Addressing the Opioid Epidemic at a Local Level

The opioid epidemic impacts every part of the country and our home state of Oregon is no exception. Oregon has one of the highest rates of prescription opioid misuse in the nation and an average of three Oregonians die every week from prescription opioid overdose. To combat abuse and dependency on a state level, Governor Kate Brown created the Opioid Epidemic Task Force.

The Opioid Epidemic Task Force’s key pillars include reducing the amount of opioids in circulation, improving access to high quality treatment, facilitating data sharing and the promotion of cutting edge education efforts. Each of these efforts will help battle the epidemic on a larger scale and I applaud the efforts of everyone involved.

As a surgeon, it’s my responsibility to address the opioid crisis in my own practice. I provide my patients quality care while controlling their perioperative pain with other effective and safer options. Years ago, I implemented a multi-modal, low-opioid pain management strategy. It decreases opioid use while more effectively managing a patient’s postsurgical pain.

Anytime a patient has a joint replacement, pain is to be expected. However, by determining which non-narcotic and narcotic pain medications work well for the individual patient before surgery, we can significantly reduce their pain and opioid use after surgery. During most of the hip and knee replacements I perform – I inject a non-opioid option called EXPAREL combined with local anesthetics and anti-inflammatories. This provides augmented pain relief for 48-72 hours after surgery and decreased opioid consumption. It helps patients manage the worst of their pain while allowing us to mobilize the patient within hours of surgery. EXPAREL is a significant reason over 90 percent of my patients are able to leave the hospital the same day as their total joint surgery. Most importantly, many patients only need to take opioids for two-to-three days after surgery and most, no more than a week, significantly reducing the risk of opioid abuse and misuse. In comparison, nationwide 42 percent of opioid-naïve total knee arthroplasty patients on opioids at three months were still on opioids at six months.

A comprehensive attempt at addressing the ongoing opioid epidemic is the key to overcoming this issue in Oregon, and other states across the country. By utilizing non-opioid pain management options and proactively determining which opioid/dose is appropriate for the individual patient, we can reduce opioid prescribing, turning the tide of the opioid crisis while improving and not compromising patient care. 

Dr. James Van Horne is an orthopedic surgeon in Grants Pass, Oregon and is affiliated with Grants Pass Ambulatory Surgery Center and Asante Three Rivers Medical Center. He received his medical degree from Drexel University College of Medicine and total Joint Fellowship at Harvard’s Brigham and Women’s Hospital. He’s been doing outpatient joint replacements for over seven years.

Comments

The "Opioid Epidemic" can be traced to a lot of different sources -- and no doubt, some physicians are responsible.  But for the most part, the proposed solutions seem to be schemes to use expensive, and marginally effective means to bilk the taxpayer -- this one, for instance.

My belief is that surgeons should be required to continue to manage post-operative pain for the remainder of the life of the patient -- Pottery Barn Rule "you break it, you fix it".  That would solve the problem of excess surgery, and free up "primary" doctors from having to deal with the messes the surgeons make after they dismiss the failures from their practice.

This is just a snippit of a random article about EXPAREL.  I don't doubt that it works, especially if the surgeon limits his patients to those who go into surgery in good mental and physical condition, and also those that have realistic expectations -- and provided that adequate physical therapy support is available and is used by the patient.

The price of a painkiller used in knee surgery is getting some doctors bent out of shape.  https://www.statnews.com/pharmalot/2015/12/14/exparel-drug-costs-painkil...

In recent weeks, two different studies have concluded that the medicine, an analgesic called Exparel, is no more effective than an older form of the treatment. Exparel combines bupivacaine, an injectable drug that has been a standard of care, with a proprietary technique for administering pain relief.

However, the wholesale price for a vial of Exparel costs about $285 versus about $3 for bupivacaine. As a result, the study authors — whose papers were released last month at the annual meeting of the American Association of Hip and Knee Surgeons — maintain the difference in price can’t be justified. Some practices have discontinued using the drug.