A Qualitative Analysis of Opioid Management in Orthopaedics

By Mary Pevear

Power tools are needed to remove damaged cartilage and bone to make room for a metal implant. Postoperative narcotics are needed so the patient can cope with a painful recovery.

A total knee arthroplasty can greatly improve a patient’s quality of life. But the recovery is indeed painful — which helps explain why orthopaedic surgeons prescribe more opioids than surgeons in any other specialty.

There are often disturbing consequences. Opioid abuse and dependency following orthopaedic procedures has increased 152% over the past ten years — part of the growing national epidemic that the Centers for Disease and Prevention (CDC) considers one of America’s five most serious health challenges. More than 1,500 people died from opioid overdoses in Massachusetts last year. Legal prescriptions are the largest source of misused opioids. Overprescribing is a major contributor to the epidemic. Recent legislation in Massachusetts designed to monitor and regulate narcotic prescriptions has not slowed the horrible pace of opioid-related deaths.

I found a significant disconnect from how the opioid problem is discussed by public health officials and how it is discussed —or not discussed at all — in orthopaedics. I observed this while working as an Orthopaedic Clinical Researcher at Tufts Medical Center.

In stunning contrast to the attention the epidemic is receiving within the public at large, articles pertaining to opioid abuse were lacking within orthopaedic literature. And no universal guidelines for orthopaedic prescribers were practiced. “Everyone is different, everyone has their own philosophy,” explained one surgeon interviewed for my MPH Applied Learning Experience (ALE).  For my ALE I conducted qualitative, semi-structured interviews with 11 surgeons from three Greater Boston hospitals.

All agreed that individual patient factors and needs challenge protocols. “The patient population drives how the protocols are,” said one surgeon. “I don’t think there’s a reasonable one-size-fits-all protocol solution.”

Common themes were identified to delve into prescriber perspectives of the opioid crisis —specifically relative to the dissemination, awareness and adoption of opioid prescriber guidelines. With the help of my preceptor, Dr. Eric Smith, a total joint surgeon at Boston Medical Center, and two key stakeholders (an American Orthopaedic Association Board member and a representative from the American Academy of Orthopaedic Surgeons Communications’ team), four a-priori themes were established as interview prompts — awareness and utilization of guidelines, policy response, education and training, and barriers to safe prescribing.

Conversations were recorded, transcribed, and analyzed. These conversations revealed surgeons coping with systemic pressures, an emphasis on patient satisfaction, the subjectivity of pain, outdated education, a lack of alternative pain-management options, patient factors, and the role of primary-care providers.  Protocols varied significantly among institutions and prescribers.

Prescribing narcotics involves complex decision-making, surgeons said. External pressures to meet patient expectations influence prescriber practices. “If I don’t prescribe, someone else will,” said one surgeon. “That’s the bottom line. Patients can choose to go to another doctor for their surgery, and that’s a lot of pressure.”  “In medical school, they taught us that if a patient is in pain, don’t be afraid to prescribe more pain meds,” said one orthopaedic surgeon.

Even amid a national opioid-abuse epidemic, surgeons remain accountable for treating postoperative pain, creating a complex problem for orthopaedic prescribers.   Major systemic changes are needed, including changing patients’ perceptions to better deal with normal postoperative pain. Education in this area is fundamental, but lacking, according to surgeons interviewed, “I learned my practices from myself through my own clinical experiences,” said one surgeon. “The mandatory continuing medical education (CME) trainings are useless because it’s the same material every two years.”

Recommendations developed from ALE findings will be presented to the American Academy of Orthopaedic Surgeons (AAOS). The overall purpose of my project was to engage key stakeholders in the orthopaedic community and spark discussion of an important topic.  These surgeons revealed a deep investment in reforming narcotic protocols, an important first step toward broadening conversations involving organizations such as the AAOS. Further exploration into solutions at the institutional, state and federal levels is also needed.

Not until I began my ALE at Boston Medical Center did I really grasp the societal impact of this disease. BMC’s proximity to several homeless shelters sharpened this awareness. On my walk to work, I encountered addicts on the sidewalks. Inside the shelter were addicts in all stages of recovery and relapse. The work being done at BMC to address this problem is inspiring and heartwarming. It is among the reasons I chose to recruit my preceptor from there. The institution recently received a donation of $25 million to launch the BMC Grayken Center for Addiction Medicine.