Opioid-free orthopedic surgery [PODCAST]

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“How do we manage this? All patients meet with the physical therapist before surgery and within two days after surgery. They use transcutaneous electrical nerve stimulation (TENS) before and after surgery. They get a regional anesthetic block from one of our anesthesiologists, supplemented with local injection during surgery. They use a cold machine to provide continuous cryotherapy. Standard medication prescriptions include a non-steroidal anti-inflammatory drug (NSAID), acetaminophen, and gabapentin. Also recommended is a cannabinoid. This is cannabidiol (CBD) for our patients, without tetrahydrocannabinol (THC), the active ingredient in marijuana.”

Michael Day is an orthopedic surgeon.

He shares his story and discusses his KevinMD article, “Opioid-free orthopedic surgery: Why (and how) my patients go opioid free after surgery.”

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Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Rate and review the show at KevinMD.com/rate. Subscribe at KevinMD.com/podcast. Today on the show we have Michael Day. He’s an orthopedic surgeon, and his KevinMD article is titled “Opioid-free orthopedic surgery: Why (and how) my patients go opioid free after surgery.” Michael, welcome to the show.

Michael Day: Thanks for having me, Kevin.

Kevin Pho: So we’ll get into the article in a little bit. First off, briefly share your story and journey to where you are today.

Michael Day: OK, so I’m a native of Pennsylvania, which is currently where I practice. I did my residency in orthopedic surgery in New York City. I was at NYU, and then I did a fellowship in sports medicine at Lenox Hill Hospital. Since I graduated from fellowship, I’ve been practicing in central Pennsylvania, working as an employed physician for a health system here. And that’s how I got into the practice of sports medicine and, specifically, opioid free, which I know we’re going to get into.

Kevin Pho: All right, so just tell me about some of the joys and challenges that you have practicing sports medicine orthopedic surgery.

Michael Day: The joys, to start off with, are that we have highly motivated patients. They usually have just one problem. That’s a great appeal of orthopedic surgery in general: one problem that is often fixed on one day. There’s a lot that goes before that, and there’s a lot that goes after that, but there’s a noticeable difference on that day of surgery, where something that’s broken is fixed, something that’s ruptured is repaired, something that’s not working is reconstructed. You can see that transition, and you can be a hands-on, big part of that for a patient, and that’s very gratifying. And when you have a motivated patient that’s often otherwise healthy, not to say that some orthopedic patients don’t have other comorbidities, but especially in sports medicine, we have a lot of healthy, motivated patients, so it makes it easy and rewarding to have a relationship with them and help them get back to mobility and back to sport.

The challenges that we face are somewhat similar to what a lot of physicians are facing: external pressures from insurers that are dictating what we do to care for our patients, how we can do it, when we can do it, and what’s approved and authorized, either from their perspective as the payer or from the patient’s perspective as someone that’s facing out-of-pocket cost. And access. This is true in primary care as well as specialty care, and with us being in a rural area, it’s especially difficult for us. Our nearest university center is more than an hour away. So we have specialists, we don’t have all the specialists, and the specialists that we have, it’s hard to get in to see them. If I refer my patients to a rheumatologist or a neurologist, that’s going to be a multi-month wait. So fortunately, as I said, with the sports medicine patients, we have a relatively small group of consultants that we work with, but access all across the system is a challenge.

Kevin Pho: All right, let’s talk now about your KevinMD article, titled “Opioid-free orthopedic surgery: Why (and how) my patients go opioid free after surgery.” Now, for those of you who get a chance to read your article, just walk my audience through it and share the story of why you decided to write it.

Michael Day: I finished my training about five years ago, so I was in medical school and in residency during the “pain is the fifth vital sign” era, and that was really harped on: that we need to control the pain, we need to combat this, we need to do everything we can to get this as close as possible to zero. And in that era, that was a very pharmacologically driven approach, and that’s how we handled it, and that was the mainstay of what we did. As residents, we were often the writers of the prescriptions, and there’s a lot of motivation to, for example, cover what’s needed and avoid refills, avoid phone calls. So you would prescribe the maximum instead of the minimum to try and cover all bases.

Kevin Pho: What would you mean by that, cover the maximum and not the minimum?

Michael Day: So if there’s a wide range of what a person after a particular surgery might take, some people are going to take a few opioid pills, and some people are going to take a lot. If you take the upper end of that and you prescribe based on that, then no one’s going to need a refill. If you take the lower end of that and people are often exceeding that, then a lot of people will need refills. So you want to not be giving too little for the average person. Back then, we weren’t even measuring that, so we didn’t even know what’s average. I think some of the data that’s come out recently is giving us some more information to help us know what can be expected, what is normal, or at least average, in different populations after different surgeries.

So, I mean, we’re familiar with the way that opioids are problematic, and so I started thinking about that in my practice, and it’s something that can’t change unless you’re measuring it. So I picked a surgery that was generally considered in sports medicine to be painful, ACL reconstruction. Anecdotally, I had noticed that there was a wide range in what patients were experiencing and consuming in terms of their opioid requirements after that surgery. I noticed that some patients took very few and some took a lot, so I started measuring that. I saw that a lot of times the patients that took few would take just one or two, maybe on the day of their first rehab appointment, and a lot of those patients were younger patients. So I thought, those are patients where we want to avoid opioid exposure to the developing brain. That’s a good target for minimizing opioids and perhaps eliminating them. So I chose to focus on the under-25 age group, which includes our high school and college athletes, who are very common ACL reconstruction patients.

And I found that, on average, all comers were taking 13 oxycodone, so I immediately lowered from my standard 30 to 15. And then, when I thought that some of these patients are taking one or two, it was a very short leap to zero. So, let’s pilot it with the under-25s. I did very little to my protocol, which was already a multimodal protocol, other than eliminating the opioid. But I think the key was then also talking about that with the patients and setting expectations and discussing reasons, and the why and how of the opioid. I found that those patients did not need opioids, and despite my offer to prescribe them if and when they would need them, as an emergency rescue prescription, I haven’t had a single patient request that yet. So it’s worked out very well.

Kevin Pho: So take us into that conversation. In general, for this under-25 age group who undergo the ACL reconstruction, what kind of pain, what kind of discomfort should they expect after a typical procedure like that?

Michael Day: I think the individual experience of pain is pretty wide-ranging, but in general, when I’m counseling them, I tell them that they’re going to experience perhaps significant but manageable pain for about two days, worst during that first 24 hours after their local anesthetic and/or nerve block wears off. It’s usually not excruciating, not extreme. And importantly, I want them to understand that it’s going to be treated in one way or another, from my perspective, from the perspective of our treatment team, and that it’s adjustable. We have a protocol, but we’re also able to individualize treatment based on response to treatment and individual needs.

Kevin Pho: So what would be examples of non-opioid pain therapy in a typical scenario like this?

Michael Day: Typically, we’ll have them start using a TENS unit, transcutaneous electrical nerve stimulation, preoperatively and two days postoperatively. We’ll have them meet with a physical therapist at least once preoperatively and then usually on day one or two postoperatively. Unless there’s any contraindication, we’ll initiate immediate weight bearing, which is counterintuitive but decreases pain. We will have the anesthesiologist get the nerve block, usually an adductor canal block. We will supplement that with some local anesthetic. We will immediately start cryotherapy, or if access to the cryo unit is not available, just regular ice.

And then pharmacologically, we will use a non-steroidal anti-inflammatory around the clock initially, acetaminophen around the clock initially, and gabapentin in an off-label use as a co-analgesic to supplement that. And then the opioid is there as an option but is not routinely prescribed. So that’s the general protocol, the multimodal protocol that we use. We also sometimes will use CBD, cannabidiol. Now, that’s something that’s not routine. It’s not prescribed in the same way as those other medications and does represent additional cost, but it’s another option that I routinely talk about with patients as a non-opioid pharmacologic option.

Kevin Pho: So talk about some of the risks of short-term opioid therapy in this age group, just from your experience. Or is there any data supporting some of the risks that we want to try to avoid?

Michael Day: Well, I remember in medical school in particular being taught, “You can’t get addicted if you’re consuming opioids as treatment for pain.” If you used those receptors in response to pain, you wouldn’t get addicted. And I think the data subsequent to that has shown that’s unfortunately just not true, and that a lot of patients that end up abusing opioids, prescription opioids or otherwise, started off with their introduction to opioids being the orthopedic injury or other surgery for which they received opioids as a legitimate prescription from a doctor prescribing appropriately, who wanted to treat their pain after an episode of acute pain. Unfortunately, that’s the story for a lot of people that get introduced and ultimately end up having trouble with an opioid abuse problem.

So I think that data has changed over the last five to 10 years, and we also know that the developing brain is particularly at risk for the adverse effects of opioids. And so that is a population where we really want to decrease exposure, because we don’t necessarily know who is going to have a problem. There are plenty of people that have acute injury, surgery, acute pain, use opioids, and it’s just episodic. And there are certainly risk factors that we can identify: prior opioid use, prior addictions elsewhere, and various social factors. We still don’t know for sure who’s going to have a problem just from a routine.

Kevin Pho: So in your small cohort there, approximately what percentage of patients did not need opioids after their ACL reconstruction?

Michael Day: Well, since the initiation of this protocol, in the patients under 25 undergoing ACL reconstruction, it’s 100 percent opioid free. Each patient is offered a rescue prescription if needed, and no patient has utilized that.

Kevin Pho: Now, is this opioid-free approach, in this procedure and in this age group, common among most orthopedic surgeons across the country, or is this somewhat unique?

Michael Day: I think it’s gaining traction, but I think the majority across the country still utilizes some opioids. Certainly there’s been a trend to curtail prescribing practices, and from what I see in the literature, there are ranges of opioids consumed that are into the low teens, I would say, on average for ACL. There have been a couple of randomized controlled trials that have compared opioid free.

What I see in a lot of the literature is that they will often compare an opioid-free cohort that uses the NSAIDs, the acetaminophen, and gabapentin. Sometimes they’ll include tramadol, which is opioid free but acts on opioid receptors. Sometimes they’ll include a benzodiazepine, which is non-opioid but has its own risk profile. And they’ll compare that to a Percocet alone, and then they’ll demonstrate a superiority with the opioid free. I think some of that is a little bit unfair, because you’re using the multimodal plus the opioid and comparing that to just a Percocet, whereas, you know, I think really you can isolate it down to the opioid.

And I even found in my patients that, paradoxically, or seemingly paradoxically, the pain scores were better with the opioid free when that was the only thing I changed. So we looked at our cohort. The two-week visual analog scale pain score average was 2.7 in patients that had taken opioids prior to this, and the average was 1.7 in the patients that were completely opioid free. And the only thing that had changed pharmacologically was the removal of oxycodone.

Kevin Pho: Are you looking to expand this opioid-free approach to other age groups and other procedures?

Michael Day: Yes. I have expanded it to all ACL reconstructions. There are some patients that, in my discussions with them, will come to the determination that they would like an opioid prescription available. So it’s not as normative as with the younger cohort, where I say, “We don’t routinely prescribe this, and we’ll prescribe it if you need it.” Some of the older patients say, “I think I’m going to need it,” and we’d have that discussion, and we prescribe it. But the routine is not to use it for ACL reconstruction.

And I’ve expanded it, among that age cohort of under 25, to not using it for any surgeries. ACL is maybe more painful. I think periarticular osteotomy is probably the only procedure I do in a young person that is more painful than an ACL. I have not had a problem with expanding that. Anyone under 25 that’s having surgery with me gets an opioid-free protocol. And then outside of that, I have not expanded it to the rotator cuff population. That’s probably the other sports medicine big pain generator, and that tends to be an older patient population. And so that certainly is not opioid free in my practice at this point. It is trending towards fewer opioids used and also utilizes the same multimodal.

Kevin Pho: And what’s the reaction to these opioid-free initiatives among your orthopedic colleagues?

Michael Day: Largely positive. I think there’s some caution that is warranted, in that we don’t want to, in our zeal for minimizing or eliminating the risks associated with these, create shame or vilify anyone that is utilizing them as part of their practice, because they have a role and they are one tool in the toolkit. I think they should be kept in that perspective and relegated to that role. There’s an appropriate caution where you say, “Hey, so-and-so is using opioids.” We don’t want to say, “This guy’s bad for using opioids.” And so I think there’s a caution there.

And there’s also a little bit of reluctance among some of my colleagues. They say, “Well, I agree with all this minimization, but I’m still just going to prescribe five, because what about that one first night when the pain is the worst? What if it hits them in the middle of the night? I want them to just have these five pills as a backup, a backup to the backup.” And I think that’s fine, because we all see ourselves headed in the right direction, that this is a problem that we contributed to as prescribers historically, and the first step is just our awareness of our role in that. And I think we’re starting to get a more universal awareness among orthopedic surgeons.

Kevin Pho: We’re talking to Michael Day. He’s an orthopedic surgeon, and we’re talking about his KevinMD article, “Opioid-free orthopedic surgery: Why (and how) my patients go opioid free after surgery.” Michael, what are some of your take-home messages that you want to leave with the KevinMD audience?

Michael Day: I think the most important take-home that I would offer from my experience is that there’s a shared mindset between the surgeon and the patient, or even outside of surgery, between the physician and the patient, and that you can, to some extent, change and choose that mindset, and that can affect a patient’s experience and outcome. That’s the thing I noticed with my transition to opioid free: I went from a mindset that this is a necessary evil for controlling pain for my patients after surgery, so that they can achieve the outcome of having a repair or reconstruction, to “This is not necessary.” And I approach my patients with that mindset and say, “What’s normal is that we don’t use this. We can use it, but the normal thing is not to use it.” And if you have that buy-in, based on trust you’ve established with the patient, then you can totally change their experience of postoperative pain, because now they’re expecting it to be not as bad.

And when we’re talking about pain, anticipation is the worst part of it, because everyone has survived all the pain that they’ve experienced, but what they are most concerned about is the pain that they’ve not yet experienced: What’s it going to be like, and how bad is it going to be? So if you start from a mindset of, one, it’s not going to be that bad, and two, if it gets to be bad, we’re going to change the plan and we’re going to control it, then you’re giving yourself a head start. You’re starting on third base with that postoperative pain control.

Kevin Pho: Michael, thank you so much for sharing your time and insight. Thanks again for being on the show.

Michael Day: Thanks for having me.

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