Instructional Course Lecture Panelists Share Fundamentals of Opioid-Sparing Total Joint, Shoulder, and Hand Surgery

The United States is the number one country in the world for opioid prescriptions, and orthopaedic surgeons are the third-highest prescribers of these medications. Despite this increased pattern of opioid consumption, there have not been significant decreases in patient-reported pain. It is essential for orthopaedic surgeons to manage patients’ postoperative pain while reducing the overall use of opioid medications.

During the Instructional Course Lecture titled “Crisis Averted: Opioid-Sparing Orthopaedic Surgery,” held during the AAOS 2024 Annual Meeting in San Francisco, panelists offered their expertise on pain control in orthopaedic surgery, focusing on multimodal pain pathways that avoid the use of opioids. The panel was moderated by John Horneff III, MD, FAAOS, assistant professor of orthopaedic surgery and director of the shoulder and elbow fellowship at Penn Medicine, and featured presentations from Antonia F. Chen, MD, MBA, FAAOS; Joseph A. Abboud, MD, FAAOS; and Asif M. Ilyas, MD, FAAOS.

Total joint arthroplasty
Dr. Chen is an associate professor of orthopaedic surgery at Harvard Medical School and chief of arthroplasty and joint reconstruction at Brigham and Women’s Hospital, where she also serves as the Michael A. Bell Distinguished Chair in Healthcare Innovation. She began her presentation with an overview of the benefits of reduced opioid use in the postoperative period following total joint arthroplasty (TJA). Her study showed that fewer opioids led to equivalent or better outcomes compared with full narcotic dosages, with reduced morbidity and mortality and lower financial burden. Furthermore, fewer opioids are also associated with fewer readmissions and operations.

Before attempting an opioid-sparing regimen for TJA, Dr. Chen recommended performing a preoperative workup to predict and reduce postoperative opioid consumption. It is important to understand risk factors of prolonged opioid use (use for >3 months postoperatively). A major risk factor to consider for TJA is previous or chronic opioid use, as many patients may already be managing chronic pain with opioids. “We want to try to reduce that beforehand,” Dr. Chen said.

She recommended several alternatives for managing pain, including a multimodal regimen of NSAIDs combined with Tylenol, acupuncture, and even mindfulness. She also noted the use of gabapentin in some cases, “to potentially address the nerve pain.” Once the patient is on a multimodal regimen, “We can build on that as needed,” she said, considering narcotic options such as tramadol, oxycodone, or dilaudid “at a very sparing or low dosage.”

On the operative side, Dr. Chen recommended the use of pericapsular injections. “This is something that we use in every single one of our cases,” she said. “You normally have a combination of analgesic and epinephrine, and there’s a bunch of others you can add to it. The one that I personally use is ropivacaine, epinephrine, clonidine, and ketorolac.”

Nerve blocks are another option surgeons can choose to reduce postoperative opioid usage in TJA. Dr. Chen reviewed several alternatives for knee and hip nerve blocks. For knees, she discussed adductor canal blocks and iPACK blocks (local anesthetic infiltration of the interspace between the popliteal artery and the posterior knee capsule), and for hips, she recommended lumbar plexus blocks and fascia iliac compartment blocks. Femoral nerve blocks can be utilized for both hip and knee cases. Another option during surgery is intra-articular pain catheters; however, she warned of several risks associated with this approach, including retained catheters in the surgical site due to breakage, infection, and reoperation.

She concluded by calling on orthopaedic surgeons to “reduce the footprint” of opioids by reducing prescriptions with alternative methods of pain control. She offered this wisdom: “Be nice to your anesthesiologist. They will help you.”

Shoulder surgery
Effective pain management begins in the preoperative period, said Dr. Abboud, who is the chief medical officer for Rothman Orthopaedics and a professor of shoulder and elbow surgery at Thomas Jefferson University. For shoulder surgery, he recommended a preoperative workup to identify patients at risk for increased pain. In addition to a multimodal pain-control regimen, Dr. Abboud stressed the importance of patient education and the establishment of postoperative expectations. These factors combined together—patient education, patient screening, and established expectations for the postoperative period—are effective, simple, and inexpensive tools to decrease both postoperative pain and opioid consumption.

“Patients need to understand what they are signing up for,” he said, particularly in shoulder surgery, where pain levels can be significant and where many procedures are elective and only performed once conservative options are exhausted. Part of educating and setting expectations is ensuring that patients understand the potential risks and complications along with what the postoperative period and rehabilitation may look like. Patients should anticipate that “pain is part of the process,” Dr. Abboud said.

Additionally, patients must be educated on opioids themselves, including the severe adverse events and consequences associated with prolonged opioid use. Opioid-related education is effective; Dr. Abboud cited a 2018 randomized study that he co-authored, published in the Journal of Shoulder and Elbow Surgery, which found that a 2-minute video and a handout about the risks of narcotic overuse and abuse were associated with a significantly lower consumption of narcotics 3 months after rotator cuff repair. Patients with a history of narcotic use who received this educational regimen were 6.8 times more likely to discontinue narcotics by final follow-up compared with controls.

Turning to multimodal analgesia, “Acetaminophen is critical,” Dr. Abboud said. He added, “You’ve got to be careful about NSAIDs. They’re great, but patients think they’re benign.” Overuse of NSAIDs is associated with increased blood pressure and cardiovascular disease, upset stomach and ulcers, kidney toxicity, and adverse interactions with other medications. If the patient is going to stay on NSAIDs long-term, Dr. Abboud recommended they be followed by their primary care physician to assess any risk of complications.

Dr. Abboud touched on some options for local and regional anesthesia, such as local periarticular injection and interscalene brachial plexus blocks. He said that his practice has moved away from continuous nerve-block catheters in favor of single-shot nerve injections.

Hand and outpatient surgery
Rounding out the session, Dr. Ilyas, hand, wrist, elbow, and trauma surgeon at Rothman Orthopaedics, presented on opioid-sparing hand and outpatient surgery. “As orthopaedic surgeons, we’re really in the middle of this [opioid crisis],” Dr. Ilyas told attendees. “We want to make sure that we can be a part of the solution, not just a part of the problem.”

The primary role surgeons can play is prevention, he emphasized. He highlighted three strategies to minimize opioid use: Avoid over-prescribing, utilize multimodal regimens, and properly counsel patients on pain management and opioids.

Regarding overprescribing, he cited a 2012 study from Rodgers et al in the Journal of Hand Surgery that found an opioid utilization rate of 33 percent among 250 hand surgery patients who were prescribed an average of 30 pills each. The low utilization rate led to more than 5,000 unused pills. Dr. Ilyas advised surgeons to determine the average utilization rate at their practice, then prescribe to that average. “It’s always better to refill than overprescribe,” he said.

Like his co-panelists, Dr. Ilyas reviewed multimodal pain-management regimens in the hand surgery setting. Strategically utilizing adjunctive pain agents in the pre-, intra-, and postoperative periods can help decrease overall opioid needs. In the preoperative period, he recommended NSAIDs, acetaminophen, and gabapentin. He advised using local anesthetics and nerve blocks intraoperatively, as well as continuing the multimodal regimen in the postoperative period. He emphasized that for a multimodal regimen to be effective, patients must take the medications consistently, not “as needed.”

Counseling patients on pain management and opioids’ potential harms reliably leads to less voluntary opioid use, Dr. Ilyas noted. He co-authored studies in the Journal of Hand Surgery in 2017 and in Orthopedics in 2021, which both found that preoperative opioid education significantly reduced opioid consumption levels.

In his practice, Dr. Ilyas shares a pre-recorded patient education video prior to procedures. “Probably the most useful thing I’ve done in the last 10 years of my practice is create this video,” he said. He finds video to be a more effective medium for educating patients than reading materials. “They’re very comfortable watching this, and you can cover a ton of ground.”

To create the video, Dr. Ilyas simply made a PowerPoint presentation on the topic of pain management and opioid education and recorded an audio track of himself narrating the presentation. He Airdrops the video to patients, and he keeps two iPads in his office for them to watch the video.

Through strategically and thoughtfully approaching pain management, orthopaedic surgeons can set the tone for how patients approach their own pain and opioid use. Dr. Ilyas told attendees, “They take it very seriously when they know you take it seriously.”

Rebecca Araujo is the managing editor of AAOS Now. She can be reached at raraujo@aaos.org.

References

1. Morris BJ, Mir HR: The opioid epidemic: impact on orthopaedic surgery. J Am Acad Orthop Surg 2015;23(5):267-71.
2. Syed UAM, Aleem AW, Wowkanech C, et al: Neer Award 2018: the effect of preoperative education on opioid consumption in patients undergoing arthroscopic rotator cuff repair: a prospective, randomized clinical trial. J Shoulder Elbow Surg 2018;27(6):962-7.
3. Rodgers J, Cunningham K, Fitzgerald K, et al: Opioid consumption following outpatient upper extremity surgery. J Hand Surg Am 2012;37(4):645-50.
4. Alter TH, Ilyas AM: A prospective randomized study analyzing preoperative opioid counseling in pain management after carpal tunnel release surgery. J Hand Surg Am 2017;42(10):810-5.
5. Ilyas AM, Chapman T, Zmistowski B, et al: The effect of preoperative opioid education on opioid consumption after outpatient orthopedic surgery: a prospective randomized trial. Orthopedics 2021;44(2):123-7.