What is the problem?

Medicine, and orthopaedics in particular, has been implicated in tragedies similar to the case detailed in the sidebar (available at the bottom of this article). In fact, orthopaedic surgeons are the third most common prescribers of opioids, and thus have an important role in addressing the current opioid epidemic. So how did we get here? Over the past few decades, there has been increasing awareness that pain significantly limits early postoperative mobilization and is an important determinant of satisfaction after surgery.

In 1990, the American Pain Society sought to address the lack of improvement in pain assessment and treatment by making pain more “visible” to professionals in documentation. Pressure was also put on physicians to be more aggressive in treating pain with the Food and Drug Administration (FDA) approval of OxyContin in 1995 following a misleading report that the drug was safe and nonaddictive. The Joint Commission (TJC), Institute of Medicine, and Veterans Health Administration all began to support systemic implementation of standards in measuring and reporting pain, and pain was established as the “fifth vital sign.”

As a result, from 1991 to 2011, dispensed opioid prescriptions increased from 76 million to 219 million. The death toll from opioid overdoses was tremendous. By 2017, nearly 218,000 people died from overdoses related to prescription opioids—five times higher than the number of overdose-related deaths in 1999. Efforts to alleviate suffering instead caused a ripple of unforeseen repercussions that reverberate today.

For many patients, surgery represents a critical event that results in exposure to opioids. The volume of surgical cases performed continues to rise annually, and more than 65 percent of hospital patients discharged with opioid prescriptions have had surgery during hospitalization. Recent evidence suggests that most of the pills prescribed go unused, and fewer than one in 10 patients dispose of unused opioids.

Unused pain pills increase the potential for misuse. The amount of prescription opioids circulating on city streets is staggering, and the amount of people who misuse those medications is equally high at 11.4 million, according to the Department of Health and Human Services (HHS).

In the current political conversations regarding the opioid crisis, it is easy to get lost in the numbers and forget that each data point is a mother, father, child, or sibling. Now, surgeons and other medical professionals must take ownership of our contributions to these tragedies and lead the charge on policy initiatives that seek to save our patients’ lives.

Where we are going

The unintended consequences of opioid medications are increasingly at the forefront of a national discussion. Some proposed solutions are born from new regulations, such as prescription drug monitoring programs and e-prescribing. It is a good reminder to us all; as orthopaedic surgeons, we prescribe 7.7 percent of all opioid prescriptions, despite representing 2.5 percent of all physicians. In many ways, this is expected and justified based on the painful nature of orthopaedic injuries and procedures. However, several studies have demonstrated that a significant number of medications are unused after orthopaedic procedures and can contribute to the supply of diverted medications.

Additionally, several studies have demonstrated that orthopaedic injuries and their subsequent procedures can introduce patients to narcotics, which can progress to long-term use. AAOS recently published an information statement titled, “Appropriate Storage and Disposal of Prescription Opioid Medicines”—an example of the beginning of an ongoing discussion that will likely continue throughout our careers.

What we can do

The opioid epidemic is a critical public health issue with devastating consequences. As physicians and orthopaedic surgeons, we must play a role in raising awareness and preventing the diversion, misuse, and abuse of opioid pain medications. Solutions to the problem require engagement of all, including healthcare professionals, hospitals, the pharmaceutical industry, insurance companies, and state and federal government agencies.

The 21st Century Cures Act, passed in 2016, allocated $1 billion in grants to states to help facilitate treatment and prevention programs to combat the opioid crisis. Several agencies, including the Centers for Disease Control and Prevention, TJC, HHS, FDA, and other federal and state government agencies, are developing policies and programs to prevent substance abuse, promote better public health surveillance, discover alternative strategies to pain management, and provide more services for addiction treatment and recovery. Regardless of practice setting—urban or rural, academic or private practice—it is imperative that we educate ourselves and have a leading voice in the national discussion to prevent opioid overdoses and deaths and preserve the safety of all patients.

Carl L. Herndon, MD, is a fourth-year orthopaedic surgery resident at Columbia University Medical Center in New York and a member of the AAOS Resident Assembly Health Policy Committee.

Peter Joo, BA, is a fourth-year medical student at the University of Rochester, an MPH candidate in health policy at the Harvard T.H. Chan School of Public Health, and a member of the AAOS Resident Assembly Health Policy Committee.   

Vivek Venugopal, MD, is an orthopaedic surgery resident at Baylor College of Medicine and a member of the AAOS Resident Assembly Health Policy Committee.  

Molly A. Day, MD, ATC, is a fifth-year orthopaedic surgery resident at the University of Iowa Hospitals and Clinics in Iowa City, Iowa, and chair of the AAOS Resident Assembly Health Policy Committee.

References

1. Baker DW: History of The Joint Commission’s pain standards: lessons for today’s prescription opioid epidemic. JAMA 2017;317:1117-8.
2. Substance Abuse and Mental Health Services Administration: The National Survey on Drug Use and Health: 2017. Available at: https://www.samhsa.gov/data/sites/default/files/nsduh-ppt-09-2018.pdf. Accessed December 2, 2019.
3. Volkow ND: America’s Addiction to Opioids: Heroin and Prescription Drug Abuse. Available at: https://www.archives.drugabuse.gov/testimonies/2014/americas-addiction-to-opioids-heroin-prescription-drug-abuse. Accessed December 2, 2019.
4. Centers for Disease Control and Prevention: CDC WONDER. Available at: https://www.wonder.cdc.gov. Accessed December 2, 2019.
5. Randazzo S: Drug Distributors in Talks to Settle Opioid Litigation for $18 Billion. Available at: https://www.wsj.com/articles/drug-distributors-in-talks-to-settle-opioid-litigation-for-18-billion-11571170730. Accessed December 2, 2019.
6. AAOS: Appropriate Storage and Disposal of Prescription Opioid Medicines. Available at: https://www.aaos.org/uploadedFiles/PreProduction/About/Opinion_Statements/advistmt/1052%20Appropriate%20Storage%20and%20Disposal%20of%20Prescription%20Opioid%20Medicines.pdf. Accessed December 2, 2019.

The police department is on the phone …

It’s Friday at 5:43 p.m. My pager alarms, and it reads: “The police department is on the phone and asking to talk to a doctor about a patient who was discharged yesterday. Can you call them back?” This was not the typical request for a Colace order that I was expecting.

I was a fledgling intern covering the floor pager, and my world was about to turn upside down. I returned the officer’s call, who turned out to be a detective on the scene of a death. The victim was a young man who had been discharged from our service the day before, following a traumatic injury. He was a large male with several injuries. Although he had required more-than-usual amounts of opiates to control his pain, his hospital course had been otherwise unremarkable. The acute pain service had been consulted and suggested a stronger opiate regimen. They planned to follow him as an outpatient for a slow wean over the next few weeks. I had even waved goodbye to the patient and his family in the elevator on their way out the door.

The detective informed me that the patient had been found dead in his home and had likely overdosed on narcotics. Signs of chronic opiate abuse were discovered throughout his home: There were bottles of pills from multiple prescribers for multiple patient names in his medicine cabinet, and he had been found wearing a fentanyl patch, which no one from our institution had prescribed. The investigation continued over the next few days, and the medical examiner finally determined that his death was the result of respiratory arrest due to narcotic overdose.

I was shocked. This clear-eyed young man had held a respectable job and had taken care of his mother. He had required more pain medicine than average for adequate pain control, but his injuries had been more severe than most. He had not seemed narcotics-seeking in any of my interactions with him. When considering his prescriptions, I had seen no red flags. A routine check of the state- wide prescription database had been clear. The medication regimen had been vetted by the pain service, and he had seemed to understand his instructions clearly. Yet, here I was, discussing his case with a detective the day after his dis- charge as he lay dead on the floor of his home.

Even though we had consulted the pain team and used the state prescription database to check for other opioid prescription medications from other doctors, our patient was dead. Prescription medicines killed him. The medicines I had prescribed killed him.

As we continue to battle the opioid epidemic in the United States, we must remain vigilant. Statewide opioid databases, increasing physician awareness, and public initiatives are steps in the right direction, but we cannot let our guard down. Even the most clear-eyed patients can overdose. Even the most genuine patients who smile and take care of their mothers can be addicted. We, as orthopaedists, cannot fail to remember that medicines we prescribe so often can be the most lethal.

—Carl L. Herndon, MD