David Kalainov, MD, is a clinical professor of orthopedic surgery in the Northwestern University Feinberg School of Medicine.
He has been in clinical practice at Northwestern Memorial Hospital for 21 years. Here, he expresses his views on ways for hospitals and clinicians in the U.S. to combat the opioid epidemic.
Question: What opioid reduction efforts can be undertaken by hospital leadership?
Dr. David Kalainov: There are several important statistics to know about opioids and why hospital leadership and orthopedic surgeons, in particular, need to be actively engaged in addressing the opioid epidemic. Orthopedic surgeons prescribe more opioids than most other surgical specialties. Approximately 6 percent of patients who receive an opioid for the first time in association with a surgical procedure are still using a prescription opioid six months later. More than 70 percent of opioids prescribed after surgery go unused by the intended user.
Excess pills warrant concerns for potential abuse and diversion with adverse socioeconomic consequences. Hospital leadership can help opioid reduction efforts by supporting the education of clinicians on applicable laws and safe prescribing practices. Authors of a recent study found that 19 percent of surveyed orthopedic surgery residents from two training programs might unintentionally over prescribe opioids relative to state law limits after distal radius fracture repair surgery. Less than half of the residents queried had participated in an opioid training program.
All states have an opioid Prescription Monitoring Program, which provides patient-specific information on pharmacy-filled opioid prescriptions. Laws in some states now mandate continuing medical education for physicians on safe opioid prescribing for maintenance of licensure. Several web-based educational videos for continuing medical education credit have been developed by stakeholders and are available online (e.g., The Hospital for Special Surgery Controlled Substances Education Program).
There are also opioid stewardship toolkits available online to assist hospitals in the development of opioid stewardship programs (e.g., Illinois Surgical Quality Improvement Collaborative Opioid Stewardship Toolkit). Secure drug drop-boxes can be positioned in monitored areas within the hospital and healthcare workers can participate in a National Prescription Drug Take Back Day program. A receptive ear to innovative ideas can be particularly helpful in curbing the epidemic.
Q: What opioid reduction efforts can be undertaken by orthopedists working in a hospital?
DK: Use of a screening tool for opioid dependence behaviors in advance of an elective orthopedic surgical procedure can be useful. Studies have shown that pain catastrophizing is associated with greater opioid consumption. Other at-risk characteristics include existing opioid use, illicit drug use, alcohol abuse, and a pain syndrome. The Illinois Surgical Quality Improvement Collaborative has a quick and easy-to-use Opioid Risk Tool that is available online. The American Academy of Orthopaedic Surgeons website also contains a short questionnaire that can be downloaded.
A preoperative conversation with each patient to set expectations for pain after surgery is imperative. In addition, integrating non-opioid, pharmacologic measures perioperatively (e.g., regional anesthesia, gabapentin, ibuprofen, celecoxib, acetaminophen) can be helpful in decreasing opioid use, and potentially eliminating opioids altogether in select orthopedic procedures.
Setting upper limits on opioid prescription pill quantities is especially important in opioid reduction efforts. Several orthopedic groups have created group-specific and institution-specific guidelines based on literature, consensus, and law that have led to reductions in prescription opioid pill numbers. One group reported no adverse effects on patient satisfaction or the number of refill requests after initiating their guidelines.
Orthopedists should consider providing all surgical patients with an educational handout regarding appropriate opioid use, the danger of concomitant benzodiazepine administration, and avoidance of driving or alcohol consumption in association with opioids. The brochure would ideally also include information on safe opioid disposal (i.e., drop-boxes in hospitals, pharmacies, and police stations, in addition to charcoal deactivation bags).
Multidisciplinary pain teams comprised of surgeons, anesthesia pain medicine specialists, psychiatrists, psychologists, pharmacists, social workers and mid-level providers may be particularly useful in providing assistance in the care of suspected opioid-dependent patients before and after surgery. The potential for opioid addiction increases with prolonged opioid use; consequently, efforts to detect and deter opioid addiction early are important.
Q: How can orthopedists participate in opioid reduction efforts when outside of hospital walls?
DK: Efforts of orthopedic surgeons outside of hospital walls would ideally parallel efforts undertaken within hospital boundaries. Surgeons operating at free-standing surgery centers could adopt hospital-based, upper limit opioid prescription defaults and/or establish their own.
Orthopedists in all practice settings can utilize non-opioid pain protocols for their postoperative patients that include directions on over-the-counter pain medications (e.g., ibuprofen and acetaminophen), icing, and limb elevation when appropriate. In addition, orthopedists in all practice environments can provide patients with a brochure or web link to general information on the opioid epidemic and directions on safe opioid use and disposal.
Q: Are there current and future technological innovations that may help with opioid reduction efforts?
DK: The electronic medical record system can be leveraged for prescribing default opioid strengths, dosing intervals, and quantities. Dr. Jonah Stulberg, an Assistant Professor of Surgery and Health Services Researcher at Northwestern has been instrumental in opioid reduction efforts at our institution. He successfully implemented default opioid prescriptions for numerous general surgery procedures based on his team’s work and working with the Illinois Surgical Quality Improvement Collaborative.
A better understanding of a patient’s pain level and opioid use after surgery could be achieved by sensor technology. Current methods of engaging individuals on pain and opioid use after surgery include telephone calls, follow-up appointments and written and electronic diaries (e.g., GetWell Loop). There are limitations with these methods due to variations in willingness to share sensitive information, recall, and survey fatigue. A sensor tablet is available for one drug used to treat bipolar I disorder and major depressive disorder. Monitoring of the ingested tablet is through a smartphone app and web portal. To my knowledge, there is no similar sensor technology for opioid medications.
A graduate-level course at Northwestern University (NUvention: Medical) employs an interdisciplinary approach to healthcare innovation. Small groups of students from the schools of law, medicine, business, and engineering come together to create business plans and prototypes of ideas directed at solving problems in healthcare. One group recently pitched a plan for a smart pain-pill dispensing device that would transmit a patient’s self-reported pain level and opioid use in real time to a designated member of the healthcare team. Similar to a sensor pill, this device would conceivably increase a patient’s response rate for opioid administration. Such data would provide for an improved understanding of opioid use after surgery and a means of identifying patients with unusually high levels of pain for early intervention.
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