Reducing Postoperative Opioid Overuse
Standard postoperative pain management involves extensive use of opioid analgesics, the overprescribing of which is an epidemic in the US.1 The American Academy of Orthopaedic Surgeons has called for reduced opioid prescribing as part of an overall culture change.2 And both the AAOS and the American Pain Society support the use of multimodal regimens in dealing with postoperative pain.2-3 Yet, despite the known shortcomings of opioids and the growing problem of overprescribing, they remain a key component of traditional postoperative pain management.1,4-7
POSTOPERATIVE OPIOID OVERUSE CAN LEAD TO UNINTENDED YET SERIOUS HARM2,8-27
REDUCING POSTOPERATIVE OPIOID USE IS AN URGENT NEED4,6,8,10
A key challenge for surgeons is that postoperative pain management plans have traditionally been opioid based. Even single-shot nerve blocks are a challenge in this regard, because their limited duration leads to rebound pain and substantial opioid supplementation.7,11-12,16,28 This can lead to complications that delay recoveries and affect outcomes.2,11,13-15
FORTUNATELY, WITH THE RIGHT TECHNIQUE, YOU CAN REDUCE OPIOIDS AND STILL GET THE OUTCOMES YOU WANT20-22,24-27
- Centers for Disease Control and Prevention. Increases in Drug and Opioid Overdose Deaths —United States, 2000‐2014. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w.
- American Academy of Orthopedic Surgeons. Opioid use, misuse, and abuse in orthopaedic practice. Information Statement 1045. http://www.aaos.org/about/statements/advisements/. Published October 2015. Accessed February 2016.
- Chou R, Gordon D, de Leon-Casasola O, et al. Guidelines on the Management of Postoperative Pain. The Journal of Pain. 2016;17(2):131-157.
- Drug Enforcement Administration. DEA to Publish Final Rule Rescheduling Hydrocodone Combination.Products. http://www.dea.gov/divisions/hq/2014/hq082114.shtml. Accessed January 25, 2016.
- Parvizi J, Bloomfield MR. Multimodal pain management in orthopedics: implications for joint arthroplasty surgery. Orthopedics. 2013;36(2 Suppl):7‐14.
- Drug Enforcement Administration. Practitioner’s Manual: An Informational Outline of the Controlled Substances Act. 2006.
- Abdallah FW, Halpern SH, Aoyama K, Brull R. Will the real benefits of single‐shot interscalene block please stand up? A systematic review and meta‐analysis. Anesth Analg. 2015;120(5):1114‐1129.
- The American Society of Interventional Pain Physicians (ASIPP) Fact Sheet. Overview on Prescription Drug Abuse. https://www.asipp.org/documents/ASIPPFactSheet101111.pdf. Accessed January 25, 2016.
- Volkow ND, McLellan TA . Characteristics of opioid prescriptions in 2009. JAMA. 2011;305(13):1299‐1301.
- Centers for Disease Control and Prevention. Opioid painkiller prescribing varies widely among states. http://www.cdc.gov/media/releases/2014/p0701‐opioid‐painkiller.html.
- Benyamin R, Trescot AM, Datta S, et al. Opioid complications and side effects. Pain Physician. 2008;11:s105‐s120.
- Bingham AE, Fu R, Horn JL, Abrahams MS. Continuous peripheral nerve block compared with single‐injection peripheral nerve block: a systematic review and metaanalysis of randomized controlled trials. Reg Anesth Pain Med. 2012;37(6):583‐594.
- Forastiere E, Sofra M, Giannarelli D, Fabrizi L, Simone G. Effectiveness of continuous wound infusion of 0.5% ropivacaine by ON‐Q pain relief system for postoperative pain management after open nephrectomy. Br J Anaesth. 2008;101(6):841‐847.
- Liu SS, Richman JM, Thirlby RC, Wu CL. Efficacy of continuous wound catheters delivering local anesthetic for postoperative analgesia: a quantitative and qualitative systematic review of randomized controlled trials. J Am Coll Surg. 2006;203(6):914‐932.
- The Joint Commission. Safe use of opioids in hospitals. Sentinel Event Alert. Issue 49, August 8, 2012.
- Aguirre J, Del Moral A, Cobo I, Borgeat A, Blumenthal S. The role of continuous peripheral nerve blocks. Anesthesiol Res Pract. 2012;2012:1‐20.
- Chelly JE, Ghisi D, Fanelli A. Continuous peripheral nerve blocks in acute pain management. Br J Anaesth. 2010;105(suppl 1):86‐96.
- Kessler RK, Shah M, Gruschkus SK, Raju A. Cost and Quality Implications of Opioid-Based Postsurgical Pain Control Using Administrative Claims Data from a Large Health System: Opioid-Related Adverse Events and Their Impact on Clinical and Economic Outcomes. Pharmacotherapy. 2013;33(4):383-391.
- Dine A. Evidence based outcomes review. Continuing review and evaluation for I‐Flow Corporation. July 2012.
- Jaeger P, Nielsen Z, Henningsen MH, Hilsted KL, Mathiesen O, Dahl JB. Adductor canal block versus femoral nerve block and quadriceps strength: a randomized, double‐blind, placebo‐controlled, crossover study in healthy volunteers. Anesthesiology. 2013;118(2):409‐415.
- Mudumbai SC, Kim TE, Howard SK, et al. Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res. 2014;472(5):1377‐1383.
- Webb C, Mariano E. Best multimodal analgesic protocol for total knee arthroplasty. Pain Management. 2015;5(3):185‐196.
- Kim DH, Lin Y, Goytizolo EA, et al. Adductor canal block versus femoral nerve block for total knee arthroplasty. A prospective, randomized, controlled trial. Anesthesiology. 2014;120(3):540‐550.
- Bianconi M, Ferraro L, Traina GC, et al. Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery. Br J Anaesth. 2003;91(6):830‐835.
- Auyong DB, Allen CJ, Pahang JA, Clabeaux JJ, MacDonald KM, Hanson NA. Reduced length of hospitalization in primary total knee arthroplasty patients using an updated enhanced recovery after orthopedic surgery (ERAS) pathway. J Arthroplasty. 2015;30(10):1705‐1709.
- Andersen HL, Gyrn J, Moller L, Christensen B, Dusanka Z. Continuous saphenous nerve block as supplement to single‐dose local infiltration analgesia for postoperative pain management after total knee arthroplasty. Reg Anesth Pain Med. 2013;38(2):106‐111.
- Perlas A, Kirkham K, Billing R et al. The impact of analgesic modality on early ambulation following total knee arthroplasty. Reg Anesth Pain Med. 2013;38(4):334‐339.
- Kean J, Wigderowitz CA, Coventry DM. Continuous interscalene infusion and single injection using levobupivacaine for analgesia after surgery of the shoulder: a double‐blind, randomized controlled trial. J Bone Joint Surg [Br]. 2006;88‐B:1173‐1177.
- Goyal N, McKenzie J, Sharkey PF, Parvizi J, Hozack WJ, Austin MS. The 2012 Chitranjan Ranawat award: intraarticular analgesia after TKA reduces pain: a randomized, double‐blinded, placebo‐controlled, prospective study. Clin Orthop Relat Res. 2013;471(1):64‐75.
- Gómez-Cardero P, Rodríguez-Merchán EC . Postoperative analgesia in TKA: ropivacaine continuous intraarticular infusion. Clin Orthop Relat Res. 2010;468(5):1242-1247.
- Beaussier M, El’Ayoubi H, Schiffer E, et al. Continuous preperitoneal infusion of ropivacaine provides effective analgesia and accelerates recovery after colorectal surgery. Anesthesiology. 2007;107(3):461‐468.
- White PF, Rawal S, Latham P, Markowitz S, et al. Use of a continuous local anesthetic infusion for pain management after median sternotomy. Anesthesiology. 2003;99(4):918‐923.
- Capdevila X, Barthelet Y, Biboulet P, Ryckwart Y, Rubenovitch J, d’Athis F. Effects of perioperative analgesic technique on thesurgical outcome and duration of rehabilitation after major knee surgery. Anesthesiology. 1999;91(1):8‐15.
- Ilfeld BM, Ball ST, Gearen PF, et al. Ambulatory continuous posterior lumbar plexus nerve blocks after hip arthroplasty: a dualcenter, randomized, triple‐masked, placebo‐controlled trial. Anesthesiology. 2008;109(3):491‐501.
- Carli F, Clemente A, Asenjo JF, et al. Analgesia and functional outcome after total knee arthroplasty: periarticular infiltration vs continuous femoral nerve block. Br J Anaesth. 2010;105(2):185‐195.
- Heller L, Kowalski AM, Wei C, Butler CE. Prospective, randomized, double‐blind trial of local anesthetic infusion and intravenous narcotic patient‐controlled anesthesia pump for pain management after free TRAM flap breast reconstruction. Plast Reconstr Surg. 2008;122(4):1010‐1018.
- Husain A, Lee GC. Establishing realistic patient expectations following total knee arthroplasty. J Am Acad Orthop Surg. 2015;23(12):707‐713.
- Dowling R, Thielmeier K, Ghaly A, Barber D, Boice T, Dine A. Improved pain control after cardiac surgery: results of a randomized, double-blind, clinical trial. J Thorac Cardiovasc Surg. 2003;126(5):1271-1278.