“We are implementing and perfecting initiatives that cover the full spectrum of opioid risk,” said Seth Waldman, MD, MBE, anesthesiologist and co-chair of the HSS Controlled Substances Task Force. “Our strategy encompasses the entire structure of the opioid life cycle. We are tackling this issue at every level to positively impact our community.”

HSS is a national leader in orthopedics, ranked No. 1 in the nation by U.S. News & World Report in its “Best Hospitals 2023-2024” survey.¹ HSS performed more than 28,000 surgical cases in 2022. Orthopedic surgery is associated with significant perioperative pain and has been identified as a risk for long-term opioid use and misuse, making it crucial for HSS to tackle this issue.2,3

In late 2017, HSS launched an interdisciplinary Controlled Substances Task Force to prevent and mediate potential problems with opioid medications. HSS has also taken strides to tackle pain management that spans the care continuum.

“Opioid stewardship has had a tremendous impact on prescribing culture at HSS,” said Bobby Stack, MS, assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the task force. “Large-scale initiatives have not only had direct effects on opioid safety at the hospital, including reduced prescribing, distribution of disposal packets, safety warnings, and patient education, but have also inspired departments and individuals to take initiative in pushing for smaller improvements.”

The Controlled Substances Task Force has achieved substantial results in curbing the opioid crisis in six key areas:

Further Reducing Opioid Prescribing
Since 2017, HSS has been implementing initiatives to reduce opioid prescribing across the hospital. These efforts have resulted in continued improvements to the efficacy of post-operative pain control, as seen by continuously improving patient satisfaction scores, as well as a reduction of roughly 1 million pills prescribed per year.

Expanding HSS Patient Education Content
HSS has continued to expand its patient education content with articles and videos covering a range of topics including safe opioid use and disposal, how to taper off opioids, and educating patients about what to expect regarding pain management after surgery. The task force is now branching out to more nuanced topics, including safe pain management for children and adolescents, safety tips for opioids and benzodiazepines, how to use naloxone, and more. Content is made available to patients through their MyHSS patient portal, as well as through QR codes in their discharge paperwork. This content is also on the HSS website and YouTube channel, with top-performing articles reaching nearly 10,000 views per month.

Offering CME Courses for Providers and Personalized Prescriber Training
Over the last six years, HSS has developed and implemented ongoing, personalized training to providers to help them prescribe appropriate amounts of opioid pills for their patients’ situations. Ongoing oversight by a multi-specialty committee tracks whether the training was effective based on provider compliance, and provides follow-up education as needed. HSS also offers numerous CME hours’ worth of educational content for new doctors, ongoing content for existing providers to meet New York State and federal prescribing requirements, as well as regular presentations and webinars focused on new developments and quality assurance in safe opioid prescribing. 

Providing Safe Opioid Disposal Methods to Patients and Staff
HSS was one of the first hospitals in the United States to distribute free prescription disposal products to patients at discharge. Since 2017, HSS has been sending every surgical patient home with DisposeRx®, a small packet of powder mixed with water and any leftover prescription pills to render them unusable. DisposeRx, Inc has also partnered with HSS on initiatives to hand out disposal products on site, as well as to mail every HSS employee a DisposeRx® packet as part of HSS’ annual Opioid Awareness Month initiatives. Our goal is to get as many safe disposal products into the community as we can. HSS also provides a safe drop-off location on campus for unused medications.

Distributing Naloxone and Providing Training for Overdose Emergencies
HSS is a proud participant in the New York State Opioid Overdose Prevention Program (OOPP). We provide free naloxone kits to high-risk surgical patients and make kits available to HSS staff upon request. This year, for Opioid Awareness Month in September, we are training staff in how to administer naloxone and focusing on an initiative to distribute naloxone kits to as many staff as we can. The more naloxone is available in the community, the more lives can potentially be saved.

Expanding Our Research

Starr Foundation Grant

In late 2019, HSS received a $3 million grant from the Starr Foundation to establish the C.V. Starr Endowed Chair in Pain Management. This grant has enhanced existing pain management studies and funded new studies, expediting the translation of research findings into practice, improving safe prescribing practices, and exploring alternatives to opioids.

Seth A. Waldman, MD, Co-Chairman of the HSS Controlled Substances Committee and Advisor of Opioid Prescribing Practices at HSS, is the inaugural holder of the chair. The grant funds a full-time PhD researcher dedicated to these topics, Alexandra Sideris, PhD

Pain Prevention Research Center (PPRC)

Founded in 2023, the Pain Prevention Research Center (PPRC) at HSS is unique in its focus and commitment to studying the prevention of pain and outcomes associated with pain. The PPRC’s goals include identifying innovative approaches to prevent pain; conducting high-quality research on the prevention of pain and its adverse effects; and expediting the development of therapies for those who suffer from pain.

Future Plans

Building on its well-rounded strategy for tackling the opioid epidemic, the HSS Opioid Task Force has future plans to both refine and expand its initiatives.

“We are working on evolving our methods to better identify patients at high risk for issues with controlled substances and pain management,” said Dr. Waldman. “We are developing new tools for preoperative screening to figure out which patients are at high risk for dependence or addiction, as well as which patients may need non-standardized pain management techniques or preventive strategies as part of their care. This information will help us to proactively provide more targeted and effective treatments and optimization throughout the patient’s clinical experience.”

“We are also working on developing media that will go beyond basic education about safe use, tapering, and disposal to delve into topics that we might not otherwise be discussing,” Ms. Stack said.

Moving forward, one of HSS’s major goals is to continue educating others about what we have learned about opioid management and education, so it becomes the standard of care at other hospitals and facilities. HSS also plans to keep learning from experts in the field to continue improving on a bio-psycho-social approach to pain management.

Seth Waldman, MD, MBE, is an anesthesiologist and co-chair of the HSS Controlled Substances Task Force. He is the Advisor for Opioid Prescribing Practices at HSS, the C.V. Starr Endowed Chair in Pain Management, a physician consultant to the U.S. Department of Justice and Drug Enforcement Administration, a consultant for the HSS Clinical Ethics Service, and a Pain Management Physician for the New York Giants.

Roberta (Bobby) Stack, MS, is an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force.

References

1. https://health.usnews.com/media/best-hospitals/BH_Methodology_2023-2024
2. Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS Journal. 2019 Feb; 15(1):57-65. doi: 10.1007/s11420-018-9652-2
3. Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017 Nov;125(5):1704-1713. doi: 10.1213/ANE.0000000000002433

“Usually for hip arthroscopy, the anesthesiologist performs a type of neuraxial block; in this case, a femoral nerve block or fascia iliaca block,” said Lisa Reisinger, MD, a research fellow at HSS and one of the authors of the study. “With these blocks, there is an adverse effect of quadriceps weakness leading to elevated fall risk and prolonged hospital stay.”

“PENG and LFCN are both motor-sparing blocks, but neither provide adequate pain relief for hip arthroscopy on their own,” Dr. Reisinger explained. “The purpose of this study was to evaluate whether these nerve blocks performed at the same time would lead to adequate analgesia with opioid-sparing effects and earlier discharge. While these are two commonly used techniques, it is not yet common to use them together for hip arthroscopy.”

Twenty-six patients who received only the PENG block and 86 patients who received both the PENG and LFCN blocks were matched to a control group of 112 patients who received only a neuraxial block using propensity score matching (1:1) and a caliper of 0.2, to match patients by American Society of Anesthesiologists classification, gender, and age.

The primary examined outcome was average opioid consumption in the PACU. Secondary outcomes included maximum numerical rating scale (NRS) pain score, intravenous (IV) rescue analgesia, and PACU readiness for discharge times.

The combination of a PENG block and LFCN block showed a significant reduction in average opioid consumption (more than 40% less) and earlier PACU discharge times (more than 1.7 hours earlier) compared with neuraxial alone.

There were also significantly lower severe pain scores in the PENG/LFCN group than the neuraxial alone group, which was demonstrated with the PENG/LFCN group using significantly less IV rescue analgesia and having lower maximum NRS pain scores. The PENG block alone did not demonstrate a significant pain relief benefit compared with the control group, although it did decrease the amount of time to discharge.

These results demonstrate that using both the PENG and LFCN nerve blocks may provide the best pain relief, reduce opioid use, and reduce discharge times compared with PENG block alone or neuraxial analgesia alone.

“Patients are looking for alternatives to minimize narcotic use after surgery,” said David Kim, MD, an anesthesiologist at HSS and lead author of the study. “This study offers an opioid-sparing alternative for ambulatory hip arthroscopy.”

“The next stage of research should be focusing on whether PENG/LFCN combination provides any longer-term outcome benefits to our patients, such as functional outcomes, post-discharge opioid consumption, etc.,” said Jiabin Liu, MD, an anesthesiologist and one of the authors of the study.

“Most blocks have a duration of 24 to 48 hours,” Dr. Kim added. “The next focus should be on methods for lengthening the duration beyond that.”

Reference

1. Lisa Reisinger, MD, Genewoo Hong, MD, JD, Edward Lin, MD, Sang Jo Kim, MD, Jonathan Beathe, MD, Douglas Wetmore, MD, Jiabin Liu, MD, David H Kim, MD. “Pericapsular nerve group block combined with a lateral femoral cutaneous nerve block decreases opioid consumption after hip arthroscopy: a retrospective cohort study.” Presented at: 6th World Congress on Regional Anaesthesia & Pain Medicine, September 6-9, 2023, Paris, France.

“There’s been considerable research and effort into reducing opioid consumption after elective surgeries, and specifically after knee replacement. Many people consider knee replacements the most painful elective surgery someone can have,” says Dr. Ast. “We’ve done a lot of great work, and we’ve already cut the amount of opioids that patients take by approximately 75% as compared to 10 years ago. But there’s still room to go, which is why we want to focus on developing novel forms of non-opioid pain medication.”

Ketamine is a well understood drug that has been approved by the US Food and Drug Administration for postoperative pain management, but it is currently only administered intravenously in the inpatient setting. A noteworthy feature of the new formulation evaluated in this study was that it was an oral medication. “Our goal was to find an effective medication that patients could take home with them,” explains Dr. Ast. “This is especially important because the average stay after total knee replacement surgery is only 24 hours, but we know that the worst postsurgical pain arises between days 3 and 10.”

Oral ketamine is already being studied as a safe alternative to opioids but has low bioavailability in its isolated form. Additionally, there are concerns about ketamine being abused, due to the feelings of dissociation that it creates. The ketamine used in this study was specially formulated for oral use and is manufactured in a way that potentially limits its ability be abused by melting or crushing.  “We’ve learned through basic science studies that nonsteroidal anti-inflammatories like aspirin can buffer the effects of other drugs by adjusting the pH. Aspirin and ketamine work together synergistically on the body’s pain receptors,” says Dr. Ast. “This allows you to use relatively low doses of the ketamine, which also aids in preventing the dissociative feelings even at larger doses.”

The trial enrolled 22 men and women between the ages of 47 and 81 who were undergoing elective total knee replacement. The criteria for enrollment were tightly controlled, including being generally in good health and having no history of opioid use. All the study participants received an oral dose of aspirin and ketamine four times a day until discharge (up to 72 hours) and were monitored for the duration of the study, including being assessed for pain using standard pain scales.

“At HSS, nothing matters more than patient safety,” Dr. Ast says. “That’s why it was so important to do this pilot study with a small number of patients who were closely followed for the entirety of their treatment before developing a larger trial.” Overall, 18 of the 22 patients reported no side effects at all from the treatment. Two of them reported feelings of dizziness. Two others withdrew from the study early because they felt they needed more pain relief.

“If this treatment proves to be as effective as we hope it’s going to be, we can imagine a world where — even after something as painful as knee replacement surgery — patients go home with only a few opioid pills to take if needed, rather than a more typical amount of 25 or 30 pills that are often provided today,” Dr. Ast says. “This could dramatically reduce the number of opioid pills that end up out on the streets every year, just from this one procedure.”

For Dr. Ast, the quest to find alternatives to opioids is personal: “Unfortunately, I grew up in an area that has been hit hard by the opioid epidemic and have seen people I knew pass away from opioid overdoses,” he says. “That’s one of the main reasons the focus of my research for the past 10 years has been on finding new forms of pain medication that can minimize opioid use and ultimately be developed and commercialized.”

A manuscript of this study is in preparation for presentation and publication. The next phase clinical trial is expected to begin at HSS in the near future.

“Patients who are not taught about opioids and pain management may have difficulty with pain control and worse functional outcomes after total joint replacement,” explained principal investigator Bradley Lee, MD, an anesthesiologist at HSS.

While research has shown benefits to educating patients about opioids, little is known about what patients understand about pain management prior to surgery.

Dr. Lee and colleagues interviewed patients via a 15-minute phone call to learn about their perceptions of pain management and opioid use. Eligible patients included those between ages 18 and 80 undergoing total hip replacement who are English-speaking with a reading comprehension above the eighth grade level. Survey questions were written by Dr. Lee in collaboration with members of the HSS Controlled Substances Task Force, an interdisciplinary committee focused on evidence-based opioid prescribing. Patients were instructed to answer the questions to the best of their ability, and if unsure to respond “I don’t know.”

Responses to the interviews revealed that while many patients acknowledge experiencing some pain after surgery is normal and that opioids should be used to reduce pain that limits function, many also believed that the goal of opioid use should be to experience minimal or no pain after surgery, reflecting somewhat inconsistent expectations.

Many patients were aware of the potential risk of addiction from opioid use. However, many did not understand the role of multimodal analgesia—that multiple forms of pain relief should be used in combination to better relieve pain, and that use of non-steroidal anti-inflammatory drugs (NSAIDs) can improve pain after surgery and reduce opioid use.

There were also gaps in patient understanding of opioid use and disposal. While many recognized the importance of keeping opioids away from children, only 15% recognized the importance of locking up these medications. The researchers also found that about half of patients were unsure of how to properly dispose of opioids.

These results show potential areas of patient education that could improve patient expectations and satisfaction, pain relief, and safety. “Patients may benefit from clinicians providing a consistent message on pain expectations and the goal of using opioids after surgery to treat pain. Patients may also benefit from education about the role of multimodal analgesia, as well as proper methods of storage and disposal,” Dr. Lee noted.

“Future research should focus on educational interventions that address gaps in patients' understanding of opioids and pain management. Research should seek to identify which interventions are effective and how they affect outcomes,” he concluded.

Reference

1. Bradley H. Lee, MD, Ryan Goydos, MS, Ejiro Gbaje, MPH, Alexandra Sideris, PhD, Christopher L. Wu, MD. “Evaluating Patient Perceptions of Pain Management and Opioid Use Prior to Hip Arthroplasty.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

Previous research indicates that prescription patterns for opioids after surgery in children and adolescents may be associated with long-term use and abuse.²

“Pediatric patients have developing brains that are uniquely vulnerable to addiction, and we need to learn to treat their pain safely without putting them at additional risk for opioid misuse,” said principal investigator Kathryn (Kate) DelPizzo, MD, an anesthesiologist at HSS.

It is therefore critical for clinicians to understand risk factors for opioid dependence in this vulnerable population, and to develop strategies to prevent long-term opioid use.

Dr. DelPizzo and colleagues examined insurance claims from Truven Health Marketscan data from patients under the age of 21 who underwent inpatient or outpatient surgery from 2013 to 2017. The primary outcome examined was persistent opioid use after surgery, defined as one or more additional filled opioid prescriptions between 90 and 180 days post-surgery.

Out of more than 3.7 million patients, about 9% (N=345,523) filled at least one opioid prescription within six months after surgery, and 0.3% (N=11,334) developed ongoing opioid use.

Several risk factors were identified for persistent opioid use: older age, female sex, earlier year of undergoing surgery (e.g., 2013 versus 2014 through 2017), higher burden of comorbidities, previous use of antidepressants, residence outside of the Northeastern United States, having undergone an inpatient or a musculoskeletal procedure (versus general surgery or other specialties), and previous opioid use.

“This data gives an indication that providers may be able to use a patient's baseline characteristics to predict which children and adolescents are most at risk for trouble with opioids during the postsurgical period,” Dr. DelPizzo noted.

HSS is committed to patient safety and being a leader in effective pain management. Its Controlled Substances Task Force continues to make strides in patient education and safe prescribing.

In addition to this study, HSS is ramping up further research on opioids with the help of a $3 million grant from the Starr Foundation. “Future research should explore what practical methods can be put into place to identify these at-risk pediatric patients and how to streamline protocols to help prevent long-term opioid dependence in these patients,” Dr. DelPizzo concluded.

References

1. Kathryn DelPizzo MD, Haoyan Zhong MPA, Lauren A. Wilson MPH, Hannah N. Ladenhauf MD, Jiabin Liu MD PhD, Jashvant Poeran MD PhD, Stavros G. Memtsoudis MD PhD MBA FCCP. “Factors Associated With Long-term Opioid Use in Pediatric Surgical Patients.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

2. Harbaugh CM, Lee JS, Hu HM, et al. Persistent opioid use among pediatric patients after surgery. Pediatrics 2018; 141:e185838.

HSS Researchers Find Duloxetine May Reduce Opioid Use and Improve Pain Management After Total Knee Replacement

• Anesthesiologist Jacques Ya Deau, MD, PhD and colleagues investigated using duloxetine after surgery to reduce pain and opioid use. They found that duloxetine, given on the day of surgery and once daily for 14 days afterwards, reduced opioid use by about 30%. Patients receiving duloxetine were also more satisfied with their pain management.

Study Identifies Risk Factors for Pediatric Opioid Dependence After Surgery

• Anesthesiologist Kathryn (Kate) DelPizzo, MD and colleagues identified risk factors for persistent opioid use after surgery in pediatric patients. Understanding risk factors for opioid dependence could help develop strategies to prevent long-term opioid use in this vulnerable population.

Knowledge Gaps on Opioid Use and Pain Relief After Surgery Offer Opportunities for Improving Patient Education

• Anesthesiologist Bradley Lee, MD and colleagues identified gaps in patient knowledge about pain management and opioid use before total hip replacement, including misconceptions about how much pain relief to expect from opioids after surgery, how to use multiple modes of pain relief, and proper opioid storage and disposal. Improving patient education about opioids and pain management could lead to improvements in pain control and functional outcomes after surgery.

Interim Study Results Suggest Oral Tranexamic Acid (TXA) Is Equally Effective as Intravenous TXA in Preventing Blood Loss in Joint Replacement Surgery

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues examined the efficacy and safety of oral TXA for joint replacement surgery. Using oral TXA versus intravenous TXA could translate to improvements in efficiency, cost and safety.

HSS Study Examines Hip Fracture Patient Characteristics and Outcomes Pre- and Post-COVID-19 Outbreak

• Anesthesiologist Stavros Memstoudis, MD, PhD, MBA and colleagues sought to compare characteristics and outcomes of hip fracture patients admitted during the COVID-19 outbreak to patients admitted before the outbreak. They also examined characteristics and outcomes of hip fracture patients with and without the virus.

Studies have demonstrated that many patients report joint pain two weeks after TKA.² Given the status of the ongoing opioid epidemic, it is critical to study safe and effective alternative pain treatments.

“Previous research has shown us how to keep most patients relatively comfortable for the first one to two days after TKA. However, patients often have significant and troubling pain during the first two weeks, once the nerve blocks wear off. They often take large amounts of opioids,” said principal investigator Jacques Ya Deau, MD, PhD, an anesthesiologist at HSS. “It is important to reduce postoperative opioid use without increasing pain or worsening the patient experience.”

Finding alternative strategies for pain relief after TKA is imperative, as improved postoperative pain management is linked to improved patient satisfaction, faster rehabilitation, and reduced complications.

Dr. Ya Deau and colleagues enrolled 160 patients undergoing TKA into the study and randomized them into a duloxetine or placebo group. Patients took 60 mg of oral duloxetine or placebo once daily for 14 days after surgery and answered questions on postoperative days one, two, seven, 14, six weeks, and 90 days. Postoperative pain management also included acetaminophen, ketorolac, meloxicam, and oxycodone as needed.

The researchers collected data on numerical rating scale (NRS) scores for pain management, opioid consumption, patient satisfaction, and questions based on the Brief Pain Inventory.

Duloxetine was found to be better than placebo for reducing opioid use and was of equal efficacy to placebo for reducing pain. Duloxetine was also better than placebo for patient satisfaction and for the effect of pain on mood, walking, working, and sleeping.

“Duloxetine, given on the day of surgery and once daily for 14 days afterwards, reduces opioid use by about 30%. Patients receiving duloxetine are more satisfied with their pain management, and pain interferes less with their activities and mood,” Dr. Ya Deau said.

HSS is committed to patient safety and being a leader in effective pain management. Its Controlled Substances Task Force continues to make strides in patient education and safe prescribing.

In addition to this study, HSS is ramping up further research on opioids with the help of a $3 million grant from the Starr Foundation. “Future research could examine optimum duration of therapy and determine whether duloxetine is also useful for other orthopedic procedures. We also need to try to understand barriers to adoption of duloxetine as a postoperative analgesic,” Dr. Ya Deau concluded.

References

1. Danya A. DeMeo BS, Ejiro Gbaje MPH, Jacques T. YaDeau MD PhD, Kethy M. Jules-Elysee MD, Yi Lin MD PhD, Enrique A. Goytizolo MD, David Kim MD, Richard L Kahn MD, Stephen C. Haskins MD, David J. Mayman MD, Douglas E. Padgett MD, Thomas P. Sculco MD, Chad M. Brummett MD, Geoffrey Westrich MD. “Effect of Duloxetine on Opioid Use After Total Knee Arthroplasty. A Double-Blinded Randomized Control Trial.” Presented at: 46th Annual Regional Anesthesiology and Acute Pain Medicine Meeting of the American Society of Regional Anesthesia and Pain Medicine (ASRA), May 13-15, 2021; Orlando, FL.

2. Lewis GN, Rice DA, McNair PJ, Kluger M. Predictors of persistent pain after total knee arthroplasty: a systematic review and meta-analysis. Br J Anaesthe 2015; 114: 551-61.

As the No. 1 hospital for orthopedics in the United States for 10 straight years, HSS has a responsibility and opportunity to set the highest standard for opioid management, as orthopedic surgeries are linked to substantial postoperative pain and higher numbers of opioids prescribed.

“As a leader in pain management, HSS is sharing knowledge and assisting other organizations in the implementation of safe, responsible and effective practices for managing postsurgical and chronic pain, and this grant will allow us to continue that work,” said Louis A. Shapiro, CEO and president of HSS. “We are very grateful for The Starr Foundation’s generosity and dedication to keeping all patients safe.”

HSS established a Controlled Substances Task Force in 2016 to build a better model for safe opioid prescribing while also effectively managing pain in a personalized and multifaceted way. Since its inception, the task force has taken a comprehensive look at current practices across the hospital and implemented new systems, guidelines and educational initiatives to improve patient safety and advance how perioperative and chronic pain are treated.

“HSS is a living laboratory for musculoskeletal pain management, in which we workshop new ideas, build scientific cases for support and work with medical and industry partners to bring our findings to life,” said Seth A. Waldman, MD, director of the Pain Management Division in the Department of Anesthesiology, Critical Care & Pain Management at HSS, who will be the inaugural holder of the chair. “We have developed science-based protocols, contributing to a safer prescribing environment and a more comprehensive care model across the hospital.”

This grant will both enhance existing pain management studies and allow for new studies to be initiated, accelerating the research timeline to translate findings into practice. It will also fund a full-time PhD researcher who will be responsible for coordinating those studies across HSS, to improve safe prescribing practices and explore alternatives to opioids.

“We are strategically focused on developing new multimodal programs and a clearer understanding of the bioethical issues related to pain treatment,” added Dr. Waldman, who explained that research can lead to the most rapid and meaningful advancements in patient care. “This grant will help us achieve our goals.”

HSS is also collaborating with other leading medical organizations to advance opioid initiatives across the healthcare community. One part of this effort was an international multidisciplinary forum titled “Toward Opioid-Free Arthroplasty: A Leadership Forum,” featuring representatives from orthopedics, anesthesiology, psychiatry, bioethics, health information technology and law. Coming out of that forum, held in 2018, was a consensus statement to shift toward opioid-free arthroplasty for hip and knee replacements.

While the Starr Endowed Chair will live within the Pain Management Division, the work will influence research studies across HSS.

HSS is a national leader in the field of orthopedics, performing approximately 32,000 surgical cases in 2018. Orthopedic surgery is associated with significant perioperative pain, and has been identified as a risk for long-term opioid use and misuse.^2,3

To prevent and mediate potential problems with opioid medications, HSS has implemented a pain management program that spans the care continuum, and in late 2017, launched the interdisciplinary Controlled Substances Task Force.

“The Controlled Substances Task Force was created in order to centralize the hospital’s opioid policy, so we’re all prescribing opioids appropriately, in an evidence-based fashion, and in a consistent way,” said Seth Waldman, MD, anesthesiologist and director of Pain Management at HSS. “Before the Task Force was created, the existing processes were somewhat haphazard. Now, we’ve standardized what prescriptions are given according to procedure; doctors can still use their clinical judgment, but they can refer to the base prescriptions. We’ve also made documentation of prescriptions consistent (i.e., what was prescribed and why?) as well as standardizing checking toxicology screens, narcotic takeback, etc. We’ve made it consistent for everyone prescribing at every circumstance.”

“The task force also aimed to make the opioid prescribing process and analysis as seamless as possible. Electronic health records have helped with that; we are able to monitor our progress, see the flow of prescriptions and whether medications are being used appropriately or not, and see the amount of opioids doctors prescribe to identify doctors who need help with prescribing and documenting,” Dr. Waldman said.

“One of the main goals of the Task Force was to change the culture of prescribing in the hospital,” said Bobby Stack, MS, an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force. “We were able to accomplish that by educating clinicians and highlighting the risks of overprescribing opioid medications.”

HSS Controlled Substances Task Force Accomplishments To Date

• Opioids issued were reduced by 500,000 over approximately 18 months, and there have been continued reductions in the number of pills prescribed at discharge due to implemented prescribing guidelines
• Preliminary internal results suggest that preoperative complex patient screening may reduce length of stay by up to 26%
• Every week, up to 30 high-risk preoperative patients are identified and put on a plan to prevent opioid use complications after surgery
• Physicians who prescribed a higher than average amount of opioid medications received one-on-one education, reducing their average number of opioid prescriptions written per month by approximately 27% compared to their pre-intervention average
• At an HSS leadership forum in June 2018, a multidisciplinary panel of experts produced a consensus statement about appropriate pain management for total hip replacement and total knee replacement: “Consensus Statement: Toward Opioid-Free Arthroplasty,” published in a special edition of HSS Journal
• Patient/provider opioid agreements were designed and successfully implemented in all service areas across the hospital, with nearly 100% patient compliance with signing

“The reason the task force has been so effective is that we have a variety of different partnerships; the clinician and administrative partnership has been vitally important,” said Dr. Waldman. “I can’t accomplish my part without Bobby on the administrative side. This effort has also required the support of CEO Lou Shapiro and hospital administration, not just financially but also culturally. And it’s been the support of the Surgeon in Chief and the Physician in Chief that has allowed us to implement preoperative screening services.”

“Since implementing these changes, the doctors have seen not only a huge difference in the care of patients, but it’s also simplified their care of patients in pain by providing better guidelines about how, when, and why to prescribe opioid medications; it’s been a support to them both medically and legally,” he added.

The Task Force’s results were achieved through actions taken in three key areas:

1. Educating Patients and Clinicians

• Mandatory prescriber education modules were created and provided online and in-person
• A short-term surgical patient/provider opioid agreement was implemented to help surgeons set patient expectations for opioid therapy perioperatively
• Opioid-focused editions of the HSS digital newsletter and educational online articles were published (Opioids: Understanding Addiction Versus Dependence; A Patient’s Guide to Opioid Tapering; Multimodal Analgesia: Move Better, Quicker After Surgery with Fewer Side Effects)
• Fact sheets were developed for patients and prescribers
• Patient-facing videos were created to provide education about appropriate use, storage and disposal of opioids
• Webinars were provided on opioid prescribing, opioid stewardship, and multimodal analgesia to share best practices with clinicians
• Opioid-related courses were created and posted on HSS E-Academy

2. Inspiring a Culture of Conservative Prescribing

• Guidelines were developed to standardize prescribing and documentation for patients receiving opioids at discharge
• Prescribing patterns for all clinicians is under ongoing analysis, which can help surgeons set patient expectations for opioid therapy perioperatively
• One-on-one counseling and training was scheduled for clinicians who deviated from the average opioid prescribing patterns according to specialty and diagnosis
• An opioid disposal mechanism was provided via a DEA approved disposal receptacle located on the HSS main campus

3. Identifying and Managing At-Risk Patients

• Complex patients who are referred to the screening program receive a comprehensive evaluation with a pain management physician, and most also receive a toxicology screen
• For patients identified as high risk, the HSS Preoperative Controlled Substances Clinical Team:
  • Engages the patient’s outside prescriber
  • Implements taper schedules
  • Makes referrals to psychiatric/psychological resources or to detox, substance use disorder facilities, 12-step groups, or private psychiatric addiction clearance facilities when appropriate
  • Delays elective surgery if necessary until the patient is treated and can safely proceed
  • Carefully monitors inpatients and implements strategies to minimize opioid use and wean medications after recovery

“The philosophy behind the Task Force is not to avoid opioid use, but to use these medications in a medically and ethically responsible way,” said Dr. Waldman. “The term that’s being used to describe this is ‘opioid stewardship.’ These medications can do a lot of good, but also terrible harm; our goal is to use them in a way that they’re not causing any more harm than they have to.”

The Controlled Substances Task Force is expanding this work with further initiatives for 2019.

“Some of the work the Task Force is looking to do moving forward includes: providing mechanisms to help patients dispose of prescriptions after surgery, becoming a registered NY state opioid overdose prevention center, continuing to educate patient and surgeon populations, providing more holistic support and alternative therapies to opioids, and sending all patients home with an opioid tapering schedule,” Ms. Stack said.

Dr. Waldman added, “This includes making more progress in use of multimodal analgesia with anesthesiologists, nurses, and physician’s assistants, and in increasing complementary treatments such as aromatherapy, virtual reality, and massage therapy.”

“I think the most important next step is to take what we’ve learned in preoperative evaluation and managing opioid prescriptions and educate others so this becomes the standard of care elsewhere. Everyone taking opioids should be evaluated before surgery and tapered after surgery, and we believe it’s important that these principles of service line guidelines are applied outside of HSS,” Dr. Waldman concluded.

Dr. Seth Waldman is an anesthesiologist and director of Pain Management at HSS. He is a physician consultant to the U.S. Department of Justice and Drug Enforcement Administration, and a master’s candidate in bioethics at Columbia University.

Roberta (Bobby) Stack, MS, is an assistant VP of Anesthesiology, Critical Care & Pain Management at HSS and co-chair of the HSS Controlled Substances Task Force.

References

1. Waldman SA, Stack RJ, Goldstein L. Clinician-healthcare administrator partnerships: effective treatment for opioid epidemic. Healthcare Business Tech. http://www.healthcarebusinesstech.com/clinician-healthcare-administrator-partnerships-effective-treatment-for-opioid-epidemic/. Accessed April 19, 2019.

2. Soffin EM, Wu CL. Regional and Multimodal Analgesia to Reduce Opioid Use After Total Joint Arthroplasty: A Narrative Review. HSS Journal. 2019 Feb; 15(1):57-65. doi: 10.1007/s11420-018-9652-2

3. Soffin EM, Waldman SA, Stack RJ, Liguori GA. An evidence-based approach to the prescription opioid epidemic in orthopedic surgery. Anesth Analg. 2017 Nov;125(5):1704-1713. doi: 10.1213/ANE.0000000000002433

Todd J. Albert, MD, HSS surgeon-in-chief, noted, "Given the opioid crisisand pendulum swinging from pain being the 5th vital sign to physicians massively overprescribing, we at HSS wanted to be leaders in opioid education and appropriate use/prescribing methodology. We started with education—our program had 100% compliance across the institution. Then we studied the before and after prescribing behavior with education, and then with guidelines."

The study, which HSS conducted with another major hospital in Chicago, included data for 2,479 patients who had undergone lumbar spine surgery.

Read the full article at Orthopedics This Week.

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.

Physicians and medical institutions are actively seeking solutions to lower the risks of opiate addiction. One focus is reducing the amounts of opioids that are initially prescribed for patients in acute pain. Excess opioid medication has the potential to lead to addiction in patients or misuse by family members or others with access to leftover opioid pills.

At Hospital for Special Surgery (HSS) in New York City (ranked Number 1 in orthopedics 2018–19 by U.S. News & World Report), a task force developed a 1-hour educational program on opiate use and misuse, the role of the orthopedic prescriber, multimodal analgesia, and state laws regarding opioid prescription. All opioid prescribers at the institution were mandated to attend the program in person or via an online presentation. A committee composed of spine surgeons, pain management physicians, anesthesiologists, and nurse managers established guidelines for prescribing opioids following spine surgery. These qualitative guidelines, based on individual patients’ consumption of opioids while in the hospital, were disseminated throughout the hospital early in 2017.

In the article "An institutional intervention to modify opioid prescribing practices after lumbar spine surgery," published today in the Journal of Neurosurgery: Spine, Francis Lovecchio, MD, and colleagues address the question of whether this intervention—mandatory provider education together with prescription guidelines—could change prescriber behavior, resulting in a lower amount of opioids prescribed at hospital discharge after lumbar surgery.

Lovecchio and colleagues compared opioid prescription data in the electronic medical records of 1177 patients treated by lumbar surgery before the intervention (March 1–November 1, 2016) with similar data in the electronic medical records of 1302 patients treated after the intervention (February 1–October 1, 2017). Because a variety of opioid medications with different strengths had been prescribed, the researchers converted the amount of opioid per prescription into an oral morphine equivalent (OME) to make comparisons possible.

The researchers found a statistically significant reduction in both the mean amount of opioid (629 ± 294 OME pre-intervention vs. 490 ± 245 OME post-intervention, p < 0.001) and the mean number of opioid pills (81 ± 26 pre-intervention vs. 66 ± 22 post-intervention, p < 0.001) prescribed after the intervention. In fact, prescriptions for 81 or more pills decreased from 65.5% to 25.5%. The researchers also found that the rate of refill prescriptions requested by patients within 6 weeks after surgery increased after the intervention; however, the difference was not significant. The researchers take this to suggest that overall pain control was not significantly altered by the reduction in prescribed opioids.

The researchers estimate that in the 8 months following dissemination of the guidelines, "the change in prescribing practices may have saved the dispensing of over 26,000 narcotic pills."

Lovecchio and colleagues show how the intervention at HSS changed prescriber behavior, resulting in a lower amount of prescribed opioids. They suggest that future studies should be undertaken to focus on how these changes in prescriber behavior may affect patient outcomes.

When asked about the importance of the study, Dr. Lovecchio said, "While we have been able to show that qualitative prescribing guidelines work to change prescriber behavior, the most practical solution to overprescribing is to define the 'minimum necessary quantity' of opioid to prescribe for the average patient after a given spine procedure. This will prove challenging, as postoperative opioid consumption likely depends on a complex interplay of biological, psychosocial, and surgery-related factors, and patient expectations. Our group and many others are working toward this end, and I look forward to finding solutions."

Lovecchio F, Stepan JG, Premkumar A, Steinhause ME, Sava M, Derman P, Kim HJ, Albert T: An institutional intervention to modify opioid prescribing practices after lumbar surgery. J Neurosurg Spine, published ahead of print February 5, 2019. DOI: 10.3171/2018.8.SPINE18386.

About The Journal of Neurosurgery: Spine

The Journal of Neurosurgery: Spine is a monthly peer-reviewed journal focused on neurosurgical approaches to treatment of diseases and disorders of the spine. It contains a variety of articles, including descriptions of preclinical and clinical research as well as case reports and technical notes. The Journal of Neurosurgery: Spine is one of four monthly journals published by the JNS Publishing Group, the scholarly journal division of the American Association of Neurological Surgeons. Other peer-reviewed journals published by the JNS Publishing Group each month include the Journal of Neurosurgery, Neurosurgical Focus, and the Journal of Neurosurgery: Pediatrics. All four journals can be accessed at www.thejns.org.

About the American Association of Neurological Surgeons

Founded in 1931 as the Harvey Cushing Society, the American Association of Neurological Surgeons (AANS) is a scientific and educational association with more than 10,000 members worldwide. The AANS is dedicated to advancing the specialty of neurological surgery in order to provide the highest quality of neurosurgical care to the public. All active members of the AANS are certified by the American Board of Neurological Surgery, the Royal College of Physicians and Surgeons (Neurosurgery) of Canada or the Mexican Council of Neurological Surgery, AC. Neurological surgery is the medical specialty concerned with the prevention, diagnosis, treatment and rehabilitation of disorders that affect the entire nervous system including the brain, spinal column, spinal cord, and peripheral nerves. For more information, visit www.AANS.org.

Surgery, particularly orthopedic surgery, is a potential risk factor for long-term opioid use and misuse. Because of rising demand for total hip arthroplasty (THA) and total knee arthroplasty (TKA), it is essential that researchers and clinicians develop strategies to minimize opioid use and protect patients from opioid dependence. 

In response, Hospital for Special Surgery (HSS) convened a multidisciplinary symposium in June 2018 to advance clinical care and research towards opioid-free total joint arthroplasty. Ellen M. Soffin, MD, and Christopher L. Wu, MD, anesthesiologists at HSS, presented the evidence to support the role of regional anesthesia and analgesia in achieving this goal. 

“The benefits of regional and multimodal analgesia for total joint arthroplasty have been supported in the literature for years. However, there were few reports focusing specifically on how much these techniques minimize opioid consumption while providing adequate pain control after hip or knee arthroplasty,” said Dr. Soffin.     

Drs. Wu and Soffin conducted a literature review to assess the state of the evidence and identify research gaps and opportunities to use regional and multimodal analgesia to protect patients from opioid-related harm after THA or TKA.

They discuss their findings on multimodal analgesia including IV agents, NSAIDs and acetaminophen; gabapentinoids; other non-opioid analgesic agents including ketamine; and regional techniques (epidural and peripheral nerve blocks and surgeon-administered local infiltration analgesia). 

Their findings support the use of multimodal analgesia as the foundation of post-TJA pain management.  Unless contraindicated, all patients should receive an NSAID and acetaminophen on a scheduled basis. 

Gabapentinoids may decrease opioid consumption, but evidence from this review suggests that the efficacy for pain relief after TJA is uncertain. 

“Some components, such as gabapentin, that were beneficial in other surgical modalities (such as colorectal surgery) did not seem as consistently effective in THA/TKA,” Dr. Wu noted.

Several studies included in the review question the overall analgesic benefits and safety of gabapentinoids. Drs. Soffin and Wu caution that gabapentinoids can be associated with several adverse effects and should be used with caution in older patients and those with renal dysfunction. However, the authors highlight encouraging data, including a recent double-blind, placebo-controlled RCT which concluded that gabapentinoids were opioid sparing after THA and TKA. 

Other non-opioid analgesic agents may be effective in postoperative pain management, although there is less data examining their effectiveness, dose, and timing. IV ketamine may be particularly promising; other options, although with less data available, include IV magnesium, PO dextromethorphan and IV lidocaine. 

Evidence also supports use of regional analgesia to minimize opioid consumption after TJA. Recent evidence suggests that a combination of peripheral nerve blocks (PNBs) facilitates the best balance after TKA, but data is lacking for THA. Novel PNBs such as the IPACK block are an emerging alternative, but also require more research on efficacy. The choice of regional anesthesia must also take into account the resources and local expertise of the facility, as not all institutions have developed regional anesthesiology services. In these cases, surgeon-administered local and intraarticular infiltration analgesia (LIA) and periarticular infiltration (PAI) may be particularly valuable.

In conclusion, effective strategies to minimize opioid use in patients undergoing TJA focus on non-opioid multimodal analgesia, including systemic and local anesthetic-based techniques. 
“Our review provides a framework for clinicians to implement standardized perioperative anesthetic-analgesic pathways with the specific goal of opioid reduction with adequate analgesia,” said Dr. Wu. 

Based on the evidence from their review, Drs. Wu and Soffin noted that acetaminophen, NSAIDs, and peripheral nerve blocks are especially valuable and are recommended for TJA. In addition, N-methyl-D-aspartate (NMDA)-receptor antagonists may help reduce opioid use in patients at risk of developing chronic pain.

More research is needed to determine how gabapentinoids, PNCs, extended-duration local anesthetics and novel PNBs may be of use in reducing risk for long-term opioid use after TJA.

Reference
Soffin EM, Wu CL. “Regional and multimodal analgesia to reduce opioid use after total joint arthroplasty: a narrative review. HSSJ. 2018. doi: 10.1007/s11420-018-9652-2
 

"Opioid misuse and addiction are a major public health issue in the United States, and approximately 70 percent of individuals who use opioids on a long-term basis have a musculoskeletal disorder, such as low back pain or arthritis," said Wimmer in a release.

According to the article, patients who participated in a meditation program said they learned how mindfulness techniques could reduce pain and stress.

Read the full article at dailymail.co.uk.

According to the study, multimodal analgesia could significantly decrease postoperative opioid consumption and severe complications.

"This study shows that adding additional modes could increase safety in this patient population," said Dr. Cozowicz.

This article appeared in the October 2018 print issue.

"What came out of it was a realization that we needed to change, and we've dramatically improved our opioid prescribing practices at the hospital. The basis for that has been multimodal analgesia, changes to our approach to physical therapy so that the physical therapy doesn't contribute to postoperative pain, and addressing patient expectations and reassuring patients that we can manage their pain without opioid medications, making recovery from surgery much safer, with fewer complications," said Dr. Cornell.

"The goal is to take good care of people, allowing them to have a safe surgery and the quickest possible rehabilitation so they can get back to where they started, which is without pain and with good function," Dr. Waldman noted.

Read the full article at Medscape.com [subscription required].

The study, "Opioid Prescriber Education and Guidelines Decreases Opioids Prescribed after Ambulatory Hand Story," was presented at the 2018 American Academy of Orthopaedic Surgeons Annual Meeting.

According to the article, study participants attended a one-hour opioid education program. Afterward, the number of opioid pills prescribed after hand surgery decreased by 45 percent.

"Our results suggest that similar nationwide standardized prescriber education and opioid prescribing guidelines will likely reduce the amount of opioids prescribed after ambulatory hand surgery," said Dr. Fufa.

"We have extended our hand study to between nine to 11 months following the guidelines and have seen a continued trend down in the pills prescribed," Dr. Fufa added.

Read the full article at painmedicinenews.com [subscription required]. This also appeared in the July 2018 print issue.

The local anesthetic is designed to provide pain control for up to three days.

Dr. Memtsoudis said "local anesthesia is one mode that has been proposed as being part of a multimodal approach to reducing opioid consumption. But we found that adding liposomal bupivacaine to the mix did not add significant benefit."

According to the article, the study reviewed data from 88,830 total knee replacements between 2013 and 2016.

"It does not seem to be the silver bullet physicians have been hoping for," Dr. Memtsoudis noted.

Read the full article at healthleadersmedia.com.

In pill form, acetaminophen is a common over-the-counter medication used to treat minor aches and pains. Its intravenous use, however,  was only relatively recently approved by the FDA in 2010, explained principal investigator Stavros G. Memtsoudis, MD, PhD, anesthesiologist and senior scientist at Hospital for Special Surgery (HSS).

Since its approval, intravenous acetaminophen use has been widely adopted as part of a multimodal analgesic approach meant to lower overall opioid consumption and decrease adverse outcomes associated with those medications.  It is also an expensive drug, adds Dr. Memtsoudis, who previously published research into its pricing in a 2015 issue of Regional Anesthesiologists and Pain Medicine. Additionally, there is not much data to back up the efficacy of intravenous acetaminophen in treating acute pain caused by orthopedic procedures in comparison to other more established and less costly alternatives.

These factors –  the limited data demonstrating its analgesic effectiveness, its high cost and its rapidly expanding use – spurred the researchers to investigate the impact intravenous acetaminophen has on postoperative pain control specifically in spine surgeries that have traditionally required high opioid use to treat postoperative pain.

Using data from 117,269 lumbar/lumbosacral spinal fusion patients enrolled in the Premier Healthcare Database from 2011 through 2014, the investigators evaluated an association between intravenous acetaminophen use with opioid use and opioid-related complications in surgeries that usually require a high dose of opioid medication.

The research team found that in 19 percent (n=22,208) of cases, at least one dose of intravenous acetaminophen was used.  Although the scientists did find a link between intravenous acetaminophen use on postoperative day 0 and 1 and opioid use, length of stay, and cost of hospitalization, the association did not coincide with a consistent pattern of significantly reducing the odds for complications, explains Crispiana Cozowicz, co-author and perioperative research fellow within the Department of Anesthesiology, Critical Care and Pain Medicine at HSS. When compared with the outcomes seen in administering other nonopioid analgesics - pregabalin/gabapentin, specifically – the impact of intravenous acetaminophen was minimal at best.

"We could not show that perioperative intravenous acetaminophen reduces inpatient opioid prescriptions and subsequently reduced odds for adverse outcomes," says Dr. Memtsoudis. "It remains to be determined if and under what circumstances intravenous acetaminophen has a meaningful clinical role in everyday practice."

In addition to reduced risk, findings indicated that patients who received more than two types of pain management had fewer respiratory complications and shorter hospital stays.

"Patients need to be aware that there are ways to treat their pain during and after surgery in addition to opioids," said Dr. Memtsoudis.

"If the doctor prescribes more than one type of medicine for your pain, it may reduce your need for opioids," he added.

This article originally appeared at health.com.

In part one, Vinnidhy H. Dave, DO, director of Medical Pain Management at HSS, discussed what older adults should know before filling an opioid prescription.

"There's the potential for addiction, but you also have to be concerned about an increased risk of osteoporosis and fractures, especially in older patients," said Dr. Dave.

According to the article, Dr. Dave occasionally prescribes opioids for patients coming out of surgery, but he encourages them to evaluate their discomfort before taking it.

"If your pain is a 6 or 7 out of 10 and you feel like you can handle it, then maybe you don't need the medication," he noted.

In part two, Dr. Dave described the warning signs of physical dependence or addiction to opioids.

Dr. Dave said physical dependence occurs when your body becomes used to receiving opioids. "You'll have withdrawal symptoms if you try to stop abruptly," he added.

In terms of addiction, Dr. Dave explained that "you become more focused on when you're taking your medication next and when your next refill is. Life becomes centered around the medication."

Read part one at silversneakers.com

Read part two at silversneakers.com

Findings indicated that multimodal analgesia (MMA) contributed to a decrease in opioid prescriptions and the average length of hospital stay for patients.

Additionally, Dr. Memtsoudis noted that the study was not designed to deduct why hospital stays might be shorter, but he believes one reason could be a reduction in complications.

"The use of MMA may also represent a practice which is closely linked with programs whose goal is to accelerate recovery, i.e. enhanced recovery after surgery (ERAS) programs. These practices are known to incorporate new knowledge faster and more systematically and thus MMA may be one of the drivers of reduced [length of stay]," he said.

Dr. Memtsoudis added, "now that we have linked MMA to better clinical and economic outcomes, the need for wider adoption of MMA becomes an ethical one. Knowing that this approach may be best for our patients, why don't we use it in everyone (barring contraindications such as allergies and others)?"

Read the full article at mdmag.com

The study, "Opioid Prescriber Education and Guidelines Decrease Opioids Prescribed after Ambulatory Hand Surgery," was presented today at the American Academy of Orthopaedic Surgeons Annual Meeting in New Orleans.

"Prescription opioid misuse is an epidemic in the United States with almost 2 million Americans having abused prescription opioid medication. It’s now the leading cause of death in adults under 50," said Daniel Osei, MD, a hand surgeon at HSS and senior investigator. "Recent studies demonstrate a consistent over-prescription of opioid medications nationwide. As physicians, we always strive to provide adequate pain control for our patients. But we are also increasingly aware that when there are excess amounts of unused medication, it can be diverted to uses other than treating pain."

Currently, there is no national standardized prescriber education course or postoperative opioid guidelines for ambulatory hand surgery. However, prescriber education previously has been shown to decrease over-prescription on a small scale.

The HSS researchers set out to evaluate the effect of the education session and the hospital’s new opioid guidelines on physician prescribing practices after ambulatory hand surgery.

HSS mandated a one- to two-hour education program in November 2016 for all employees qualified to prescribe controlled substances. The hospital also formulated prescribing guidelines after an extensive review of the medical literature on the amount of pain medication commonly needed after hand surgery. The new guidelines, which recommended a specific number of pills based on the type of hand surgery performed, were disseminated to staff in February 2017.

To see if there was a change in prescribing practices, investigators reviewed postoperative opioid prescriptions for patients who underwent ambulatory hand surgery in the two months prior to the mandatory education session; in the two months following physician education; and during the two-month period that followed the dissemination of prescribing guidelines.

A total of 731 ambulatory hand surgeries with postoperative opioid prescriptions for patients were included in the study. All three time periods had a similar ratio of surgery types. Researchers found a 45 percent reduction in opioids prescribed after the education session and distribution of guidelines.

"It would be difficult to overstate the importance of this study. A 45 percent reduction is a huge amount and demonstrates the success of the program in reducing the amount of prescribed narcotics," said Dr. Osei. "Our results suggest that similar standardized education and prescribing guidelines on a national level could reduce the amount of opioids prescribed after ambulatory hand surgery nationwide."

The next step for Dr. Osei and his colleagues at HSS will be an analysis of how well the prescribing practices worked in terms of pain control and patient satisfaction for those in the study. He noted that among his own patients, he did not notice an increase in requests for more pain medication.

According to the article, total hip replacement patients who received more than two methods of pain relief along with opioids had up to an 18.5 percent decrease in opioid prescriptions.

"While opioids have an important role to play perioperatively, their utilization and our reliance on this drug class should be minimized to improve outcomes. This is especially important as we are trying to understand if perioperative opioid exposure may contribute to the ongoing opioid epidemic," said Dr. Memtsoudis.

Read the full article at medpagetoday.com

A pain management institution is conducting a clinical trial to evaluate a new spinal cord stimulator. According to the segment, this procedure provides relief by sending electrical waves throughout the spinal cord and blocking pain signals to the brain.

Billups interviewed HSS chief of Spine Service Frank Schwab, MD, who offered his perspective on spinal cord stimulation.

"Many patients come and are considering dorsal column stimulation in lieu of surgery, or in lieu of other treatments. But if there is a clearly diagnosed problem that can be treated or fixed definitively with another procedure, then I think that's probably a better approach."

This segment originally appeared at ny1.com. This aired during the January 3, 2018 broadcast.