Postoperative pain management after orthopedic procedures requires physicians to balance the risks of respiratory depression, delayed ambulation and opioid abuse with the goal of lessening patient discomfort after surgery, and many physicians are looking to multimodal routes to accomplish this objective.
“Opioids have been the mainstay for treatment of postoperative pain for many years, but over the last several years, both physicians and patients have noticed more adverse reactions or side effects for opioids and they are numerous,” said Paul F. Lachiewicz, MD, of the Department of Orthopaedic Surgery at Duke University Medical Center in Durham, N.C. Among the risks of opioid use are abuse, confusion, nausea, vomiting, itching, constipation and respiratory depression. Patients who are administered too much opioid medication can undergo respiratory arrest and require admission to the intensive care unit and possible intubation, Lachiewicz told Orthopedics Today.
Patients with sleep apnea, particularly undiagnosed, are at an increased risk for respiratory adverse effects with opioids, according to physicians interviewed for this story.
“These [sleep apnea] patients already have trouble breathing, so to add the respiratory depression to opioid use, can cause increased complications,” saidSheyan J. Armaghani, MD, of the Department of Orthopaedics and Rehabilitation at Vanderbilt University Medical Center in Nashville. “At our institution, we send all patients with a history of sleep apnea who need opioids post-surgically to a monitored unit to help prevent respiratory complications.”
Clinton James Devin, MD, said that multimodal pain management allows for reduced dosage of opioids, improved pain control and more rapid mobilization.
Image: Joe Buglewicz
Opioids also can induce potential adverse events, such as hypotension, and gastrointestinal effects including nausea, vomiting and constipation. Elderly patients — particularly those who have never taken opioid medications — are more likely to suffer cognitive effects.
“If older patients, say in their 80s and older, are not used to taking Percocet or other oral opioid medications and then are given opioids in the hospital, they can get confused, disoriented or delirious,” Lachiewicz said.
Obese patients present an added concern for practitioners as opioids can accumulate in fatty tissue. Patients with psychiatric conditions also may be more likely to abuse opioids, according to Clinton James Devin, MD, assistant professor of orthopaedic surgery and Neurosurgery at Vanderbilt Spine, Nashville. “Opioids are then used to not only manage the perceived pain, but also the patients attempt to decrease their worsening depressive or anxiety symptoms,” he told Orthopedics Today.
Complications and comorbidities often have a lasting effect for patients since they can lead to a delay in ambulation, and overall recovery. “We are trying to mobilize, get the patients up and walking, participating in physical therapy, and finally getting them out of hospital early after major surgery,” Lachiewicz said. “If the patient has respiratory depression, gastrointestinal upset or confusion, they are not going to be able to do [physical therapy] PT, and they are not going to be able to get out of the hospital per protocol.”
Orthopedic surgeons also consider the potential for abuse when prescribing pain medication, though long-term usage of medications most often falls under the purview of a pain physician. However, surgeons often screen for opioid abuse or potential in patient interviews. Selene G. Parekh, MD, MBA, an orthopedic foot and ankle surgeon, at the North Carolina Orthopaedic Clinic and Duke University Durham, N.C., said he looks for warning signs such as depression, history of opioid abuse and drug abuse, or past medical or social issues, gathered from self-reported information on patient intake forms. “If there is something that gets flagged in the electronic medical [record] history, then we bring that to the attention of the patient and discuss it,” he said.
Parekh also said that in cases where there is prior abuse, he only allows a designated pain management physician to prescribe narcotics to patients to eliminate the possibility that multiple practitioners are providing narcotic medications.
Abuse risk with opioids
Patient information also can be cross-checked with databases in many states, according to Armaghani.
“In Tennessee, we are fortunate to now have a state-wide database that registers opioid prescriptions, including dose, amount and date prescription filled, that providers can look up online to see if a patient has been doctor shopping,” he said. “This has been a great tool to identify those who are abusing the system and looking for prescriptions.”
