Orthopedic surgeons among the top opioid prescribers – Dr. Marilyn Heng shares strategies, studies on combating the epidemic

Practice Management

With President Donald Trump declaring the opioid crisis as a national epidemic, physicians are turning to alternative pain management solutions to treat patients.

Marilyn Heng, MD, is an orthopedic surgeon at Boston-based Massachusetts General Hospital. In a recent interview with Becker's Spine Review, she discussed the opioid epidemic and how orthopedic surgeons can work to curb it.

Question: Does being exposed to opioids prior to surgery affect a patient's opioid dependency following treatment? Are the effects positive or negative?

Dr. Marilyn Heng: Certainly, the literature and the research in opioids and orthopedic surgery shows that if the patient has a prior history of long term use of opioids those patients are at greater risk of continued long-term use of opioids after surgery. We know people develop a tolerance for opioids, and if they have been on them before surgery, it makes it all the harder to stop using opioids following surgery. So, patients with prior use of opioids are the ones at risk for both higher opioid needs after surgery as well as long-term use.

Regarding opioid exposure prior to surgery for acute traumatic injuries, let's say a patient is admitted with a hip fracture. In this case, we would treat the patient’s pain prior to surgery, and often we do treat the patient with opioids. However, there hasn’t been many studies looking at the effects of opioid consumption in the period from injury to surgery on opioid dependency and long-term use in these patients following surgery. However, in general the research coming out shows that an approach that minimizes opioid exposure probably is the most appropriate treatment course. During all processes of care, physicians are looking to reduce narcotic exposure.

When educating patients, setting expectations and talking to patients leads to better outcomes and a lesser chance a patient will become opioid dependent. For example, one of the reasons orthopedic surgery is involved in the opioid epidemic is because orthopedic surgery is painful. Pretty much every surgery will result in pain and patients need to expect the pain and understand what is normal. I talk to my patients about what to expect and determine an acceptable level of pain where they can still be mobilized.

Q. Are there specific surgeries that result in high levels of opioid dependency? How do you cope with this?

MH: In a recent analysis, we looked at historic prescribing patterns based off fracture patterns. This indirectly means different fracture surgeries. There was a difference in the number of opioids we would prescribe based on the fracture surgery. There is no track, 1-to-1, that leads to opioid dependency. However, in another study, we looked at the number of opioids prescribed at hospital discharge after surgery for a fracture and its association with long-term opioid use. We found that more opioids prescribed at discharge did lead to a higher chance of long-term opioid use. While you can't say that a certain surgery will lead to an opioid dependency, the prescribing patterns after certain surgeries can lead toward longer term use.

From the knowledge of the variation we found in our discharge prescribing, we proposed an initial guideline for prescribing opioids after fracture surgery. The guideline we proposed begins with a base discharge opioid prescription of 20 tablets of 5 mg oxycodone after wrist fracture surgery and then using regression modelling we suggest a scale for other types of fractures. One way to mitigate surgeons’ contributing to patients developing opioid dependency is for us to prescribe based on concrete guidelines and more objective approaches toward opioids. It is helpful to start low and work up. Much of the legislation to limit opioid prescribing at the states-level is aimed at this approach.

Q. How can surgeons help curb the opioid epidemic?

MH: Firstly, I think surgeons should acknowledge their role and take responsibility for our impact in creating the opioid epidemic. Orthopedic surgeons are among the top prescribers of opioids. We should be using data to analyze our prescribing patterns. Using state prescription monitoring program database to look up patients who we are prescribing for should be routine in our clinical practice. Orthopaedic practices can delineate practice guidelines regarding opioids and should communicate this with their patients in order to set proper expectations regarding pain management after surgery. Lastly, it is also important to research other modalities that can help manage a patient's pain instead of opioids.

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