Here are eight things to know about orthopedic and spine pain management.
1. Orthopedic surgeons are the third-highest physician prescribers of opioids, behind primary care physicians and internists, according to a study in The Journal of the American Academy of Orthopaedic Surgeons.
2. Baltimore-based Johns Hopkins Medicine researchers published the nation's first set of operation-specific opioid prescribing guidelines. They determined orthopedic surgery warranted the highest number of opioids, stating that zero to 20 pills is an acceptable range for three of four reviewed orthopedic procedures. Here is the report published in the Journal of the American College of Surgeons.
3. In its 2019 final payment rule for hospital outpatient surgery departments and ambulatory surgery centers, CMS aims to address the opioid crisis by making separate payments for non-opioid pain management drugs for ASCs. The only HCPCS code falling into this category is Pacira Pharmaceuticals' Exparel, which will now receive separate payment when used in the ASC setting.
To learn more about Exparel use and billing from ASC owners, administrators and industry experts, register for a webinar titled "CMS Reimburses Non-Opioid Postsurgical Pain Management in the ASC: Review of the New CMS Rules and Opportunity for ASCs."
4. To avoid opioid use, the best practice is employing short-acting anesthetic agents for outpatient spine surgery patients, according to a study in Spine. A panel of three neurosurgeons, three anesthesiologists, one orthopedic spine surgeon and a registered nurse conducted a three-round modified-Delphi method to generate best practice statements. Preoperative analgesia plans are necessary and the panel recommended using mild analgesics for initial pain control before administering opioids for persistent pain.
5. Single-shot, low-thoracic epidural anesthesia can reduce fentanyl consumption in elective lumbar spine surgery patients compared to patients who only received general anesthesia.
In a Spine study, one group received a single-shot epidural block with 0.25 percent bupivacaine plus four milligrants of morphine with a total volume of 10 milliliters before receiving general anesthesia with desflurane and cisatracurium. The other patient group received general anesthesia with desflurane, cisatracurium and any systemic analgesia the attending anesthesiologist deemed appropriate.
At 24 hours postoperatively, average fentanyl consumption was 80 micrograms for the group who received the single-shot epidural block in the postanesthesia care unit compared to 386 micrograms for the general anesthesia group.
6. Patients with intractable spine or limb pain have less pain when treated with spinal cord stimulation compared to medication, according to research presented at the American Academy of Pain Medicine 2018 Annual Meeting, in Vancouver, Canada, April 25-29.
The study involved 12 randomized controlled trials. In three trials, spinal stimulation increased the likelihood of pain relief by at least 50 percent compared with medical therapy including gabapentin, tricyclic antidepressants and opioids.
7. Exparel significantly reduced opioid use in a study of 20,907 Medicare-insured total knee arthroplasty patients and 12,505 commercially insured TKA patients, according to results published in The Journal of Medical Economics.
The study found:
- Hospital length of stay was 0.6 days shorter with Exparel
- Exparel patients were 1.6 times more likely to be discharged home than to a skilled nursing facility
- Total hospitalization costs for TKA were lower with Exparel: $616 less for Medicare patients and $775 for commercially insured patients
- Opioid consumption was lower with Exparel in both payer populations.
8. Enhanced Recovery After Surgery is becoming more widely used among orthopedic and spine surgeons to optimize the patient before and after surgery, with a focus on pain management. In February 2017, the Agency for Healthcare Research and Quality granted the Baltimore-based Johns Hopkins Armstrong Institute for Patient Safety and Quality $4 million to begin the first phase of ERAS implementation among colorectal surgery and abdominal patients, with a phase two option featuring a $12 million grant to incorporate four other specialties, including orthopedic surgery.
Click here to learn about how Daniel Hoeffel, MD, is applying ERAS with his orthopedic surgery patients in Minnesota.