In 2017, more than 47,000 Americans died after overdosing on opioids, such as heroin or fentanyl, a potent synthetic drug, government data show. Some 1.7 million more had a substance abuse disorder involving a prescription opioid. 

Patients who undergo joint replacement surgeries of all kinds conventionally have received an opioid prescription for their recovery—presenting critical opportunity for reducing the reliance on these medications and preventing abuse of the drugs. 

HSS is taking a multi-pronged approach to the problem, explained Michael P. Ast, MD, an orthopedic surgeon at the institution. HSS recently launched a hospital-wide initiative to reduce opioid use among its patients and to better understand when the powerful drugs are appropriate to prescribe, and in what quantities. The initiative has involved surgeons, anesthesiologists, nurses and other members of the care team.

A primary focus of the pain-management pathway is the emphasis on multimodal analgesia. The practice involves the combination of local anesthetics, nonsteroidal anti-inflammatory drugs, IV acetaminophen and, possibly but not necessarily, opioids. Multimodal analgesia for knee and hip replacement surgeries has been associated with a decrease in the use of opioids, according to the American Society of Anesthesiologists (https://www.asahq.org/about-asa/newsroom/news-releases/2018/03/multimodal-approach-to-pain-management-reduces-opioid-use).

Another aspect of the initiative involves research, and HSS currently has more than a dozen ongoing studies to assess alternatives to opioid analgesia. "We’re doing things like intraoperative and post-op acupuncture therapy and we’re looking at alternative treatments in the form of nerve blocks," said Peter K. Sculco, MD, orthopedic surgeon at HSS and also senior author on the study said. "We’re also looking at understanding prescribing patterns and how that affects how patients use their medication—if they are given a smaller prescription will they use less over time?"

The effort also has a strong patient-centered component. The new pain-management pathway includes educational programs for patients undergoing joint surgeries, including new additions to the preoperative education to manage pain expectations, early intervention by the pain management team for patients on preoperative or chronic opioids, and a multi-disciplinary inpatient team to treat and educate patients on alternatives to opioids for pain management. Although still in its early phase, data so far show that the pathway has led to a significant decrease in the use of opioids with no sacrifice in pain control. 

Dr. Sculco and his colleagues presented their findings at the 2019 annual meeting of the American Academy of Orthopaedic Surgeons in Las Vegas (exhibit SE35).

Other authors include: Ameer Elbuluk, MD; Michael Alexiades, MD; and Michael Cross, MD; all from HSS.

For more information on opioid prescription and pain management at HSS, please view the February 2019 issue of HSS Journal.

With important improvements in both materials and operative techniques in the past decades, there are still opportunities to perfect the procedure. Michael M. Alexiades, MD, hip and knee surgeon at HSS, explains that researchers are working to combat the risk of infection with different strategies including "coating the implant with an antibiotic that’s bonded to the metal". According to Dr. Alexiades, this tactic is still in very early stages.

Read the full article at Popsci.com. 
 

Read the full article at BeckersSpine.com.