surgery because of pain. It is increasing the need for people to manage their pain and manage their symptoms, if they have this reluctance to get the surgery. Obviously, the way to eliminate opioid use is, appropriate opioid use is, to eliminate pain. And so while we are beginning and have begun to perform outpatient elective surgeries, there's still a backlog of people that probably need it.
It just emphasizes the fact that we need to be careful and thoughtful about it. And I think communication with your patients about it, if the consideration is being made to start narcotics is important.
Host:Well it certainly is. And as I said at the start, this is a really great topic. And during this pandemic, I'm glad you discussed if they're not having surgery, what are they doing to manage that chronic pain? So, as we wrap up Dr. Terry, what would you like other providers to know or take away from this segment, from your studies? And I'm going to ask the question, right at the beginning, offering optional opioid prescriptions for orthopedic postoperative pain control. Is it possible to eliminate some of these medications?
Dr. Terry: It absolutely is. And the other thing that we can do, that's really helpful is working with our anesthesia team and performing nerve blocks for people so, that they get through that initial evening, for instance, without pain and then communicating with the patients about why and you want to avoid utilization of pain medication, don't overprescribe your pain medication.
It seems to be, definitely much more of a problem than under-prescribing, and multimodal therapies I think are going to be the things that help us do that, reduce or eliminate postoperative opioid use.
Host: I'm sure they will. So, thank you so much, Dr. Terry for joining us today, really an informative segment. To refer your patient, you can visit our website at nm.org/ortho to get connected with one of our providers. That concludes today's episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine Podcasts. This is Melanie Cole.
Offering Optional Opioid Prescriptions for Orthopaedic Postoperative Pain Control
Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we examine eliminating opioid medications for post-operative pain control. Is it possible? Joining me is Dr. Michael Terry. He's the Dr. Charles and Leslie Snorf Professor of Orthopedic Surgery at Northwestern Medicine. Dr. Terry, it's a pleasure to have you with us today. This is a really great topic. It's one that is of interest to consumers and other providers alike. We know that peri-operative pain management is such an important aspect of quality patient care. Why is it so important for physicians to pay special attention to the amount of opioids that they're prescribing patients? What's going on in the world? Tell us a little bit about some of the parameters.
Michael Terry, MD (Guest): Well, as you know, opioids have a long list of side effects that are problematic for people, whether they be small things like constipation to large things like respiratory arrest. So we’ve long known that, and the trouble that opioids present with regard to addiction and abuse. I think that's become clearer, more recently as it seems that everyone has noticed now, the opioid epidemic and the addiction epidemic that's around. So, as providers, we need to be careful, to do everything we can to avoid leaving excess opioids out in public, after people are done using them, and to not over prescribing and I think that lately the public has become much more aware of it, too.
Host: Well, certainly it's been, really talked about more in the media. Is there an optimal number of opioids to prescribe after an orthopedic procedure? Does it vary from patient to patient? Obviously, pain tolerance is somewhat subjective. So, tell us any parameters that you've got now or guidelines in the past. What's different now? Tell us a little bit about how stewardship is working for you.
Dr. Terry: Yeah, so it's a great question. And the answer is it varies by a lot of different things. We find that people that have been using preoperative medications, pain medications, or even muscle relaxants will require more narcotics. Certainly, the subjectivity of pain tolerance is also another factor. And what procedure you have done, a knee scope would be a much different pain generator, than for instance, an osteotomy, or some of our bigger procedures. I think it's important to have the conversation and to follow up with people about it so that you can get an estimate of what you need.
We looked at a systematic review of literature regarding pain medicine, and what we found is that, on average, people are prescribing 30 to in some cases, 60% too many pain pills.
Host: Wow. That's quite a statistic. So, what have you observed? Tell us a little bit about some of the recent studies and how do you personally determine when to initiate or continue opioids?
Dr. Terry: One of the things that we do is we try multimodal pain management prior to jumping to opioids. We know that the opioid utilization after surgery will be higher if it's used before. So, we really try to pull back on that. Now you can't do it all the time, but I think you can do it. And I think very often, if you tell the patients that, they'll be a lot more responsive to trying different things so that they can avoid that extra medication that we know they'll need post-operatively. So, we try a multimodal approach. We try to make the patients aware, so that they work with us on trying to limit, or eliminate opioid use for the varying procedures that we do.
Host: As I said before, it's a great topic. So, you recently published a study in the American Journal of Sports Medicine that was determining if patients would take fewer opioids, if given an optional prescription versus patients with opioids included in this multimodal pain management plan. Tell us a little bit more about the study, the methods you used. Give us a little overview.
Dr. Terry: Yeah, so, in the study, one of the things that we were considering is if patients didn't have pain medicine, they had to do something to get it and would they utilize pain medicine in the same way? Would we have less utilization if patients had to go fill an extra prescription for pain medicine only if they needed it. And what we found is that's not the case. People utilize the same amount of pain pills in both groups. What we did find is that there were fewer unutilized pills, with the patients beforehand. So, it was interesting, because that's one of the things that we know is problematic from an opioid abuse standpoint is having pills around and available and not having pain at the time.
Host: Tell us about the results. What'd you find?
Dr. Terry: So, we found that patient’s utilization of pain medication, whether they have the option, to avoid filling a prescription or they just have the prescription from the beginning, were the same. The procedure, and the patient are probably what makes the biggest difference, not whether you, you make them jump through a hurdle, but if you do give people the option not to fill the medication, some people won't. So, I think that will lead to fewer prescription opioids being available for abuse.
Host: Well certainly and circulating in the community, as you said before. So, speak a little bit more. Expand for us on that multimodal approach used at Northwestern Medicine and for other providers, Dr. Terry, tell them what that means and what you're doing that's pretty unique.
Dr. Terry: So, we use a lot of different for things in different situations to try to avoid using narcotics. And some of the most common things are, standard first aid, rest, ice, elevation that can help people avoid pain and get their pain levels down. We utilize a lot of anti-inflammatories. Anti-inflammatories and orthopedics, seem to go hand in hand.
We use ice, with just about every surgery that we do. We send people home with an ice pack that can circulate ice water 24 hours a day. Acetaminophen is another good analgesic and it's nonnarcotic. So, we try to do all of those things before we even open the door to narcotic use, opioid use.
Host: Well then now, kind of the elephant in the room, how has COVID-19 pandemic affected this? Has the recommendation or patient desire to delay elective orthopedic surgeries, increased patient's reliance on opioids? Tell us what this pandemic has sort of reaped as far as what you've seen happen with people that have had surgery, maybe right before the pandemic or any elective surgeries that you are doing now, how are you managing pain during this?
Dr. Terry: You're absolutely right. The pandemic has changed people's desire to get elective surgery. And very often in our arena, or most often in our arena, patients are having that surgery because of pain. It is increasing the need for people to manage their pain and manage their symptoms, if they have this reluctance to get the surgery. Obviously, the way to eliminate opioid use is, appropriate opioid use is, to eliminate pain. And so while we are beginning and have begun to perform outpatient elective surgeries, there's still a backlog of people that probably need it.
It just emphasizes the fact that we need to be careful and thoughtful about it. And I think communication with your patients about it, if the consideration is being made to start narcotics is important.
Host:Well it certainly is. And as I said at the start, this is a really great topic. And during this pandemic, I'm glad you discussed if they're not having surgery, what are they doing to manage that chronic pain? So, as we wrap up Dr. Terry, what would you like other providers to know or take away from this segment, from your studies? And I'm going to ask the question, right at the beginning, offering optional opioid prescriptions for orthopedic postoperative pain control. Is it possible to eliminate some of these medications?
Dr. Terry: It absolutely is. And the other thing that we can do, that's really helpful is working with our anesthesia team and performing nerve blocks for people so, that they get through that initial evening, for instance, without pain and then communicating with the patients about why and you want to avoid utilization of pain medication, don't overprescribe your pain medication.
It seems to be, definitely much more of a problem than under-prescribing, and multimodal therapies I think are going to be the things that help us do that, reduce or eliminate postoperative opioid use.
Host: I'm sure they will. So, thank you so much, Dr. Terry for joining us today, really an informative segment. To refer your patient, you can visit our website at nm.org/ortho to get connected with one of our providers. That concludes today's episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine Podcasts. This is Melanie Cole.